A fall at the playground, a nasty bump on a table edge – most children suffer a bang to the head at some point.
If concussion occurs – the telltale symptoms include loss of consciousness, a period of confusion or memory loss, and visual disturbances such as “seeing stars” – the official advice is that children are carefully monitored for 48 hours to ensure that it does not develop into anything more serious. If that time passes without incident, most parents tend to forget about the concussion and move on.
But scientists are learning more about how even seemingly mild bangs to the head can have long term effects.
Last week, researchers at the University of Stirling reported that repeatedly heading a football can trigger short term changes in memory and brain function. When players had headed the ball 20 times - as might be done in a routine practice - their memory was reduced by up to 67 per cent in the 24 hours afterwards. One of the authors suggested that football (or headers) should be avoided before an exam.
"The biggest problem is not necessarily the body’s inability to repair after a blow to the head, but the way the incident is managed socially and emotionally"
“It takes 24 hours to recover - so I would say that, for that 24 hour period, if you’ve got something important coming up, you shouldn’t play football,” said neuropathologist Dr Willie Stewart.
That research followed a study earlier this year in the prestigious PLOS Medicine journal, which found children who suffer a brain injury, such as a concussion from a fall or playground accident that requires a visit to hospital, are less likely to do well at school and can even be at an increased risk of early death. The UK, US and Swedish researchers analysed more than a million people under 25 and found that those who had suffered a traumatic brain injury were less likely to gain secondary school qualifications, more likely to receive a disability pension and almost twice as likely to have been admitted to hospital for psychiatric reasons.
Given that in England alone, more than 33,000 children under 19 were admitted to hospital with head injuries in 2013-14, the findings will be worrying for parents.
“Of the million or so head injuries we looked at, more than 80 per cent did not experience any of these outcomes,” says Prof Seena Fazel, one of the study’s authors. “These problems affect a minority of people.”
Antonio Belli, professor of trauma neurosurgery at the University of Birmingham, says that it depends on the type of the injury suffered – and the person it happens to. “We’re all wired differently and have different vulnerabilities. With minor injuries, I wouldn’t really expect significant long-term problems. But there are a minority of people, particularly children, who can develop long-term problems, often if they have a pre-existent vulnerability.”
The biggest problem is not necessarily the body’s inability to repair after a blow to the head, but the way the incident is managed socially and emotionally, says Prof Belli. After concussion, some people can develop short-term difficulties, such as memory loss or struggles with multitasking and processing information. This is due to internal cell damage in the brain, meaning signals cannot travel to the nerves as fast as they should. Typically, these problems can clear up after a number of days or weeks but, particularly in a child, they can cause a spiral of problems that may lead to academic failures, mental health problems and disabilities.
“When these difficulties aren’t managed properly, the child can develop a loss of confidence,” says Prof Belli. “They can fall behind with the curriculum and struggle, especially if they were used to performing well. It can result in issues such as anxiety and a loss of sleep, which can have a vicious cycle of psychological effects.”
A mild traumatic brain injury, such as concussion after a fall, can be “entirely reversible” and will have no “long-lasting effects” – so long as victims are given the support they need, whether that is ensuring they have time off school or providing consultations with educational psychologists.
The other major obstacle to recovery is repeated injury, a particular risk in contact sports, such as martial arts or rugby, as a child who has hit their head may be injured again. In March, 70 doctors and academics called for a ban on tackling in children’s rugby matches because the repeated injuries sustained – including those to the head – could cause lifelong consequences. If the brain is hit once, it can often repair itself, but a second hit can lead to an accumulative effect where inflammation builds up around the cells, amplifying the damage.
In a worst-case scenario, the brain tissue may not heal, says Prof Belli. “The cells can get beyond repair, so nerves will degenerate and you can lose function and brain tissue,” he says. “That manifests itself with symptoms such as irritability, depression, personality changes, memory loss and cognitive problems.”
“Prevention is key,” says Prof Fazel. “If your child is dazed or concussed, or loses consciousness, make sure they don’t rush back into whatever they were doing.”
For adults, the long-term effects of concussion are similar, though they are less at risk than children, who are more vulnerable because their bodies are still developing. Adults should still seek medical help after concussions and monitor their behaviour, taking time to return to work if they are struggling after a blow to the head. Like children, they should make sure they avoid repeated injuries.
When repeated injury is avoided, and post-concussion effects are properly managed, experts are confident that long-term effects can be prevented. They urge parents to monitor their child after a mild traumatic brain injury, looking for issues such as balance problems and changes in behaviour, and reporting them to their doctor. If there has been a loss of consciousness, vomiting or difficulty speaking, seek medical help.
If a child is experiencing short-term issues, Prof Belli suggests speaking to their school, to discuss changing their schedule and homework routine to ensure they have time to recuperate. In some cases they may need to be referred to educational psychologists who can help create new ways for them to learn.
Parents may also worry about a child returning to sport, for example playing cricket if a ball gave them concussion, but Prof Belli says: “You have to balance the risk of brain injury with that of inactivity and social problems. We don’t want to stop children doing sport.”