Mild Traumatic Brain Injury and Concussion in Infants, Children, and Adolescents: An Evidence-Based Clinical Guide

The Greek physician Hippocrates (≈460 BCE) described concussion in his medical and surgical text De Vulneribus Capitis (Wounds of the Head) as a state that occurs after a head injury, characterized by loss of speech and hearing. The term commotio cerebri (shaken brain), a synonym for concussion, was used in medical texts for centuries (Sandel, 2020, p. iv). The word “concussion” derives from the Latin “concutere,” meaning “to shake violently.”

Beginning in the early 20th century, mild traumatic brain injury was studied extensively in boxers (punch drunk syndrome), which was caused by repeated blows to the head (Martland 1928). However, the realization was slow in coming that the same injury to the brain could occur in football players and other hard-contact sports, causing early-onset dementia.

The World Health Organization (WHO) Collaborating Centre Task Force on Mild Traumatic Brain Injury (Carroll et al., 2004) offered the following operational definition of mild TBI (MTBI):

MTBI is an acute brain injury resulting from mechanical energy to the head from

external physical forces. Operational criteria for clinical identification include: (i) one

or more of the following: confusion or disorientation, loss of consciousness for 30

minutes or less, post-traumatic amnesia for less than 24 hours, and/or other

transient neurological abnormalities such as focal signs, seizures, and intracranial

lesion not requiring surgery; (ii) Glasgow Coma Scale score of 13–15 after 30

minutes post-injury or later upon presentation for healthcare.

The ASHA Practice Portal: Pediatric Traumatic Brain Injury (n.d.) provides the following description of mild TBI: (1) loss of consciousness for less than 30 minutes; an initial Glasgow Coma Scale (GCS) or Pediatric Glasgow Coma Scale (pGCS); or (2) score of 13 to 15 after 30 minutes of injury onset; and posttraumatic amnesia for not greater than 24 hours (CDC, 2017). (Note: Bruce and Dorney [2020] reported that loss of consciousness occurs in ≈10% of athletes with mild TBI.)

Recent guidelines support the interchangeable use of mild TBI and concussion. Mild TBI and concussion are often used interchangeably because concussion is considered a subtype or form of mild TBI (Didehbani et al., 2013). Although concussion and mild TBI are frequently used interchangeably, they may carry different connotations for families, researchers, and healthcare professionals, leading to misinterpretation (DeMatteo et al., 2010). The term concussion is generally considered preferable when speaking with patients, clients, family members, teachers, coaches, physical trainers, and others because of its familiarity with the public, and it is less threatening than the terms traumatic brain injury or mild traumatic brain injury; however, patients and family need to understand that a concussion is a mild traumatic brain injury (Tator, 2013).

Public concern has been growing about the short- and long-term effects of pediatric mild traumatic brain injury/concussion. This concern is amplified because mild TBI has the potential to go undiagnosed in acute care settings, placing children at increased risk for reinjury before complete recovery. In the United States, 70 to 90% of the 1.7 million annual traumatic brain injuries are classified as a concussion (Arbabi et al., 2020).  However, “mild” is a misnomer, as ≈20 to 50% of patients with mild TBI experience persistent problems lasting months to years after injury (Richter et al., 2024). General areas of impairment for mild TBI include physical, sensory, cognitive/executive functions, communication, emotions and moods, and behaviors. If only a small proportion of children with mild TBI have adverse outcomes, then this is a significant public health problem (Yeates & Taylor, 2010).

For decades, mild TBI was considered a functional disorder and plagued by reported "malingering," primarily due to a lack of structural imaging findings. The “invisible” nature of mild TBI, notably the lack of any external physical evidence of head or brain damage, was an important factor in the earlier impression of its inconsequentiality. Unfortunately, this resulted in the dismissal of the lived experiences of thousands of patients of all ages. More recent research indeed finds changes in neurophysiology, cellular communication, and microstructure.

 Concussion has long been within the scope of practice for speech-language pathologists (ASHA, 2016). However, the emergence of concern over the last 10 to 20 years about the cumulative effects of sports-related concussions shifted the focus from rehabilitation to prevention, to early identification and removal from play, thus involving coaches, athletic trainers, emergency department medicine, sports medicine, and pediatric medicine (pediatricians) (O’Brien et al., 2022).

Two populations that are considered high risk for mild traumatic brain injury/concussion are athletes who play in high-impact sports and the military, specifically those in combat. (Note: Approximately 15% of military personnel are under 21 years of age, with the Army having the largest number of individuals under 21 [Statista, 2023].) Although most research on children with mild TBI is on adolescents and the sequelae of sport-related injuries, more than one-third of concussions in this age group are caused by other factors (e.g., struck by an object, assault, motor vehicle accident, skateboards, bicycles, scooters) (Haarbauer-Krupa et al, 2018).

A concussion causes a shockwave (pressure wave) in the brain. When the head is struck or experiences sudden deceleration, the brain can move within the skull and collide with its inner walls. This impact can create a shockwave that propagates through the brain tissue. The shockwave's effects are not limited to the point of impact. The shockwave can be reflected and refracted by the skull and brain structures, causing damage in several regions. The more severe the impact, the greater the shockwave, which affects more brain regions. (Much like a bullet, the greater the speed of the bullet, the greater the shockwave it creates.) Even minor concussions can result in widespread neuronal death from pressure waves. The pathophysiology of concussion is involved and complex and can occur in just an instant (Al Mahmud et al., 2022).

Evidence-based screening, evaluation, and assessment of children and adolescents of three age ranges (1) infants, toddlers, and preschoolers, (2) elementary school and middle school, and (3) high school and college (late adolescents) is essential information for SLPs in a variety of settings: hospitals, schools, clinics, rehabilitation centers, and private practices. Observing a child across different settings, interviewing the child, parents, and teachers, and selecting standardized and nonstandardized (clinician-devised) assessments provide direction for treatment. Fortunately, SLPs now have several evidence-based treatment approaches for children and adolescents with concussions, always keeping in mind the need for multidisciplinary and interdisciplinary treatment.

The Centers for Disease Control and Prevention Guidelines on the Diagnosis and Management of Mild Traumatic Brain Injury (Ciccia et al., 2019) provide guidelines on the prevention, diagnosis, prognosis, and management of mild TBI in children. ASHA, in conjunction with a multidisciplinary panel of subject-matter experts (the Guideline Development Panel), developed guidelines to provide best-practice recommendations for delivering cognitive rehabilitation to adults with cognitive dysfunction associated with acquired brain injury (Brown et al., 2022). These guidelines may also be applied to children and adolescents with acquired brain injury and with appropriate age-related modifications. MacDonald (2017), in her article in Brain Injury, “Introducing the Model of Cognitive-Communication Competence: A Model to Guide Evidence-Based Communication Interventions After Brain Injury,” bridged the gap between evidence and practice by promoting a comprehensive and consistent view of communication competence for evidence synthesis, clinical decision-making, outcome measurement, and interprofessional collaboration. Several other guidelines and treatment approaches for mild traumatic brain injury in infants, children, and adolescents are provided in Fogle’s new book, Mild Traumatic Brain Injury and Concussion in Infants, Children, and Adolescents: An Evidence-Based Clinical Guide.

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