Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management

      Objective

      To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes.

      Study design

      A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients.

      Results

      Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations.

      Conclusions

      Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.

      Keywords

      Abbreviations:

      CHOP ( Children's Hospital of Philadelphia), ED ( Emergency department), EHR ( Electronic health record), ICD-9-CM ( International Classification of Diseases, Ninth Revision)
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      References

        • Kirkwood M.W.
        • Yeates K.O.
        • Taylor H.G.
        • Randolph C.
        • McCrea M.
        • Anderson V.A.
        Management of pediatric mild traumatic brain injury: a neuropsychological review from injury through recovery.
        Clin Neuropsychol. 2008; 22: 769-800
        • Suskauer S.J.
        • Yeates K.O.
        • Sarmiento K.
        • Benzel E.C.
        • Breiding M.J.
        • Broomand C.
        • et al.
        Strengthening the evidence base: recommendations for future research identified through the development of CDC’s Pediatric Mild TBI Guideline.
        J Head Trauma Rehabil. 2019; 34: 215-223
        • Arbogast K.B.
        • Curry A.E.
        • Pfeiffer M.R.
        • Zonfrillo M.R.
        • Haarbauer-Krupa J.
        • Breiding M.J.
        • et al.
        Point of health care entry for youth with concussion within a large pediatric care network.
        JAMA Pediatr. 2016; 170: e160294
        • Chrisman S.P.D.
        • Lowry S.
        • Herring S.A.
        • Kroshus E.
        • Hoopes T.R.
        • Higgins S.K.
        • et al.
        Concussion incidence, duration, and return to school and sport in 5- to 14-year-old American football athletes.
        J Pediatr. 2018; 207: 176-184
        • Howell D.R.
        • Kriz P.
        • Mannix R.C.
        • Kirchberg T.
        • Master C.L.
        • Meehan W.P.
        Concussion symptom profiles among child, adolescent, and young adult athletes.
        Clin J Sport Med. 2019; 29: 391-397
        • Nelson L.D.
        • Loman M.M.
        • LaRoche A.A.
        • Furger R.E.
        • McCrea M.A.
        Baseline performance and psychometric properties of the Child Sport Concussion Assessment Tool 3 (Child-SCAT3) in 5- to 13-year-old athletes.
        Clin J Sport Med. 2017; 27: 381-387
        • Murdaugh D.L.
        • Ono K.E.
        • Morris S.O.
        • Burns T.G.
        Effects of developmental age on symptom reporting and neurocognitive performance in youth after sports-related concussion compared to control athletes.
        J Child Neurol. 2018; 33: 474-481
        • Centers for Disease Control and Prevention
        Child Development. Middle childhood (6-8 years old).
        (Accessed February 1, 2020)
        • Master C.L.
        • Scheiman M.
        • Gallaway M.
        • Goodman A.
        • Robinson R.L.
        • Master S.R.
        • et al.
        Vision diagnoses are common after concussion in adolescents.
        Clin Pediatr (Phila). 2016; 55: 260-267
        • Mucha A.
        • Collins M.W.
        • Elbin R.J.
        • Furman J.M.
        • Troutman-Enseki C.
        • DeWolf R.M.
        • et al.
        A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings.
        Am J Sports Med. 2014; 42: 2479-2486
        • Risen S.R.
        • Reesman J.
        • Yenokyan G.
        • Slomine B.S.
        • Suskauer S.J.
        The course of concussion recovery in children 6-12 years of age: experience from an interdisciplinary rehabilitation clinic.
        PM R. 2017; 9: 874-883
        • Suskauer S.J.
        • Rane S.
        • Reesman J.
        • Slomine B.S.
        Caregiver-report of symptoms following traumatic brain injury in a small clinical sample of preschool-aged children.
        J Pediatr Rehabil Med. 2018; 11: 7-14
        • Mayer A.R.
        • Wertz C.
        • Ryman S.G.
        • Storey E.P.
        • Park G.
        • Phillips J.
        • et al.
        Neurosensory deficits vary as a function of point of care in pediatric mild traumatic brain injury.
        J Neurotrauma. 2018; 35: 1178-1184
        • Sady M.D.
        • Vaughan C.G.
        • Gioia G.A.
        School and the concussed youth: recommendations for concussion education and management.
        Phys Med Rehabil Clin N Am. 2011; 22: 701-709
        • Swanson M.W.
        • Weise K.K.
        • Dreer L.E.
        • Johnston J.
        • Davis R.D.
        • Ferguson D.
        • et al.
        Academic difficulty and vision symptoms in children with concussion.
        Optom Vis Sci. 2017; 94: 60-67
        • Zemek R.
        • Barrowman N.
        • Freedman S.B.
        • Gravel J.
        • Gagnon I.
        • McGahem C.
        • et al.
        Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED.
        JAMA. 2016; 315: 1014
        • Ledoux A.A.
        • Tang K.
        • Yeates K.O.
        • Pusic M.V.
        • Boutis K.
        • Craig W.R.
        • et al.
        Natural progression of symptom change and recovery from concussion in a pediatric population.
        JAMA Pediatr. 2019; 173: e183820
        • Corwin D.J.
        • Wiebe D.J.
        • Zonfrillo M.R.
        • Grady M.F.
        • Robinson R.L.
        • Goodman A.M.
        • et al.
        Vestibular deficits following youth concussion.
        J Pediatr. 2015; 166: 1221-1225
        • Bernard C.O.
        • Ponsford J.A.
        • McKinlay A.
        • McKenzie D.
        • Krieser D.
        Predictors of post-concussive symptoms in young children: injury versus non-injury related factors.
        J Int Neuropsychol Soc. 2016; 22: 793-803
        • Corwin D.J.
        • Propert K.J.
        • Zorc J.J.
        • Zonfrillo M.R.
        • Wiebe D.J.
        Use of the vestibular and oculomotor examination for concussion in a pediatric emergency department.
        Am J Emerg Med. 2019; 37: 1219-1223
        • Arbogast K.B.
        • Curry A.E.
        • Metzger K.B.
        • Kessler R.S.
        • Bell J.M.
        • Haarbauer-Krupa J.
        • et al.
        Improving primary care provider practices in youth concussion management.
        Clin Pediatr (Phila). 2017; 56: 854-865
        • Haarbauer-Krupa J.
        • Arbogast K.B.
        • Metzger K.B.
        • Greenspan A.I.
        • Kessler R.
        • Curry A.E.
        • et al.
        Variations in mechanisms of injury for children with concussion.
        J Pediatr. 2018; 197: 241-248.e1
        • Corwin D.J.
        • Zonfrillo M.R.
        • Master C.L.
        • Arbogast K.B.
        • Grady M.F.
        • Robinson R.L.
        • et al.
        Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population.
        J Pediatr. 2014; 165: 1207-1215
        • Iverson G.L.
        • Gardner A.J.
        • Terry D.P.
        • Ponsford J.L.
        • Sils A.K.
        • Broshek D.K.
        • et al.
        Predictors of clinical recovery from concussion: a systematic review.
        Br J Sports Med. 2017; 51: 941-948
        • Howell D.R.
        • O’Brien M.J.
        • Beasley M.A.
        • Mannix R.C.
        • Meehan III, W.P.
        Initial somatic symptoms are associated with prolonged symptom duration following concussion in adolescents.
        Acta Paediatr. 2016; 105: e426-e432
        • Kontos A.P.
        • Deitrick J.M.
        • Collins M.W.
        • Mucha A.
        Review of vestibular and oculomotor screening and concussion rehabilitation.
        J Athl Train. 2017; 52: 256-261
        • Master C.L.
        • Master S.R.
        • Wiebe D.J.
        • Storey E.P.
        • Lockyer J.E.
        • Podolak O.E.
        • et al.
        Vision and vestibular system dysfunction predicts prolonged concussion recovery in children.
        Clin J Sport Med. 2017; 28: 1
        • Pearce K.L.
        • Sufrinko A.
        • Lau B.C.
        • Henry L.
        • Collins M.W.
        • Kontos A.P.
        Near point of convergence after a sport-related concussion.
        Am J Sports Med. 2015; 43: 3055-3061
        • Snedden T.R.
        • Pierpoint L.A.
        • Currie D.W.
        • Comstock R.D.
        • Grubenhoff J.A.
        Postconcussion academic support in children who attend a primary care provider follow-up visit after presenting to the emergency department.
        J Pediatr. 2019; 209: 168-175
        • Giza C.C.
        • Hovda D.A.
        The new neurometabolic cascade of concussion.
        Neurosurgery. 2014; 75: S24-S33
        • Storey E.P.
        • Wiebe D.J.
        • DʼAlonzo B.A.
        • Nixon-Cave K.
        • Jackson-Coty J.
        • Goodman A.M.
        • et al.
        Vestibular rehabilitation is associated with visuovestibular improvement in pediatric concussion.
        J Neurol Phys Ther. 2018; 42: 134-141
        • Schneider K.J.
        • Meeuwisse W.H.
        • Nettel-Aguirre A.
        • Barlow K.M.
        • Emery C.A.
        Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial.
        Br J Sports Med. 2014; 48: 1294-1298
        • Gallaway M.
        • Scheiman M.
        • Mitchell G.L.
        Vision therapy for post-concussion vision disorders.
        Optom Vis Sci. 2017; 94: 68-73
        • Mucha A.
        • DeWitt J.
        • Greenspan A.I.
        The CDC guideline on the diagnosis and management of mild traumatic brain injury among children: what physical therapists need to Know.
        Phys Ther. 2019; 99: 1278-1280
        • Halstead M.E.
        • Mcavoy K.
        • Devore C.D.
        • Carl R.
        • Lee M.
        • Logan K.
        Returning to learning following a concussion.
        Pediatrics. 2013; 132: 948-957
        • Blackwell L.S.
        • Robinson A.F.
        • Proctor M.R.
        • Taylor A.M.
        Same care, different populations.
        J Child Neurol. 2017; 32: 327-333
        • Zuckerbraun N.S.
        • Atabaki S.
        • Collins M.W.
        • Thomas D.
        • Gioia G.A.
        Use of modified acute concussion evaluation tools in the emergency department.
        Pediatrics. 2014; 133: 635-642
        • Stache S.
        • Howell D.
        • Meehan W.P.
        Concussion management practice patterns among sports medicine physicians.
        Clin J Sport Med. 2016; 26: 381-385
        • Putukian M.
        • Riegler K.
        • Amalfe S.
        • Bruce J.
        • Echemendia R.
        Preinjury and postinjury factors that predict sports-related concussion and clinical recovery time.
        Clin J Sport Med. 2018; (in press.)
        • McCrea M.
        • Guskiewicz K.
        • Randolph C.
        • Barr W.B.
        • Hammeke T.A.
        • Marshall S.W.
        • et al.
        Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes.
        J Int Neuropsychol Soc. 2013; 19: 22-33
        • Williams R.M.
        • Puetz T.W.
        • Giza C.C.
        • Broglio S.P.
        Concussion recovery time among high school and collegiate athletes: a systematic review and meta-analysis.
        Sport Med. 2015; 45: 893-903
        • Kamins J.
        • Bigler E.
        • Covassin T.
        • Hnery L.
        • Kemp S.
        • Leddy J.J.
        • et al.
        What is the physiological time to recovery after concussion? A systematic review.
        Br J Sports Med. 2017; 51: 935-940
        • Henry L.C.
        • Elbin R.J.
        • Collins M.W.
        • Marchetti G.
        • Kontos A.P.
        Examining recovery trajectories after sport-related concussion with a multimodal clinical assessment approach.
        Neurosurgery. 2016; 78: 232-241
        • Lumba-Brown A.
        • Yeates K.O.
        • Sarmiento K.
        • Breiding M.J.
        • Haegerich T.M.
        • Gioia G.A.
        • et al.
        Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children.
        JAMA Pediatr. 2018; 172: e182853
        • Slobounov S.
        • Slobounov E.
        • Sebastianelli W.
        • Cao C.
        • Newell K.
        Differential rate of recovery in athletes after first and second concussion episodes.
        Neurosurgery. 2007; 61: 338-344
        • Eisenberg M.A.
        • Andrea J.
        • Meehan W.
        • Mannix R.
        Time interval between concussions and symptom duration.
        Pediatrics. 2013; 132: 8-17
        • Wasserman E.B.
        • Kerr Z.Y.
        • Zuckerman S.L.
        • Covassin T.
        Epidemiology of sports-related concussions in National Collegiate Athletic Association athletes from 2009-2010 to 2013-2014.
        Am J Sports Med. 2016; 44: 226-233
        • Nelson L.D.
        • Guskiewicz K.M.
        • Barr W.B.
        • Hammeke T.A.
        • Randolph C.
        • Ahn K.W.
        • et al.
        Age differences in recovery after sport-related concussion: a comparison of high school and collegiate athletes.
        J Athl Train. 2016; 51: 142-152