Traumatic Brain Injuries in Youths

Although a concussion is described as a mild brain injury, all brain injuries should be taken seriously, including concussions. Children and youths respond differently to brain injuries than adults. Traumatic brain injuries are the leading cause of death and disability in children, according to the Japan Neurological Society.

Types of Traumatic Brain Injuries

According to the Cleveland Clinic, concussions are the most common type of brain injury, accounting for approximately 75 percent of all traumatic brain injuries in a given year. If the trauma leading to injury results in unconsciousness that lasts 30 minutes or longer, the injury is classified as more severe than a concussion.

  • Level of Severity

    If the loss of consciousness lasts longer than 30 minutes but less than a day with associated changes on the head CT or brain MRI, the injury is a moderate traumatic brain injury.

    It becomes a severe traumatic brain injury if the loss of consciousness lasts longer than a day and there are associated changes on imaging tests.

  • Complicated or Uncomplicated

    If imaging tests yield results that do not show changes, the traumatic brain injury is considered uncomplicated. A complicated traumatic brain injury is accompanied by changes, such as bleeding in the brain.

  • Closed or Open

    A closed traumatic brain injury is swelling of the brain caused by a jolt or blow without associated penetration of the skull. In an open or penetrating traumatic brain injury, a foreign object has pierced the skull, such as a weapon or bone fragment from a broken skull.

  • Nontraumatic Brain Injuries

    A nontraumatic brain injury occurs from something other than a blow or a jolt, such as a loss of oxygen to the brain. This may occur in cases of drowning.

Signs and Symptoms of a Concussion

If you witness your child experience an accident that results in a sudden impact, such as a fall or a car accident, it is wise to suspect a concussion and watch for the signs.

According to the Mayo Clinic, even if you are unaware of such an incident, the following are telltale signs of a concussion:

  • Headache
  • Nausea and/or vomiting
  • Drowsiness
  • Temporary loss of consciousness (though this doesn’t always occur)
  • Slurred speech
  • Delayed response to questions
  • Dazed appearance
  • Repeatedly asking the same question

In small children, you may observe the following:

  • A dazed appearance
  • Irritability
  • Loss of balance
  • Excessive crying
  • Vomiting
  • Seizures

What should I do if I think my child has a concussion?

If you suspect your child has a concussion, seek immediate medical treatment. The severity of traumatic brain injuries is not always immediately apparent, and a prompt medical evaluation may prevent a worsening condition. After you return home, the Mayo Clinic recommends the following:

  • Require your child to take a break from all physical and mental activities that need a lot of concentration.
  • When your child is ready to return to school, advise the school that they may need a lighter load during recovery.
  • Do not allow your child to return to sports or other physical activities until approved by a doctor.

How are concussions diagnosed?

Your doctor will perform an examination and ask questions about the injury. They may perform some or all of the following based on their findings:

  • Examination of balance, coordination, and reflexes
  • An assessment of your child’s hearing and vision
  • Testing of your child’s strength and sensation
  • Assessments of your child’s thinking skills, such as memory and concentration
  • Imaging tests

The doctor will most likely perform imaging tests if your child experiences severe symptoms, such as seizures or vomiting, especially if these symptoms worsen. If imaging tests are necessary, MRIs are more favorable for children due to reduced radiation exposure. However, a CT scan may be ordered in certain cases.

Physical Symptoms

Your child may experience the following physical symptoms after experiencing a concussion:

  • Nausea and vomiting
  • Seizures
  • Loss of consciousness
  • One pupil larger than the other
  • Slurred speech
  • Extreme drowsiness
  • Headache or head pressure
  • Dizziness
  • Impaired balance
  • Double visions
  • Fatigue
  • Inability to awaken
  • Sleep issues

Cognitive symptoms

Until the brain heals, your child may experience the following cognitive difficulties, even after returning to school:

  • Difficulty concentrating
  • Memory issues
  • Confusion
  • Slower thinking
  • Delayed response to others

Emotional symptoms

Emotional symptoms following a concussion may be caused by the concussion itself or by your child’s response to the symptoms of the concussion. According to the Brain Injury Association of America, your child may experience the following emotional symptoms:

  • Mood swings
  • Anxiety
  • Depression
  • Lack of motivation
  • Restlessness
  • Difficulty controlling emotions

Signs and Symptoms in Infants and Toddlers

Concussions can be harder to recognize in infants and toddlers. The Benioff Children’s Hospital at the University of California in San Francisco has observed the following concussion symptoms in these age groups:

  • Irritability
  • Excessive crying
  • Behavioral changes
  • Loss of interest in activities usually enjoyed
  • Blank expressions
  • Increased crying when moving the child’s head
  • Loss of motor skills
  • Sensitivity to light, sound, or touch
  • Loss of appetite
  • Changes in sleep
  • Drowsiness
  • Difficulty concentrating
  • Confusion
  • Memory issues
  • Inability to answer questions

Severe Symptoms That Indicate a Cause for Concern

If you observe the following symptoms in your baby or toddler, you have a medical emergency, especially if the symptoms worsen:

  • Large bump or swelling on the head
  • Blood or fluid from the ears or nose
  • Robotic motions that may be seizures
  • Eyes to one side
  • Inability to wake up
  • Persistent vomiting
  • Corresponding neck injuries
  • Head pain
  • Convulsions


Treatment of psychiatric symptoms following concussion/mTBI should be based on individual factors and the nature and severity of symptom presentation. It may include physiotherapy, psychotherapeutic, and pharmacological treatment modalities.

Physical Rehabilitation

TBI may result in a decrease in short and long-term global health (physical and behavioral) and put them at an elevated risk for disability, pain, and handicap (i.e., difficulty with a return to work, maintaining peer networks.) Rehabilitation therapies like physical therapy, occupational therapy, speech-language therapy, and assistive devices and technologies may help to strengthen patients to perform their activities of daily living.


  • Initial education, long-term support groups (symptom-focused and process groups), family education, and social issues like financial, legal and transportation.
  • Virtual reality and videogaming-based therapy in treating balance, coordination, and cognitive issues like attention and concentration data are under larger scale clinical trials to prove efficacy.


  • Depakote, NSAIDs, and triptans: May be considered for headaches which are the single most common symptom associated with concussion/mTBI
  • SSRIs: Citalopram 10 mg daily for 1 week, then 20 mg daily if tolerated (up to 80 mg daily if needed). Sertraline 25 mg daily increasing weekly in 25 mg increments to a maximum dose of 200 mg/day for depression
  • Anticonvulsants: mood stabilization and seizure prevention
  • Atypical antipsychotics: for agitation and irritability with beta-blockers in severe cases
  • Dopaminergic agents: for concentration and focus
  • Cholinesterase inhibitors/cognitive enhancers for memory
  • Atypical agents: Buspar for emotional stabilization and Modafinil for focus.

General Guidelines for Using Medications

  • Start low, go slow, whenever medications are required
  • Rule out social factors first, such as abuse, neglect, caregiver conflict, and environmental issues
  • No large quantities of lethal medications, high suicide rate due to disinhibition
  • Full therapeutic trials, since under treatment is common
  • Minimize benzodiazepines (impairs cognition), anticholinergics (induces sedation), seizure-inducing (impedes neuronal recovery), and antidopaminergic agents
  • No caffeine (due to agitation and insomnia), no diet, herbal, or energy drinks (may precipitate aggression).

Other Considerations in Treating PTSD in Patients with mTBI

  • Present information at a slower rate
  • Use a structured intervention approach with agenda, outline, or handouts
  • In groups, ask “PTSD” to respond first, then ask others to respond
  • Allow free contribution, use refocus/redirection with a clear transition between topics
  • The therapist should avoid frustrating mTBI patients by forcing them to recall incidents that are only partially encoded.

Management of Sleep Dysfunction

Immediately following TBI, the difficulty in falling asleep and frequent waking is common; whereas, after several years excessive somnolence is more typical.

  1. Acute Phase less than 3 months: Provide education about concussion about changes in sleep quality and duration sometimes associated with concussion. Provide information on good sleep habits with specific suggestions to improve the quality and duration of sleep (regularly scheduled bedtime). Sleep medications may be helpful in the short-term. Zolpidem 5 mg at night, if poor results after 3 nights of therapy, increase to 10 mg nightly. Also, prazosin, with 1 mg at bedtime for 3 days, may increase to 2 mg at bedtime through day 7.
  2. Chronic phase: more than 3 months: Review current medications and other current health conditions for factors that might contribute to chronic sleep disturbances, including chronic pain or co-morbid psychiatric conditions. Consider sleep study to provide objective evidence of sleep disturbance and to rule out coexisting sleep apnea or other sleep disorders. Consider a course of cognitive-behavioral therapy (CBT) focused on sleep.

Hyperbaric Oxygen Therapy (HBO2)

Some researchers discussed the role of oxygen delivered at supraphysiological amounts in the treatment of TBI. A study published in 2010 included closed-head trauma victims with GCS scores of 3 to 8 after resuscitation, without effects from paralytics, sedation, alcohol, and/or street drugs. HBO2 treatment began within 24 hrs post-injury admission to hospital with a mild or moderate TBI compared the effect of HBO2 to normobaric oxygen. They found a significant post-treatment effect of HBO2 on cerebral oxidative metabolism due to its ability to produce a brain tissue PO2 greater than or equal to 200 mmHg (higher cerebral blood flow lead to higher PO2, lower levels of lactate by 13% compared to control group, and lower intracranial pressure). However, in severe TBI, it is not an all or nothing phenomenon but represents a graduated effect. Some controversy still surrounds the use of HBO2 due to the limitations of studies such as the lack of blinding to the intervention, cost, time-consuming practice, and the validity of the actual diagnoses of the patients with reported TBI and PTSD who had a subsequent improvement.


Studies have shown some controversy in the practicality of this practice depending on the patient’s characteristics (age, the initial GCS, the presence or absence of pupillary abnormalities, and CT-based classification of the severity of the injury). In general, there has been an increased belief that cooling the body to systemic temperatures around 34 C to 35 C, helps reduce secondary injury and improve behavioral outcomes. Studies have suggested that this occurs because of the ability of hypothermia to suppress the post-traumatic inflammatory response, in turn, preserving the blood-brain barrier and reducing the number of cytokines released as well as glutamate.

Medical Measures to Reduce Intracranial Pressure

Head end-of-bed elevation to 30 degrees, transient hyperventilation, hyperosmolar therapy, therapeutic cooling, and medically induced comatose state are some measures to reduce intracranial pressure. Some patients will need monitoring of intracranial pressure.

Surgical Measures to Reduce Intracranial Pressure

This involves the evacuation of intracranial hematoma or decompressive craniectomy.

Concussions and Sports

Brain injury is the leading cause of sports injury deaths, according to Stanford Children’s Hospital. Sports injuries account for 21 percent of traumatic brain injuries. Nearly 50 percent of sports-related injuries occur during bicycling, skateboarding, and skating events.

Brain Injuries and Car Accidents

During a car accident, the entire body, including the head, experiences strong forces with a high potential for concussions or more serious brain injuries. Concussions may happen during the following common car accident occurrences, according to Advantage Healthcare Systems:

  • Striking a solid object in the vehicle
  • Whiplash as a result of the head snapping forward, then backward while wearing a seat belt
  • Being thrown from a vehicle

Most of these would cause closed head injuries, but striking an object or being thrown from the vehicle could cause an open head injury.

Children Under 10

Children under the age of 10 have larger heads in proportion to their bodies, weaker necks, and thinner skulls. As a result, children under 10 who are thrown from a car will almost certainly land on their heads.

They are also more predisposed to skull fractures and brain bleeds. Head injuries are the leading cause of death in children in car accidents. The most important protective measures for children in cars are as follows:

  • Use the proper size car seat or booster seat. A 5-point restraint system is most effective.
  • Drive safely and obey traffic laws.

Falls and Head Injuries

Falls are the leading cause of traumatic brain injuries in children under 4, according to the National Center for Injury Prevention and Control. Effective childproofing is the most important means to protect against falls and head injuries in babies and toddlers.

  • Use straps to secure heavy furniture, such as bookshelves, to the wall.
  • Install padding on sharp corners.
  • Install window guards on windows above the first floor.
  • Use safety gates around stairs, avoiding accordion-type gates with large openings.
  • Never leave babies unattended on top of any piece of furniture.
  • Never leave a window open more than 5 inches.
  • Use slip-resistant mats in bathtubs and surfaces that could become slippery.
  • Secure area rugs to the floor using rubber padding or double-sided tape.
  • Keep floors clutter-free.
  • Ensure your child only plays on age-appropriate playground equipment with soft turf and supervision.
  • Avoid the use of a baby walker.

Parents and caregivers should remember that children are naturally curious and will explore the world around them. They are not aware of the danger of falling, even down a flight of stairs. They are unsteady on their feet. Never assume a baby cannot roll off of furniture. There is always a first time.

Safety Tips/Prevention

Most head injuries are preventable with a small amount of safety preparedness.

  • Require children and teens to wear helmets for dangerous activities, especially bicycling, skating, and skateboarding.
  • Make sure your child’s helmet is the correct type for the activity and fits properly.
  • Teach your children safety awareness with an emphasis on protecting themselves from head injuries.
  • Be a role model. Children who see parents wear helmets and practice other safety precautions are more likely to adopt safe habits.

For Parents

If you suspect your child has a concussion, assess the situation and look for the signs and symptoms of concussions. If you are unsure, err on the side of caution and contact a health care professional or go to the nearest emergency room.

For Coaches

If a player shows signs of having a concussion, such as a dazed appearance, unusual clumsiness, loss of consciousness, or vomiting, remove the athlete from the activity immediately and notify the parents. Do not allow the athlete back into the game until you receive clearance from the player’s doctor.

Teachers and School Officials

The CDC recommends that teachers who are aware that a student has experienced a blow to the head or a rapid jolt should watch for the signs of a concussion and promptly notify the parents if the child exhibits changes in thinking or function.

Students returning to school after a concussion may need additional accommodations, such as the following:

  • Rest breaks
  • Less time at school
  • More time to complete assignments
  • Additional help with schoolwork
  • Less time in tasks that involve reading, writing, and computer activities

Children are often frustrated with their difficulties and need patience and support while they recover.

The primary treatment is mental and physical rest. Since concussions impact brain function, the brain needs rest to recover. This means limiting mental activities that require intense thinking and concentration, such as playing video games, watching TV, reading, doing schoolwork, and using a computer.

Limiting physical activities ensures the injury is not exacerbated. A second impact before an existing concussion has healed can result in brain swelling, brain damage, paralysis, or death. Even a minor blow to the head can cause this. This is unique to young people under the age of 21.

An image of a young girl lying on a hospital bed with a bandage on her head, having received treatment for injuries sustained in an accident.


The recovery process varies for every child. The average concussion recovery time is 7 to 10 days, according to the Premier Neurology and Wellness Center, but if your child develops post-concussive syndrome, it could take months to over a year.

Post-concussive syndrome occurs when three or more concussion symptoms linger. These cases typically resolve within three months and require additional rest. In any case, a return to normal activities should always be gradual.

Returning to School

Concussions affect memory and attention during the recovery period. Children returning to school may need such accommodations as the following, according to the Brain Injury Association of America:

  • Additional time to complete work
  • Extra breaks
  • Allowing the student to record classroom instruction
  • Clear oral and written directions
  • Reduced emphasis on spelling and grammar
  • Additional time to complete tasks

The child may be traumatized. This can add to the difficulties with concentration and performance. In addition, the child likely remembers how much easier schoolwork was before the injury, and this may be frustrating.

Most doctors recommend returning to school approximately 2 to 3 days after the most severe symptoms have disappeared, according to the CDC. Patience is necessary. The student will still have challenges, and all students recover at different rates.

Returning to Sports and Activities

return to sports and physical activities should only be attempted after approval by the doctor. Even with medical clearance, it is important for your child to make a gradual transition back into sports. The CDC recommends the following 6-step procedure:

  • Back to school
  • Light aerobic activity
  • Moderate activity
  • Heavy, noncontact activity
  • Practice and full contact
  • Competition

If symptoms return upon the initiation of any step, the athlete should stop, rest, and start again with the previous step.

Long-Term Risks

A study by the Parkinson’s Foundation revealed that even a single concussion increases the risk of developing Parkinson’s disease or dementia later in life.

Increased Risk of Diagnosis After a Single Concussion

  • Parkinson’s disease: 57 percent
  • Dementia: 72 percent
  • ADHD: 39 percent
  • Mood and anxiety disorders: 72 percent

The risks of Parkinson’s disease and dementia increase with multiple concussions, according to the Parkinson’s Foundation.


Experts believe that multiple concussions and blows to the head cause the neurodegenerative disorder chronic traumatic encephalopathy (CTE). The condition can be officially diagnosed only after death.

A single concussion or even a few concussions have not been linked to cases of CTE. It requires multiple concussions combined with several sub-concussive blows.

Symptoms of CTE may include dementia, brain fog, personality changes, mood disorders, impulsivity, and aggression. It is a progressive condition. The symptoms vary for everyone. Researchers are not sure why these differences exist, but they believe it may be related to the region of the brain where CTE starts.