Concussions Among Adolescents
Concussions are a common injury among adolescents—about a fifth of adolescents report having at least one concussion in their lifetime. Sports are one of the more common causes of concussions, but concussions can occur in many different situations, from falls to car accidents.
Adolescence brings unique challenges to managing concussions; increasing responsibilities and greater independence through middle and high school can make it more difficult to navigate concussion recovery, academics, and social activities. While the adolescent brain is still developing, it is less adaptable than during early childhood, so it may be more difficult to recover after a brain injury. This makes managing a concussion properly as an adolescent crucial.
Contents
To adolescents: how to navigate life with a concussion
Sleep | Physical activity | Mental health | Screen time | Return to school and sport
To parents: supporting your adolescent
The first 24-48 hours at home | Returning to school | Supporting your adolescent |
Managing your own stress
To coaches: supporting adolescent athletes
Concussion best practices | Risk reduction | Recognition | Cultivating a supportive team culture
To teachers: supporting students
Return-to-learn | Creating a supportive classroom | Social impacts | Emotional health
To adolescents: how to navigate life with a concussion
Concussion recovery can be difficult to navigate. Different people may experience different symptoms and may be helped by different treatments. No matter your symptoms, your experience is valid, and there are resources to help.
This section will provide an overview of ways to care for yourself during your recovery. Specifically, we’ll talk about sleep, physical activity, mental health, and screen time, as well as the process of returning to school and sports after a concussion.
Sleep
Getting a good night’s sleep can be tough even without a concussion—you have to balance schoolwork and extracurriculars, not to mention time with friends and other social activities. Having a concussion can make it even harder to get good sleep. You may be anxious about your injury or stressed about keeping up with your responsibilities, and, on top of that, concussions themselves can cause sleep disruptions.
However, bad sleep quality after a concussion has been associated with changes in the brain that may increase concussion symptoms. So, it is important to do your best to get good sleep after a concussion. You do not need to be woken up every few hours. After the first 24-48 hours, it’s best to avoid napping during the day, as it is unlikely to help recovery.
Here are some things you can do to promote good sleep:
Aim to get 9-9.5 hours of sleep each night
Keep your sleep schedule consistent
Keep your sleeping environment dark, comfortable, tidy, and quiet
Using a sleep mask or earplugs can help with this
Avoid screen time 2 hours before bed
Avoid caffeine completely (coffee, caffeinated tea, energy drinks)
You may need to taper your caffeine consumption to avoid caffeine withdrawal headaches
If you are having trouble sleeping:
Consider taking melatonin (for short-term use)
Talk to your doctor about prescription medications to help with insomnia
See our resources on sleep and sleep hygiene for more information.
Physical Activity
You may have heard that the best thing to do for a concussion is to rest. This is not true. During the first 24-48 hours after a concussion, it is recommended to engage in relative rest, meaning that “activities of daily living including walking and other light physical and cognitive activities are permitted as tolerated.”
After that, it is best to begin gradually returning to normal activities, including physical activities, as your symptoms can tolerate it. In fact, research has shown that exercise early in recovery can actually lead to a faster recovery. Exercise should not significantly worsen your symptoms, but a small and temporary increase in symptoms is okay (1-2 points out of 10 that return to baseline within an hour of finishing the activity). Exercise has also been associated with lower anxiety and better sleep quality post-concussion—both of which promote recovery.
Graduated exercise therapy is a good way to put these recommendations into practice. Graduated exercise therapy involves following a personalized exercise plan which includes stages that progressively increase in intensity. If possible, it is best to work with a physical therapist to create and carry out your exercise plan. However, if you do not have access to a physical therapist, you can do aerobic exercise at home with a heart monitor. See our resource on aerobic exercise managed by the patient for more information.
Note: sometimes your symptoms may limit what kind of aerobic exercise you can do. For instance, a stationary cycle is a good alternative if you have significant neck pain, and recumbent stationary cycles are safer if you have significant dizziness or balance problems.
Be careful to avoid activities that may lead to another head impact.
Do not drive, ride your bike, use heavy machinery, or climb ladders until cleared by a healthcare provider. Reaction time, vision, and thinking may be affected by a concussion.
“Don't do activities with risk of falls or re-injury, play sports, do heavy chores or activities that could lead to another concussion or cause symptoms to worsen.”
Mental Health
Concussion recovery can be tough on your mental health. Not only do you have to deal with concussion symptoms and disruptions to your normal routine, you also may experience emotional effects from the concussion itself, such as mood swings, irritability, anxiety, and depression.
Research shows that concussions can both intensify existing mental health disorders and lead to the emergence of new mental health disorders. In turn, mental health symptoms can worsen concussion symptoms. With this in mind, it is especially important to care for your mental health after a concussion.
Here are some ways to care for your mental health after a concussion
Seek social support: Social support can be an important part of concussion recovery. A study conducted among high school girls found that social support aids in recovery by decreasing anxiety, increasing feelings of social inclusion, and providing validation. Close friends and people with a personal history of concussion may be especially well-equipped to support you.
Set realistic expectations for your recovery: Concussion recovery can take time, and is not always linear. Be patient with yourself and your recovery. Standard recovery time is four weeks; symptoms that last longer than that are considered persisting.
Experiencing persisting symptoms can be frustrating, but does not mean that you won’t get better. There are many ways to treat persisting symptoms—it’s just a matter of finding the approach that works best for you. If possible, it’s best to go to a multidisciplinary clinic so you can work with a team of specialists to determine how to best treat your symptoms.
Embrace identity change: You may feel like you’ve changed after a concussion. Maybe you can’t do the same activities you could do before, or maybe you can’t participate to the same extent. Be open to shifts in your roles and identity. Although this process can be stressful and difficult, it’s important to remember that identity change happens throughout your life, even without a concussion.
Identify coping strategies that work for you: Different people have different coping strategies that work for them. Think about what might help you feel better if you’re feeling worried or down. For example, you might consider journaling, mindfulness, creative practices, light physical activity, or talking with a friend.
Create a routine: It can be helpful to have a sense of structure during your recovery. Having a routine can also help maintain a consistent sleep schedule, which is helpful both for your mental health and for concussion recovery.
Talk to trusted adults: Concussion recovery can have a lot of moving parts—coordinating your return to school and sports, figuring out academic adjustments or accommodations, making doctor’s appointments, or even just learning about concussion recovery and self-care. It’s okay to ask for help with these things. Trusted adults can provide practical support during your recovery.
Seek professional support: Concussions can have a big impact on mental health. Don’t hesitate to seek support from a mental health professional if you’re struggling.
See our resource on mental health among high schoolers for more information.
Screen Time
Current international concussion guidelines recommend limiting screen time, including phones, computers, and TV, in the first 48 hours after a concussion. Research shows that patients who limited their screen time to 65 minutes a day for the first two days recovered twice as fast as those who did not limit their screen time.
After the first 48 hours, it is best to return to moderate screen time as tolerated—screen time can be a key source of social support, which is important for recovery. In fact, a recent study found that returning to moderate amounts of screen time after 48 hours led to milder concussion symptoms in the 30 days following injury than either very low or very high screen time. The study defined moderate screen time as 2-7 hours.
Return to School and Sport
It’s natural to be eager to resume your normal activities. However, it is important to follow return-to-learn and return-to-sport guidelines to make sure that you aren’t prolonging your recovery or risking further injury. These guidelines outline a step-by-step process for returning to school and sports safely.
Talk to your doctor, parents, teachers, coaches, and other trusted adults to arrange your gradual return to school and sports. They are there to support you. You will likely need to coordinate academic adjustments, accommodations, and a reduction or break from participation in school and sports during this time. This process can be tiring and difficult; it’s okay to ask for help.
Return to Learn Guidelines
Current guidelines recommend that you return to school as soon as you are able to tolerate engaging in cognitive activities without exacerbating your symptoms, even if you are still experiencing symptoms. In fact, complete absence from school for more than a week is generally not recommended.
Return to Sport Guidelines
You can start your gradual return to sports before completing your return-to-learn protocol, but you should be fully returned to school before you return to full-contact practice in sports. Keep in mind that you will need medical clearance before returning fully to athletic activity.
To parents: supporting your adolescent
Supporting your adolescent through a concussion can be confusing and stressful, especially at first. You may not know what to do or how to handle the situation effectively. That is okay.
This section will guide parents on how to properly care for an adolescent with a concussion. Specifically, we will go over what to do in the first 24-48 hours, the return to school process, persisting symptoms, and managing your own stress.
Go to the ER immediately if you see any red flags after a suspected concussion. In all cases, be sure to take your adolescent to see their pediatrician or other healthcare provider within two days of injury. Early intervention is linked with better recovery. Learn about concussion signs, symptoms, and “red flags” at the CDC website.
The first 24-48 hours at home
You may have heard that you should have your adolescent “cocoon,” or rest in a dark, quiet room until their symptoms resolve. This is not true. In fact, research has shown that cocooning impedes recovery. The newest guidelines recommend relative rest during the first 24-48 hours after injury. Relative rest involves engaging in light activities that don’t worsen symptoms, such as doing light housework, taking a walk, or hanging out with a friend. It is best to limit screen time to 65 minutes a day during this time. After the first 24-48 hours, your adolescent should gradually and safely increase their activity level.
Your available time to support your adolescent may vary. That is okay. Do what you can with the time that you have, and don’t be afraid to ask for additional support.
Returning To School
An adolescent shouldn’t be out of school for longer than a week. Helping your adolescent communicate with their teachers and coaches can take some stress off their shoulders, allowing them to focus on resting and recovering. Establishing a good relationship between your adolescent’s teachers and doctors can ensure that everyone is on the same page and can work together to create the best environment for your adolescent.
Accommodations and Adjustments are important to an adolescent's recovery. Be ready to talk with your adolescent and their doctor to determine what accommodations might be helpful in your adolescent's recovery. Adjustments, unlike Accommodations, are smaller temporary changes in the adolescent’s daily routine, workload, or environment. Accommodations are longer-term strategies to support an adolescent's learning and participation. They often require a note from a doctor. To learn more about adjustments and accommodations, see our section for teachers below.
Depending on their symptoms, your adolescent may be able to return to school after working out informal adjustments with their teachers, or they may need to go through the formal accommodations process.
Persisting Symptoms:
If your adolescent is experiencing persisting symptoms (lasting longer than four weeks), it may be necessary to establish formal accommodations with their school. Consider looking into a 504 plan or Individualized Education Program (IEP). These plans create formal support structures to get your adolescent the help they need to thrive in an academic setting as they rehabilitate their persisting symptoms.
Supporting Your Adolescent
Being supportive is very important, but being supportive doesn’t mean being a “Helicopter Parent.” It is important to find a good balance between giving your adolescent space and helping them through their recovery. “Helicopter Parenting” can increase stress and anxiety, which can exacerbate concussion symptoms. In fact, a study emphasizes that parents who engage in “helicopter parenting” can prolong recovery and worsen isolation and mental health issues. Furthermore, This approach may lead to your child holding information back and not sharing how they are truly feeling regarding the concussion recovery.
To learn more about the impacts of overparenting, visit our section on Overparenting.
Encouraging some independence in your adolescent’s recovery process can be helpful, allowing for a greater sense of control and promoting faster concussion recovery. As a parent, it is important to recognize the symptoms of a concussion and understand the impact having a concussion can have on your adolescent's life. Your attitude towards the concussion can have a big impact on how your adolescent feels about it. The best way to support them is to be a calming presence and be there for them when they ask for help. Listen to your adolescent and believe what they tell you about how they’re feeling.
If you are interested for more details, we recommend visiting these pages on our website:
Managing Your Own Stress
As a parent, you may be worried about your adolescent’s recovery. However, finding ways to manage your stress is crucial, as your stress can impact your adolescent’s recovery. In fact, a study has shown that a parent’s stress can prolong concussion recovery for adolescents.
Here are some strategies to manage your own stress:
Seeking support (joining a parents group)
Practice mindfulness and meditation
Doing some physical activity
For more stress management techniques, click here.
It might be tempting to push your adolescent back into sports and daily activities so they don’t fall behind, but it's crucial to prioritize their health first, making sure they are fully recovered before resuming any high-risk activities. Pushing them too quickly can lead to prolonged symptoms or further injury.
Read our page Concussion Management for Children and Adolescents to learn best practices for concussion management.
To coaches: supporting adolescent athletes
Sports are a common cause of concussions among adolescents. As a coach, it is crucial that you are aware of how to reduce concussion risk, recognize concussion signs and symptoms, and react when a concussion does occur. Lack of knowledge in these areas can be unsafe for your team, as repeated concussions have been associated with persisting symptoms. The Concussion Awareness Training Tool has a module for coaches that can provide you with additional knowledge in these areas.
Concussion Best Practices
Following concussion best practices is a crucial part of supporting athletes’ safety. Players with a suspected concussion should be removed from play immediately and assessed for concussion. Players who have sustained a concussion should follow return-to-play guidelines to safely return to their sport. Clearance from a medical professional is required before returning to full-contact sports. Repeated head injuries can be incredibly dangerous, especially for players who have not yet fully recovered from a previous concussion.
The Lystedt Law mandates the following:
Concussion education must be made available to for athletes, parents, guardians and coaches before the season begins
An athlete with a suspected concussion must be immediately removed from play
An athlete who has sustained a concussion must be cleared by a licensed medical professional to return to full-contact sports
Exercise can play an important role in concussion recovery. Indeed, early gradual reintroduction of physical activity during concussion recovery has been associated with lower symptom levels and faster recovery. However, athletes should not engage in physical activity that significantly exacerbates their symptoms or puts them at risk of further injury. Generally, an activity is too intense if it causes a symptom increase of more than 2 points on a 10 point scale or a symptom increase that does not return to baseline after an hour. Be sure to consult return-to-play guidelines and talk to injured players individually to work out a plan for their return.
Risk Reduction
Although you may not be able to prevent concussions altogether, there are steps you can take to reduce the likelihood of a concussion occurring:
Ensure that protective equipment fits properly and is up to date
Avoid (or limit) contact at practices
Wait until highschool to introduce tackling, heading, and other maneuvers that involve impacts to the head
Include neuromuscular training during warm-up
Educate yourself about reducing stigma among athletes, parents, coaches, and doctors
See our preventative measures resource for more information.
“There is not a safe time to hit your head repeatedly.”
Dr. Stamm is the author of The Brain on Youth Sports and a member of Concussion Alliance’s Expert Advisory Board.
Second-Impact Syndrome
Second Impact Syndrome is a rapid and catastrophic swelling of the brain that can occur if multiple concussions are sustained over a short time. It is rare, but it can cause permanent brain damage or death if it does occur. To reduce the risk of second-impact syndrome, be sure to remove players with a suspected concussion from play immediately.
Recognition
A concussion is a type of traumatic brain injury that can occur when the head, neck, or body experiences a blow, resulting in an impulsive force being transmitted to the brain that causes the brain tissue to stretch, compress, and twist inside the skull. This tissue movement causes a cascade of chemical changes in the brain and can stretch and damage brain cells—often on a level that is too small to see on standard imaging tests. These chemical and physical changes cause symptoms that can affect how a person thinks, feels, acts, learns and sleeps.
Diagnostic and screening tools currently rely on concussion signs and symptoms to identify concussions. As a coach, it is important to recognize those signs and symptoms, remove the athlete from play, and act accordingly. Click here for a detailed guide on concussion recognition.
See below for a list of concussion signs, symptoms, and red flags:
Image is comprised of excerpts from the Concussion Recognition Tool 6.
Cultivating a supportive team culture
Team culture can have a huge impact on athletes’ safety and concussion recovery. Athletes often experience pressure to play through injury or to return to play before they are ready. In fact, one study found that one-fourth of college athletes experienced pressure from teammates, coaches, parents, or fans to continue playing after a head impact. Notably, those who experienced these pressures expressed a lower intention to report concussion symptoms in the future, which could increase the risk of repeated concussions and second-impact syndrome.
Strive to make your team a safe place to report concussions and prioritize athlete safety over competition. Make sure that your team does not pressure athletes to play through injury or return to play before they are ready. As they feel up to it, encourage injured players to come to practices to observe and support their teammates, even if they cannot participate in drills or scrimmages. Be aware of the timeline and trajectory of concussion recovery—athletes should return to play gradually, and may take four weeks or longer to be able to participate fully in practices and games. Having a concussion can be an isolating experience, but cultivating these norms goes a long way to make players feel supported in their recovery.
To teachers: supporting students
Teachers are a very important part of a student’s concussion recovery process. Because concussion recovery is highly individualized, it’s important for teachers to work with their students, and any other supportive stakeholders, to understand their situation and create a plan that addresses their specific needs. This section will help teachers navigate the challenges associated with concussion management in their students.
Return to learn
The Canadian resource, Concussion Awareness Training Tool (CATT), provides resources and an interactive training to help teachers and students return to school. Their Return to Learn plan outlines four steps a student and their teachers can take on their return to school.
Identify a school contact
Identify the student’s support system
Identify the students needs
Create a Return to Learn Plan (RTL)
Return to learn (RTL) guidelines are designed to provide a structured approach to a student's return to academics. Since returning to school or a full course load too early might make a student's concussion symptoms worse, RTL guidelines are a more gradual step-by-step approach to returning to full school participation.
PedsConcussion is a living guideline for pediatric concussion that is regularly updated by leading experts from the U.S. and Canada. We recommend their return-to-learn protocol.
For more information, we recommend taking a look at the RTL section on our Concussion Management for Children and Adolescents page.
As concussion education has evolved greatly over the past few years, checking sites like PedsConcussion and CATT for the latest guidelines and resources will help ensure you stay updated with the most recent RTL protocols
Creating a supportive classroom
While a student may have returned to the classroom, that doesn’t mean that they have fully recovered from their concussion. Clearance from a medical or healthcare professional is not required to return to low risk at-school or at-home activities. Concussion recovery in adolescents can be a slow gradual process and easing back into their regular daily lives without significantly worsening their symptoms is an important part of that.
Teachers can help make this process easier by:
Implementing the learning accommodations recommended by doctors.
Working with the student and their doctors to set expectations for schoolwork and attendance.
Documenting recommendations for physical activity.
Monitoring symptoms and adapting accommodations and adjustments to support the student’s needs.
Students may come into the classroom with physical symptoms like headache, fatigue, or vision problems that make it difficult to read or watch videos; they may also have issues with attention, concentration, memory, and/or mood. CATT recommends that students should start their schoolwork at home, in a controlled environment, before even returning to the classroom.
Depending on their symptom and energy levels, students may need to start off with half days or lightened course loads to not overexert their brain. Depending on their recovery timeline and symptoms, students may not be able to fully catch up on all missed schoolwork or tests. Teachers can combine, shorten, or otherwise adapt assignments, give flexible deadlines, or exempt the student from some assignments altogether. Teachers may need to delay tests, and some students may require extra time or distraction-free test environments.
As the student recovers, they will need fewer adjustments and accommodations, and they will be able to work back to full days in school and a full course load.
Things you can do to adjust a student’s workload to help them ease back into school
Reducing, combining, or dropping homework assignments
Extending deadlines for assignments
Creating alternative assignments
Allowing students to use assistive technology in the classroom
Concussion Alliance has created an accommodations guideline for college students with concussions that lists potential accommodations and adjustments which can provide more insight on the different accommodations.
Despite being different, both adjustments and accommodations should be personalized to an adolescent's needs and address specific problems that the adolescent may have during the recovery process, like light and sound sensitivity. Here are some more examples:
Adjustments:
Allowing frequent breaks while doing homework or in class
Resting in a quiet, low light areas
Reducing your screen time
Accommodations:
Allowing students to wear sunglasses in class.
Extended time for assignments and exams
Allowing students to use assistive technology in the classroom (text to speech, etc.)
For a more comprehensive list and guidance, please take a look at these planning tools and accommodations guides for K-12 on our website.
Social Impacts
The social impacts of concussions may get overshadowed by the cognitive and physical impacts, but, in some cases, can prolong the recovery process of an adolescent. Maintaining social connections is important for the emotional well-being of adolescents returning from a concussion. Students with fatigue and sensory sensitivities could benefit from low stimulation activities, like small group classwork activities and quiet lunches. You could offer to host the student and their friends in your classroom during lunch.
Also, be aware of the stigmas surrounding concussions. Briefly educating the class on what a concussion is and encouraging peer support could be really helpful in creating a supportive environment. Consider facilitating a buddy system where classmates can help the recovering student take notes or keep them involved in student activities.
Emotional Health
Keeping an eye on the student’s emotional health is an important component in preventing mental health issues like anxiety and depression that can arise during recovery. Many students with concussion feel isolated during their recovery—they may not be able to participate in school or other activities and their peers may not be able to understand or relate to how they are feeling.
Bullying can be particularly dangerous for students with concussions, who are more vulnerable to physical harm and emotional distress.
Creating a supportive environment for students returning to school after a concussion is an important task. Teachers can play a big role in the recovery process by assisting the student in returning to academics and also helping the student return to social play as well. This approach not only aids in recovery but also supports students' overall well-being.
For more information, see our pages The Invisible Injury and Mental Health Among High Schoolers.