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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
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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
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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
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doi:10.4103/2152-7806.102945.
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