Sarah Hull

Concussions and Age

Concussions are a type of TBI, or traumatic brain injury. They are caused by a bump or

blow to the head that, at times, can seem to be insignificant. However, the symptoms of a

concussion can show up from a day to weeks after the trauma to the head. The amount of force

behind the bump or blow has little meaning in terms of damage that can be done. Each person

has his or her own level of ability to cope with a blow or bump. Some people may never receive

a concussion from bumping their head on a shelf while others could be affect by that minor

bump. Either way, concussions are a large problem in society that has only recently received

attention from researchers. Many studies are being conducted both for sports and non-sports

related concussions and the implications they have on lives. Researchers have looked at a wide

variety of information ranging from the lasting effects of a concussion to the short-term costs of

receiving a concussion. Other researchers have taken on the task of conducting research on those

people who have received multiple concussions and are now living with those consequences.

One particular area that, while lacking in collective research, is still interesting to look at is the

effects of concussions on different age groups.

The majority of the focus for age groups that suffer from a concussion are the

adolescents. This is because adolescents have the highest rating of athletic activities, whether

this is related to organized sports or non-sports related functions. Either way, adolescents have

received a higher amount of attention when the topic of concussions is brought up for debate.

Researchers have attempted to study a variety of age ranges, though not many of the elder age

groups - those around six-five and up - have been study because concussion related problems

may also be linked to their memory loss or balance problems. There are conflicts among the sets

of research data for the different age groups. Different studies have different conclusions, each

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containing support for their reasoning. Some say that there is a difference between the short and

long term effects of a concussion between different age groups, while other research claims the

exact opposite of there being no difference. For those who say that there is no difference, the

main point they place on the table is that a brain injury is a brain injury, and anyone who suffers

from a TBI is at the exact same level of danger. Even if symptoms are not noticeable, there is

the possibility of damage that can remain undetected which leaves many questions unanswered.

On the opposite of that argument, researchers have different tests that they have used in order to

detect a difference in age groups with concussions. The majority of the tests are the same within

their core. For example, memory tests may have different names or rules, but they still test the

short term memory of the subject. All of the research that saw a difference in age groups agree

on one significant point; adolescents - those between the ages of ten and nineteen - suffer from a

broader range of symptoms when compared to children and adults. These symptoms also

appeared to have lasted for a longer amount of time.

According to the CDC, the age group that has the highest amount of visitations to the

hospital because of TBI are the fifteen to twenty-four year olds (Centers for Disease Control and

Prevention). The only group who exceed that age group was the four and under age group.

While children have been looked at for concussions within research, those who are four and

younger are unable to do many of the tests without the help of an adult—standing in one place

for a long period of time or memory tests that require a higher knowledge of language.

Typically, researchers look at age groups that ranged from elementary school all the way up to

those who have established themselves within the career area. Researchers use the different test,

as mentioned before, and separate the subjects based on both oral report and medical history.

Many of the concussions have been reported and diagnosed from a doctor beforehand, then those

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subjects are brought in for testing and compared to either their own baseline or a control group

who suffered no concussion.

Many of the tests that medical and psychological professions use have different names,

but the premises are the same. The most popular test for a concussion, both before and after, is

the Baseline ImPact. VCU Children’s Hospital and outreach clinics offer ImPact (Immediate

Post-Concussions Assessment and Cognitive Testing) to their patients (Virginia Commonwealth

University Children’s Hospital handout). They recommend having every child take this

preliminary test in case of an emergency in the future. Other children’s hospitals are offering the

test as many professionals recommend all children taking the test every-few-years to keep the

scores up-to-date and to offer professionals a baseline in case a concussion occurs. The ImPact

is a test meant to evaluate a concussion, not cure a concussion (ImPact). The test is meant to be

taken before a concussion occurs to offer a baseline. If a concussion occurs, the person retakes

the test to evaluate the severity of the concussion. However, ImPact does point out the test is not

meant to replace the diagnosis of a professional, only aid in helping to define the severity of the

concussion. The ImPact looks at the person’s visual and verbal short-term memory, his or her

reaction time, and the individual’s processing speed. The tests include matching, word recall,

color matching, and others meant to provide professionals with a basic idea of the individual’s

capabilities. The ImPact test is not the only one recommended.

Two other tests that are recommended to be used are the King-Devick (K-D) test and the

Modified Balance Error Scoring System (BESS) (Benedict et al., 2015). The K-D test is a basic

test that measure eye tracking movements when looking at a picture. It focuses on where the eye

goes to focus in the picture and how long it takes a person to eye-track a picture. The BESS test

is a beginner test that looks at a person’s balance. The individual has to stand in three different

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positions, each for about twenty seconds with his or her eyes closed. The first position is foot-to-

foot, the second is on the least dominate foot, and the final position is heel-to-toe. The person is

allowed ten mistakes within the twenty-seconds. Both of these tests are not confirmations of a

concussion, but they allow professionals to have a starting point in diagnosing a concussion. The

test that is slowly becoming the most popular is the Baseline ImPact test. This is because an

individual’s scores are compared to each other rather than with a control group. Since everyone

is affected differently by a concussion, the ImPact allows for a doctor or a psychologist to see

how much the person is affected by the concussion.

However, no matter the test, they all measure the same functions such as physical

attributes like balance and eye-tracking abilities, and psychological attributes like word recall,

reaction time, and short-term memory. All of the studies had similar tests, though many picked

ones that resembled the ImPact. The studies either compared the participants to a control group

or to the participants own scores. Those test that shows possible age-related differences tended

to compare post-concussion scores between the groups without a control group. However, there

still was a difference within the tests, such as in Melvin Field’s experiment.

Melvin Field and his associates completed an experiment between college age athletes

and high school aged athletes. All of the participants had completed a Post-Concussion

Symptom Scale test to create a baseline before entering the sports season (Field, M., Collins, M.

W., Lovell, M. R., & Maroon, J., 2003, p. 4). The researchers took that baseline information and

had the athletes complete another assessment of the Post-Concussion Symptom Scale after seven

days post-concussion. The results showed high school students reporting a significant increase

in post-concussion symptoms while college students showed a net decrease in post-concussion

symptoms. Field and his associates pointed out that this was one of the first experiments and

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papers that focused on possible age-related differences with concussions (Field et al., 2003, p.

10). Since the majority of the results were based on self-report, the experiment was not meant to

be a conclusive paper. Rather, it was meant to open the door to whether or not baseline testing

should become a requirement for all sports and ages. Field and his associates do not claim their

experiment proves there is a difference between ages and concussions, but they do suggest that

age may have an impact on how a concussion affects a person and how long recovery may take.

In a study conducted by Peter Benedict and associates (2015), they examined both sports

related and non-sports related TBIs. Their patients came from outreach-patient care clinic. The

tests that Benedict and colleagues used were for vision, the King-Devick (K-D), and balance,

Balance Error Scoring System (BESS)—tests that are recommended to be used right after a

concussion has occurred (Benedict et al., 2015). The researchers took the information from

about 206 patients of different ages and genders, then compared the results with each other. The

final results from this comparison showed that between both male and female there was not

much difference in results, or any correlation that could be seen between the amount of

symptoms and the gender of the subject. However, when they compared ages together there was

a correlation between the subject’s age, and the number of symptoms and the severity of those

symptoms. As the age of the subject increased, the scores on the tests decreased showing an

association between older subjects as suffering from a higher severity and broader amount of

symptoms. However, Benedict and his associates did mention that sideline assessments have not

been widely investigated as indicators of the level of severity for a concussion. Even with this

fact, the comparison did show a difference between ages and the amount of symptoms in a

subject.

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Annie Baillargeon, Maryse Lassode, Suzanne LeClerc, and Dave Ellemberg completed a

research study that suggests adolescents suffer from more persistent concussion when compared

to children and adults. Within the study, ninety-six male athletes were recruited who all had

suffered from a concussion about a year before the test, and who no longer reported any physical

symptoms (Baillargeon, A., Lassonde, M., Leclerc S., & Ellemberg D., 2012, p. 212). Overall,

each of the males who had average vision, and had not reported or had history of mental illness

and substance abuse, including alcohol (Baillargeon et al., 2012, p. 212). The males were

separated into age groups: 9-12, 13-16, and older. Half of the participants suffered from a

previous concussion while the others sustained no concussions. After the subjects were labeled

and place into groups, they were all placed through the same tests. There were seven

neuropsychological assessments that measured visual eye-tracking, short-term memory within an

oral and reading context, and response time in different contexts (Baillargeon et al., 2012, p. 213-

214). After the participants had completed the assessments, the results were compared between

each age group. Originally the researchers had assumed that children, based on previous

readings, would suffer from a worse outcome with concussions. However, the results from this

experiment are inconsistent with those beliefs. This study showed adolescents as being more

vulnerable to the effects of a sports-related concussion. One possible explanation that was at the

forefront regarding adolescents having a greater vulnerability is due to the frontal lobe

undergoing the final stage of development. Therefore, a blow to the head could be causing a

higher amount of damage during that critical stage of development (Baillargeon et al., 2012, p.

218). However, because the selection of subjects for the experiment was based on self-report,

there is no comparison of the baseline between the individual with himself, and not all the tests

were appropriate for the age groups though all groups took each assessment (Baillargeon et al.,

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2012, p. 218-219). To summarize this, while there are some flaws with the experiment, there is

evidence that concussions do affect ages different, and adolescents are the ones who have a

higher vulnerability for damage when compared to children and adults.

Scott Zuckerman and associates researched the amount of time it took adolescents and

young adults to return to baseline after a sports-related concussion. After gathering the results,

they compared the two groups together to determine who took the longest amount of time (days)

to show a recovery to baseline. The sample for the experiment included two-hundred athletes

who had already completed the Baseline ImPact test (Scott Zuckerman et al., 2012, p. 3). Of

those two-hundred, one-hundred were placed into a thirteen to sixteen year range, and the other

hundred was separated into an eighteen to twenty-two year range. Once a week, the participants

would retake the Baseline ImPact test and have their scores compared to the baseline scores.

Each participant was only compared with his or her own scores rather those within the same

group. After all participants had returned to baseline—their scores matched those taken before

the concussion—the scores were then individual and the average of each age group was

compared to the other age group. The results showed that those within the younger age group—

thirteen to sixteen—took several days longer to return to baseline than those in the older age

group—eighteen to twenty-two (Zuckerman et al., 2013, p. 5). Zuckerman and associates

pointed out that one possible confound within this experiment was the lack of a control for each

age group who had taken the Baseline ImPact test and did not have a concussion. However,

without the control group, the results to show that those athletes who do receive a concussion

and are within the younger age group do take longer to recover from a concussion than those

athletes who are older.

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Nigel King compared the results of twenty studies, out of seventy-seven papers, which

were related to his topic of interest (King, 2014, p. 743). Each of the final papers looked at the

post-concussion symptoms dealing with age. King analyzed and separated each of the

experiments into age groups and then compared the results of those studies. In his findings, he

discovered that those who were of an older age had a higher vulnerability of suffering from post-

concussion symptoms three to six years after the concussion took place (King, 2014, p. 746).

King offered one explanation stating that this vulnerability may come from neurological

processes having already been set within an adults mind. Younger ages are still developing and

the mind can cope easier with trauma while those who are older have already developed their

neurological processes. King, however, also said that post-concussion symptoms may be present

longer in older ages because of other psychological explanations, such as depression being more

prevalent in those who are older (King, 2014, p. 747). In conclusion, those who are older are

more likely to suffer from post-concussion symptoms than those who are younger.

Melvin Field and his associates were one of the first group of researchers who looked at

how age can affect the outcome of a concussion. Their results suggest that age does have an

effect, though there was not any conclusive ending as they clarified that the experiment. If the

experiment had last longer, they believe the high schoolers may have recovered faster due to

plasticity when compared to college students. However, the end results showed high schoolers

as self-reporting more symptoms post-concussion that college students. In the end, while their

experiment does not have a conclusive ending, there was some signs of age differences when

dealing with concussions. Benedict and associates, and King both show results that lean towards

those who are older in age are more effected by concussions that those who are younger. To

contradict these, Baillargeon and associates, and Zuckerman and associates collected results that

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show younger ages, specifically adolescents, are more susceptible to suffer a broader amount of

effects that are caused by a concussion. For Benedict and King, adults who have already fully

developed cognitively and physically are more likely to suffer damage because the brain has

been fully developed. Since the brain is fully developed, any damage sustained can cause

permanent damage which is hard to heal when the brain has already shaped itself. However,

Baillargeon and Zuckerman counter that argument by discussing how adolescents are more

vulnerable because their frontal brain is still developing, and any blows can cause damage and

hinder the brains development. All four research groups agree on the aspect that there is a

difference between ages when it comes to vulnerability after a concussion.

While those five suggest there is a difference in how a concussion effects different ages,

other studies show there is no difference between ages. Ann-Christine Duhaime takes on the

opposing argument and criticizes others in saying there is a difference. Duhaime points out that

many sports do not require their athletes to take a baseline test, and those that do have trouble

getting athletes to self-report symptoms as many do not want to be taken out of the sports. Since

many tests do require a self-report, those tests are not accurate and many can under-report the

symptoms he or she may be experiencing. Another criticism of Duhaime is that there is no set

definition for the term concussion (Duhaime, 2013, p. 535). The medical field lacks a uniform

definition for concussions and there is not set testing that is performed for those who have a

concussion. Without a uniform definition, there is a harder time identifying what does and does

not count as a concussion. Testing goes the same way. Different clinics and hospitals value

certain tests over others. This makes comparing data between ages difficult as many do not

always end up taking the same test. Duhaime also argues that age should not be a factor in how

a concussion is treated. Since a concussion is a type of traumatic brain injury, all head injuries

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should be confronted and treated with care. Each case is shaped to the individual as each

individual is affected differently. Age is not a factor because two children of the same age could

receive the same “type” of concussion yet have two very different set of symptoms and level of

severity (Duhaime, 2013, p. 535). She finishes her argument by stating age is not a factor in the

damage that can be caused by a concussion, any brain injury is traumatic and should be treated as

such no matter the age.

Another study that actually completed an experiment was done by Young Lee, Mitchell

Odom, Scott Zuckerman, Gary Solomon, and Allen Sills. Within their experiment, participants

were chosen based on age, thirteen to sixteen and eighteen to twenty-two, they were enrolled in a

high school or college sport, and the participants had completed two post-concussion ImPact

tests (Lee, Y. M., Odom, M. J., Zuckerman, S. L., Solomon, G. S., & Sills, A. K., 2013, p. 539).

The final sample size was 184 athletes with ninety-two in each age group, all of who matched the

previous requirements. During the experiment, the participants were measured for the number of

symptoms, the severity of symptoms, and the duration of post-concussion symptoms. The final

results showed no statistically significant difference between the age groups (Lee et al., 2013, p.

543). The age groups matched in terms of number of symptoms, the severity of those symptoms,

and the duration of those symptoms. On average, the age groups had the same amount of

symptoms with similar levels of severity, and the post-concussion symptoms showed a

significant amount of extinction after thirty-days for both age groups. The amount of time the

younger and older athletes took to return to symptom baseline had no significant difference. The

majority of people who were a part of this experiment were also a part of another experiment that

took place in 2012. That experiment, as listed before with Zuckerman heading the experiment,

concluded with there being a difference between ages with concussions. This experiment,

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however, contradicts Zuckerman’s original one by saying there is no difference. There are,

however, faults within this experiment. The faults are that the sample size was smaller than

preferred due to the strict matching criteria, the participants came from specific area of the

country, and the statistics were possibly too ridged (Lee et al., 2013p. 543). However, this

experiment does set forth the question of whether there is, in fact, an age-related difference in

concussions. Field and his associates did not find a difference between ages and how a

concussion effects each age group differently.

For both Duhaime and Lee et al., age did not show any effect on concussions. Duhaime

took on a medical side explaining people should not be looking for differences in ages. By

spotting these differences, people may begin to treat their own concussions as less significant

because of the age. This can cause those people to under-report their symptoms in order to

continue as they had. Duhaime advocates for the idea that all concussions should be treated as

traumatic brain injuries, and each concussions should be treated for the individual. Duhaime also

goes on to explain that age does not matter in cases where someone has received a blow to the

head because a head injury is still damaging no matter what age the person is. All cases need to

be treated with care. Lee and his associates back this up in their own experiment where their

findings show no difference with concussions and the age of the person.

Overall, the age of the person should not matter when it comes to concussions. Any

damage to the brain can hinder a person and cause post-concussion symptoms that are long-

lasting. In terms of treatment, each case should be treated individually and fit the individual

rather than the age. Since concussions are becoming a more prominent part of society as sports

become more popular, all head trauma cases should be treated with the utmost care because the

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brain makes people who they are and any damage to the brain can hinder a person no matter

what his or her age is.

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References

Benedict P. A., Baner, N. V., Harrold, G. K., Moehringer, N., Hasanaj, L., Serrano, L. P., Sproul,

M., Pagnotta, G., Cardone, D. A., Flanagan, S. R., Rucker, J., Galetta S. L., & Balcer, L.

J. (Jun 2015). Gender and age predict outcomes of cognitive, balance and vision tsting in

a multidisciplinary concussion center. Journal of the Neurological Sciences, Vol 353 (2-

1), 111-115. doi: http://dx.doi.org/10.1016/j.jns.2015.04.029.

Baillargeon, A., Lassonde, M., Leclerc S., & Ellemberg D. (March 2012). Neuropsychological

and neurophysiological assessment of sport concussion in children, adolescents and

adults. Brain Injury, 26(3). 211-220. doi: 10.3109/02699052.2012.654590.

Centers for Disease Control and Prevention. Rates of TBI-related Emergency Department Visits

by Age Group—United States, 2001-2010. 2014.

Duhaime, Ann-Christine. (2013). The challenge of matching across ages. Journal of

Neurosurgical Pediatrics, 12. 535-536. doi: 10.3171/2013.4.PEDS1396.

Field, M., Collins, M. W., Lovell, M. R., & Maroon, J. (February 2003). Does age play a role in

recovery from sports-related concussion? A comparison of high school and collegiate

athletes. Journal of Pediatrics. 1-15. doi:10.1067/mpd.2003.190

ImPact. (2015). The ImPact test. ImPact. Retrieved: impacttest.com/about.?The-ImPact-Test-4.

King, Nigel. (2014). Permanent post concussion symptoms after mild head injury: a systematic

review of age and gender factors. NeuroRehabilitation 34. 741-748. doi: 10.3233/NRE-

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Lee, Y. M., Odom, M. J., Zuckerman, S. L., Solomon, G. S., & Sills, A. K. (2013). Does age

affect symptom recovery after sports-related concussion? A study of high school and

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college athletes. Journal of Neurosurgical Pediatrics, 12. 537-544. doi:

10.3171/2013.7.PEDS12572.

Virginia Common Wealth University Children’s Hospital. (2015). Concussion clinic handout.

Zuckerman, S. L., Lee, Y. M., Odom, M. J., Solomon, G. S., Forbes, J. A., & Sills, A. K. (Oct

2012). Recovery from sports-related concussion: days to return to neurocognitive

baseline in adolescents versus young adults. Surgical Neurology International.

doi:10.4103/2152-7806.102945.