The Invisible Injury of Concussions

A neuropsychologist’s work identifies a responsibility to protect students from a sports culture that minimizes health consequences
BY DENNIS L. MOLFESE/School Administrator, September 2017

Dennis Molfese, shown with an MRI machine, sees a need for better communication between home and school during a student’s concussion recovery.
For years, athletes labeled concussions as “dings” and were told by teammates, coaches and medical personnel to “walk it off.” This reaction lingers today among youth who view concussions as badges of toughness and courage.

Unfortunately, such beliefs and practices place thousands of athletes at risk of brain injuries that can be life-altering. The Centers for Disease Control and Prevention reported 329,000 children, 19 or younger, were treated in 2012 for injuries that included a diagnosis of concussion.

A few years ago, I met a student who had once collapsed on the sidewalk as he walked home from high school. He’d suffered two concussions in a short period playing football. Although it was five months later, he could no longer find his bedroom in his own home and, sadly, he has not recovered.

A Fragile Organ
My work as a developmental neuropsychologist involving more than 45 years of research has deepened my understanding of the inter-relationships between a healthy or damaged brain and cognition, language, learning and sleep. What I can share with educators and trainers can guide school districts’ practices and policies.

Medically speaking, a concussion is considered a mild traumatic brain injury, the consequence of a blow to the head or upper body that snaps or twists the head. What people may not realize is how fragile the brain is. Its Jell-O-like consistency is easily damaged when the head rapidly rotates, disrupting connections between brain cells.

Concussions generally are believed to not involve gross structural damage resulting from having brain tissue ripped by jagged pieces of the skull. Instead, it usually results from a rapid rotation of the head and brain that causes shearing or stretching of brain pathways.

Although serious concussions are less common, permanent cognitive impairments and learning disabilities can have lifelong consequences for a young person’s future. Educators and coaches always ought to err on the side of caution, especially because young children and adolescents are in a critical period of brain development.

Prevailing Symptoms
Because a concussion is an invisible injury and symptoms may be subtle (such as slower processing speed), students do not always realize they have a brain injury. Teachers, coaches, trainers, medical personnel, students and parents should be on the lookout for symptoms.

The short- and long-term negative effects of a concussion include decreased attention and concentration, comprehension problems, increased irritability, depression and anxiety, persistent disabling headaches, balance issues and sleep disruptions. These symptoms can persist for a day, weeks, months or longer.

So far, scientists have not found structural changes in the brain due to a concussion, although my published work and other studies indicate the brain’s electrical activity is disrupted. Unfortunately, we still do not know which interventions can treat concussions successfully or how to accelerate recovery after a concussion.

No magic age exists after which a child’s risk of concussion decreases. In soccer, the current notion of allowing players to start practicing headers at the age of 14 is arbitrary. No data support this age marker.

Diagnosis Challenges
Diagnosing a concussion is difficult because no definitive medical or psychological tests are available. Concussion evaluations rely heavily on self-reporting of symptoms augmented by symptom checklists. Unfortunately, no single symptom or group of symptoms can predict the severity or duration of a concussion.

A child may report one symptom and experience it for a year or more, while another reports 10 symptoms that disappear after a few hours. Younger children (5- to 8-year-olds) are less able to be introspective and report symptoms or select from a list. An additional complication is that symptoms may not appear immediately.

Frequently, children and adolescents do not report symptoms. They may believe their symptoms do not warrant attention or they may fear ridicule or being shunned by their peers. Competitive athletes may hide symptoms to get more playing time.

When I was part of a review of concussion screening test histories at one college, we discovered senior athletes were advising freshmen to perform less than their best when taking the preseason ImPACT concussion screening test. That way, if a freshman experienced a head injury during a game, a repeat test on the sideline would show little change in performance and players could return to play, putting themselves at greater risk for a second and more severe concussion.

One critical problem K-12 school leaders face is both athletic trainers and physicians vary widely in their professional training and education on concussion diagnosis and intervention. I have seen adolescent soccer players experience six or more concussions over a season only to have their family physician clear them to return to practice and competition. All of these students had extensive learning disabilities and frequent headaches that marginalized their academic performance when formerly many were excellent students.

Another limitation is that only 37 percent of high schools employ athletic trainers for their interscholastic sports programs, according to the National Athletic Trainers’ Association.

A medical degree, a doctorate or trainer certification does not automatically qualify someone to accurately assess a child for a concussion. Instead, personnel must have certified training in concussion identification and intervention, as well as regular training updates to provide accurate diagnosis and effective intervention.

Safety First
Multiple concussions increase personal danger and can be life-threatening. Once students experience a concussion, they are more likely to have a second concussion. In addition, when the intervals between concussions decrease, the number of concussions increase, as does the severity and duration of the symptoms. The risk of death increases if a subsequent concussion occurs before previous symptoms have disappeared.

Such outcomes indicate that the brain becomes more vulnerable with each additional concussion, increasing the likelihood of permanent brain damage that will limit the young person’s ability to succeed and function fully in future years.

Unfortunately, sports helmets — even the latest models being introduced in hard-hitting scholastic sports — do not protect children from concussions, only from skull fractures. Ensuring that a student is pulled from play immediately after a possible concussion is critical.

Educators, coaches and medical personnel have a responsibility to intervene to protect students from a sports culture that tells players they are betraying the team if they stop playing after a potential concussion.

Brain Drain
Accommodations are an area that needs more attention. Our current system remains imperfect. Most students recover within 21-28 days of a concussion. While the symptoms may disappear during this time, the fact that the brain is more likely to experience a second concussion and the intervals between concussions get shorter as more are experienced, all suggest that the brain never completely heals.

However, during that time and perhaps beyond, teachers need to continually assess how much of a “cognitive load” students can carry. Often students find it difficult to focus continuously during a class and need more time between classes to help them cope with what the field calls “brain drain.”

Unfortunately, most teachers simply allow the child more time to complete an assignment. This assumes that extra time alone is sufficient, but it fails to consider the state of the child’s cognitive system for mastering new concepts. It also does not take into ac-count sleep disturbances that impact a child’s ability to concentrate for any length of time and that lead to microsleeps where the student “zones out” for seconds or even minutes at a time.

Teachers must build repetition into their lectures to prevent the brain-injured student from missing information because of attention, memory and concentration limitations.

Supporting students during recovery requires good communication between home, school and medical personnel. One fruitful approach is a concussion management team that includes teachers, coaches, parents and health professionals who develop lessons and athletic activities around the child ‘s current and changing abilities, strengths and weaknesses.

The key is to raise awareness of the danger of this invisible injury.
DENNIS MOLFESE, a neuropsychologist, is founding director emeritus of the Center for Brain, Biology and Behavior at the University of Nebraska-Lincoln in Lincoln, Neb. E-mail:

Additional Resources
Author Dennis Molfese recommends these informational resources to gain better insights into the neuroscience of concussion, management and treatment of prolonged symptoms.

» “High School Football’s Hidden Danger,” video produced by The New York Times in September 2007.

» “Sex Differences in Reported Concussion Injury Rates and Time Loss From Participation,” by Tracey Covassin, Ryan Moran and R.J. Elbin, Journal of Athletic Training, May 2016.

» “Sports-Related Concussions in Youth: Improving the Science, Changing the Culture,” by Committee on Sports-Related Concussions in Youth for the Institute of Medicine and National Research Council, National Academy of Sciences.