Physical activity contributes to the healthy development of children and young people and should be encouraged. In the school and sport setting it is important for school staff to know the signs and symptoms of concussion; and if they suspect a concussion, remove the child from play immediately.
Concussion is defined as a form of mild traumatic brain injury that occurs as a result of a direct impact to the head or impact to the body that causes transmission of forces to the head and brain. (Professor Gary J Browne, Concussive head injury in children and adolescents, 2016) A concussion may be caused by collision with another person or object that involves a direct or indirect force to the head, face, neck or elsewhere with a force transmitted to the head.
A child does not need to be knocked out (lose consciousness) to have concussion - 92% of concussion injuries do not involve any loss of consciousness.
Concussion in children and adolescents
Traumatic brain injury is one of the most common causes of neurological morbidity, and is more common in childhood and adolescence than at any other time of life. Young people are more susceptible to concussion due to the pediatric brain having different mechanical and compositional properties. There is increased water content, an increased transition of acceleration/deceleration forces due to lesser neck strength and also decreased myelin (insulating layer that forms around nerves in the brain).
Concussions in young people account for 90% of all traumatic brain injuries, with one in five children experiencing a concussion by the age of 10 years. The most common causes of concussion in young people are falls and sports-related activities. Rugby League, Rugby Union, Australian Football and Football have the highest reported rates of sport-related concussion. The highest rates of concussions are reported in males aged 10 - 19 years.
Young people have a more prolonged recovery from concussion, and will require a gradual and supportive return to learning and play. The Australian Institute of Sport and the Australian Medical Association recommend a minimum of 14 days from when symptoms cease, plus medical clearance before a young person returns to sport or physical activity.
There are a number of factors which have been suggested to affect the risk of a young person sustaining a concussion or having a more protracted course (longer recovery). Risk factors include:
- History of prior concussion
- Learning disorder
- Mood disorder
- Playing style of individual (aggressive or passive)
- Sport played
Signs and symptoms of concussion
If a student receives a bump or blow to the head or body that causes a jarring of the head or neck, they should stop the activity they were engaged in immediately. It is then vital to monitor the student for signs and symptoms of concussion. For subtle concussions, it is not always the medical practitioners who will pick up on the signs, instead it is people who know the young person well - parents, carers, teachers and friends. Signs and symptoms may not show up until 24 - 48 hours after the head injury.
Signs observed by others
- Appearing dazed or stunned
- Repeating questions
- Confused about events
- Can’t recall events before or after the injury
- Showing personality or behaviour changes
Symptoms reported by the young person
- Headache or “pressure” in the head
- Dizziness and/or loss of balance
- Weakness, numbness or tingling in the arms, legs or face
- Feeling tired (fatigued)
- Sensitivity to light and/or noise
- Does not “feel right”
- Feeling more emotional, e.g. sad or nervous
- Trouble thinking clearly, concentrating or remembering
If a student has any of the signs or symptoms listed, they should be assessed by a doctor. It is important for schools and parents/carers to record these symptoms by noting when they occurred, how long they lasted, and how severe they were, so that a doctor can be informed. The Sydney Children's Hospital Network Concussion Action Plan is a useful tool to support schools and parents/carers in the monitoring process. The early detection of concussion, proper evaluation and follow-up care are key factors that may influence recovery time.
If at any time the student's symptoms worsen or if there is uncertainty, the student should be taken to the hospital. The acronym HEADMBUMPS should be used to assess if urgent medical attention is required.
H - worsening headache, seizure, unconscious
E - worsening eye problems
A - abnormal behaviour change
D - dizziness, persistent vomiting
B - balance dysfunction with weakness or numbness in limbs
U - unsteady on feet, slurred speech
M - memory impaired, confused, disoriented
P - poor concentration, drowsy
S - something is not right
Responding to concussion
The 5Rs of concussion is an easy-to-remember concussion management strategy to ensure that the health and wellbeing of students of all ages remains the number one priority when responding to a suspected concussion.
- Recognise that it may have occurred by using direct visualisation and/or speaking to other students/staff who may have witnessed the incident.
- Remove the student from play and follow school first aid procedures.
- Refer involves:
- informing the principal or relevant line manager of the incident
- contacting parents of the student who has a suspected concussion
- following Incident Notification and Response Procedures.
- Rest, on both a cognitive and physical level. Children and adolescents should not exercise, use computer screens, play video games or study for at least 24 - 48 hours. The student will need some time away from school and sports.
- Return to play/school in a step-wise or graduated sequence. A gradual and staged return to school and sporting activities should be planned by the student's doctor and adhered to by teachers and staff.
Concussion management tool
To meet the department's duty of care, principals need to be able to demonstrate that systems are in place to identify risks and that once identified, precautions are taken to avoid or minimise those risks. In the school setting, the Concussion management tool (PDF 173KB) provides a step-by-step procedure to support schools in adhering to correct practices if there is a suspected head injury.
Concussion management procedure
The Concussion management procedure (PDF 182KB) provides key steps and information for responding to a suspected head injury at School Sport Unit programs and events.
Teachers, school leaders and support staff are expected to know and follow the documents below when responding to and reporting concussion:
- First Aid Procedures
- Incident Notification and Response Policy
- Incident Notification and Response Procedures
- Reporting School Accidents
- Sport safety guidelines
- Requirements for all sport and physical activity
A concussion is a serious head injury and therefore needs to be responded to and reported as an incident. Incidents and injuries are reported in accordance with the Incident Notification and Response Policy and Incident Notification and Response Procedures.
In the event of an incident, the safety and wellbeing of students, staff and others is the first priority. When an incident occurs employees must:
- provide emergency care and first aid
- contact emergency services if applicable
- report the incident to their relevant line manager
- notify their principal or line manager so the incident can be reported as soon as possible, as set out in the Incident Notification and Response Procedures, ensuring that the department is able to properly manage and respond to the incident
- complete and correctly store a Reporting School Accidents (school setting) or Form 038 (School Sport Unit program and events).
Returning to school following a concussion
It can take up to several weeks for the brain to heal after a head injury. Upon returning to school it is common for students who have suffered head injury to experience headaches and difficulties with attention, concentration and memory during this time. Recovery from a brain injury is an individual process so there may be significant variation in symptom presentation and duration in those affected.
The symptoms experienced by the student may affect academic performance. Heavy concentration, memorisation, studying, problem solving or note taking can actually cause symptoms and prolong recovery. The goal is to keep cognitive activity below the level that triggers symptoms. Cognitive demand should be gradually increased until the student can fully participate in learning tasks symptom free.
The most important treatment for a head injury is complete physical and mental rest. Children and adolescents should not exercise, use computer screens, play video games or study for at least 24 - 48 hours. Children will need some time away from school and sports.
Students returning to school following a concussion will require a gradual return to learning and activities before full participation in school. The recommended learning tasks for each stage of returning to school in the School Sport Unit - Return to school plan should be used by schools to provide support to young people as they gradually return to the school setting.
Students returning to school following a concussion will require teaching and learning adjustments to enable them to access educational content and outcomes on the same basis as their peers. Potential adjustments for concussion symptoms may include:
- Frequent breaks
- Identifying triggers and reducing exposure to them
- Rest breaks – planned or as needed in a quiet area
- Allow student to put head down and rest
- Give student early dismissal from class and extra time to get from class to class to avoid crowded walkways
- Shortened school day
- Rest breaks
- Allow the student to have lunch in a quiet area with a classmate
- Limit or avoid band, choir, music and lessons that involve loud noise
- Use of ear plugs
- Give student early dismissal from class and extra time to get from class to class to avoid crowded walkways
Memory and concentration
- Avoid testing or completion of major projects while recovering
- Simplify learning tasks
- Provide extra time to complete tasks
- Provide student with pre-printed notes
- Reduce exposure to computers, tablets, smart boards and videos
- Reduce brightness on screen
- Use of audiobooks for reading tasks
- Turn off fluorescent lights
- Seat student at the centre of classroom activities
Returning to sport and physical activity after a concussion
It is important to remember that the most important treatment of a head injury is physical and mental rest. Return to school and learning should take priority over returning to sport. A concussed student should not plan to return to sport until they have successfully returned to normal school activities.
Students should not participate in sport or physical activity until they are completely symptom free for 14 days and have received written clearance from a doctor to do so.
Following a concussion, a child or adolescent's reaction time and thinking may be slower, putting them at risk of further injury. A doctor will advise parents/carers of gradual and staged return to activity. Teachers and school sport coaches should be informed of, and involved in, the return to school plan and learning adjustments for a student who has suffered a head injury.
Following a concussion there should be a staged return to activity before full participation in a sport or other physical activity. An outline of each stage and examples of activities can be viewed below.
Stage 1 - Rest
In this phase, students need physical and cognitive rest. Activities in the rest phase may include:
- painting and drawing
- basic cooking
- cloud gazing
- talking to friends.
Stage 2 - Light activity
Light activities include those with a light cognitive load, raise the heart rate slightly, do not cause the student to huff and puff and can be participated in individually or in a small group of 3 - 4. Activities to participate in at school may include:
- tag games
- mini golf
- french cricket
- continuous tennis
- footy golf
- bike riding
- table tennis.
Stage 4 - Non-contact practice
Students may now participate in non-contact modified games of increased duration and intensity. These games cause students to huff and puff. Activities in Stage 4 may include:
- continuous cricket
- newspaper hockey
- modified football (soccer)
- mini volleyball
- modified court games
- drills and skills sessions.
Students should only progress to the next stage when they have completed 24 hours at the current stage without recurrence of symptoms. If at any time a student reports symptoms, or shows signs of concussion, they must be removed from play immediately and school first aid procedures followed. A student can return to their pre-concussion level of sport and physical activity once written medical clearance is obtained from a doctor.