The Pediatric Concussion Compass: A Neuropsychological Guide for Parents, Educators, and Coaches

As a pediatric psychologist with a specialization in pediatric neuropsychology, I understand that the word "concussion" can trigger fear in any parent or caregiver.

Whether the injury results from a fall off a bike (one of the most common causes of head injury in children), an accidental tumble during play, or a collision on the soccer field, the primary question remains: Is my child okay, and what do I do next?

Pediatric concussion—or mild traumatic brain injury (mTBI) is a significant public health issue, impacting an estimated 2.7 million children annually.

While research has advanced rapidly, the successful recovery of a child depends entirely on a coordinated, informed team effort between parents, educators, coaches, and healthcare providers.

This guide is designed to empower you with the latest understanding, best practice guidelines, and a realistic perspective built on both caution and hope.

Part 1: What Exactly Is a Concussion? (Beyond the "Bump")

A concussion is best understood not as a major structural break in the brain, but as a temporary, functional injury—think of it as a temporary electrical or chemical overload that causes a momentary "glitch" in the brain's processing. Depending on many factors…acceleration, deceleration, torsion, angle and velocity a concussion (mTBI) can occur. The brain has some defenses as it sits in a fluid filled sac inside the skull.

But to put it in the terms my young granddaughters can understand, “your wonderful brain ’bounces’ inside your head”. Yes, you might say to your first grader, “that smart brain of yours just got ‘tossed around’”.

But to parents, the anxiety and fear legitimately emerges and to pediatricians, emergency medicine physicians, pediatric neurologists and pediatric neuropsychologists, we begin to immediately assess numerous risk variables, using algorithms and standardized measures as well as both the observable and reported presentation of symptoms in the child or teen.

Simply, a concussion is an injury caused by a bump, blow, or jolt to the head, neck, or body that transmits force to the brain, temporarily disrupting its normal function.

Crucial Fact for All Adults: Your child does NOT need to lose consciousness (be "knocked out") to have a concussion. In fact, loss of consciousness (LOC) occurs in only about 10% of play and sports related concussions.

Relying solely on this dramatic sign will lead to missed injuries, regardless of whether the injury happened during a simple fall on the pavement or playing full contact football.

Symptoms: The Three Domains of Disruption

Because a concussion is a functional injury, symptoms appear in three key areas. Watch for signs in the hours or even days after the event, as some symptoms may not be noticeable right away:

• Physical Symptoms: This includes headaches (the most common symptom), nausea, dizziness, feeling sensitive to light or noise, problems with balance, and fatigue.
• Cognitive Symptoms: Watch for trouble concentrating, feeling "foggy," difficulty remembering new information, or taking much longer than usual to complete tasks like homework.
• Emotional and Sleep Symptoms: A child might seem more irritable, sad, anxious, or nervous. Look for changes in sleep patterns, such as sleeping much more or much less than normal, or difficulty falling asleep.

Part 2: Immediate Action and Risk Management

Your priority as a parent, educator or coach is twofold: 1) recognizing the injury and 2) knowing when to seek emergency care.

The Non-Negotiable Rule: Immediate Removal from Activity

For parents, educators and coaches involved in the supervision of our children or adolescents’ activities, this is the “prime directive”:

If a concussion is even suspected, the child must be immediately removed from the activity. This is critical for two reasons:

1. Protecting the Brain: Continuing to play significantly increases the risk and duration of symptoms.

2. State Law: All 50 U.S. states and the District of Columbia have enacted laws requiring the immediate removal of youth from an activity if suspected of a concussion.

Caution: The severe risk of Second Impact Syndrome (a rare but highly dangerous complication of sustaining a second injury before the first one has healed) underpins this mandatory removal policy. Always err on the side of caution.

Knowing the Red Flags: When to Go to the Emergency Room

While most concussions can be managed by your pediatrician, certain symptoms require immediate transport and assessment in the Emergency Department (ED). The presence of any of these "Red Flags" indicates a potential emergent condition:

• Worsening Headache: A headache that gets significantly worse or more severe over time.
• Drowsiness/Loss of Alertness: If your child looks very drowsy or cannot be easily awakened (a change in their state of consciousness).
• Repeated Vomiting: Throwing up repeatedly.
• Changes in Mental State: Increasing confusion, extreme irritability, inability to recognize people or places, or unusual changes in behavior.
• Neurological Signs: Slurred speech, seizures, or weakness/numbness in the arms or legs.
• Neck Pain: Any severe neck pain.
• Medical Assessment Note: The initial assessment at the hospital focuses first on ruling out structural injuries (like intracranial bleeding).

Because a concussion is a functional injury, brain imaging (CT or MRI) is not routinely used to diagnose the concussion itself; it is only used if specific warning signs are present.

Part 3: The Recovery Plan: A Bit More Active, Not Passive

Important Change in “Best Practices”: One of the most significant changes in concussion management is the move away from complete "cocooning" (total darkness, no screens, no activity) that was common years ago.

Current “best practice” is a sequenced "Active Recovery”:

1. Initial Rest is Brief: Limit physical and mental rest to no more than 2 days. Beyond this brief period, prolonged rest can actually lead to negative outcomes like social isolation, anxiety, and worsening mood.

2. Gradual Return to Routine: After the initial 2 days, children should gradually return to non-sports activities as tolerated. Encourage low-intensity activities like listening to music or reading.

3. Screen Time: While prolonged screen time (like video games or extended internet scrolling) that worsens your child's symptoms should be limited, it is safe to return to normal screen use after the initial 2 days, taking breaks as needed. The key is to monitor whether the activity is provoking or worsening symptoms.

Part 4: The School Partnership: Return-to-Learn (RTL)

For children and adolescents, the Return-to-Learn (RTL) process is the most crucial step, and it must be successfully

completed before any return to sports or high-risk activity.

Academic performance is often the first functional domain to reveal persistent cognitive symptoms.

The goal of RTL is to use temporary accommodations to safely manage the child’s symptoms while gradually increasing their cognitive workload.

The ability to manage a full academic schedule without symptoms is the true functional benchmark for readiness.

Practical Accommodations by Educators

School professionals—teachers, counselors, and nurses—are essential partners. Accommodations should be individualized based on the symptoms:

For Cognitive Issues (Trouble thinking, slowed processing, memory problems):

• Reduce homework and class assignments, focusing only on the key tasks.
• Allow extra time on tests and assignments.
• Provide copies of class notes or outlines to reduce the demand for writing and visual tracking.

For Physical/Sensory Issues (Headaches, light/noise sensitivity):

• Allow frequent rest breaks (20–30 minutes) from demanding tasks.
• Offer preferential seating away from bright windows, glare, or noisy areas.
• Allow the use of sunglasses or request dimming of lights.
• Limit participation in noisy activities like the cafeteria or band.

For Emotional/Fatigue Issues (Irritability, sadness, anxiety, trouble sleeping):

• Allow frequent check-ins with a school counselor or trusted adult.
• Use flexible deadlines for assignments.
• Allow the student to eat lunch or take tests in a quiet, low- stimulus area.

Once a student can tolerate a full, unrestricted school day (including homework, tests, and all classes) without accommodations, they may then begin the graduated Return-to-Play progression.

Part 5: When Recovery is Protracted: The Role of Pediatric Psychology

Assurance: The vast majority of children recover fully, typically within four weeks. The median length of acute recovery for “sports mTBI injuries” in specialized clinics is often around 17 days. By six months, functioning is typically comparable to uninjured peers.

Caution: A significant minority (around 25%) experience Persistent Post-Concussion Symptoms (PPCS), lasting more than four weeks.

For this subset, specialized care from an interdisciplinary team—which ideally includes a pediatric neuropsychologist—is necessary.

Key Risk Factors for Prolonged Recovery

Identifying patients at higher risk for a longer recovery allows for earlier intervention. If your child exhibits these factors, early referral to a specialist is wise:

• Prior Concussion History: Having had previous concussions.
• Acute Symptom Severity: Having severe or a high number of symptoms immediately after the injury.
• Pre-existing Conditions: A history of anxiety, depression, or Attention-Deficit/Hyperactivity Disorder (ADHD).
• Anxiety, in particular, has been shown to be a powerful driver of prolonged symptoms, magnifying physical issues like headaches and dizziness.
• Adolescent females (age 13–18 years) are also noted to be at increased risk for prolonged recovery.

Targeted Treatment in PPCS:

As a neuropsychologist, I emphasize that both neurological/health factors and psychological factors can both contribute as drivers of a more prolonged recovery, not just consequences of the injury.

For children and teens struggling with PPCS, the brain needs more than just time; it needs targeted intervention. This can include Brief Neuropsychological Rehabilitation techniques (NPR) combined with Cognitive Behavioral Therapy (CBT). Together these are a highly effective, evidence-based psychological treatment, and can be adapted to treat children and adolescents with persistent symptoms. NPR/CBT works by helping children and parents:

Understand the Injury: Providing education that the symptoms are temporary and treatable (Psychoeducation and positive progress with neuropsychological techniques can rapidly improve both functioning and adjustment).

• Manage Fear: Identifying and replacing negative catastrophic thoughts (e.g., "I must have permanent brain damage") with realistic, healing-focused thoughts (Cognitive Restructuring).
• Return to Life: Developing structured plans to safely reintroduce activities and normalize sleep patterns (Activity and Sleep Management).

Successfully treating the residual neuropsychological symptoms as well as anxiety and mood symptoms that accompany concussion often leads to a significant reduction in overall physical symptoms, improving function and quality of life.

Summation: Caution, Assurance, and Hope

My Caution to All Adults: Remain vigilant about safety, from proper equipment fitting to enforcing safe play techniques. Always enforce the immediate removal rule for any suspected injury. And never rush the recovery process; the Return-to-Learn progression is the functional gateway back to a full, healthy life.

My Assurance and Hope to Parents: The future for pediatric concussion recovery is bright. We are no longer waiting it out in the dark; we are actively treating it.

The majority of young people recover fully and quickly. For the subset who face a longer road, we have evidence-based, specialized, multidisciplinary treatments available—including neuropsychological and psychological therapies—that effectively address persistent symptoms and restore optimal function, ensuring your child can return to the classroom, the neighborhood, the field, and a healthy life.

As always, if I can be of assistance, please reach out.

Dr. M