When student athletes and other kids take a hit on the head, coaches, parents and others often urge them to just shake it off — especially if they don't get knocked out.
"What we're finding is that a lot of people say, ‘I was told if he didn't lose consciousness, he must not have a concussion,'" says Gerard A. Gioia, PhD, chief of pediatric neuropsychology at Children's National Medical Center in Washington, D.C. "I tell them that losing consciousness only happens one in 10 times."
Correcting that kind of misinformation and educating kids and everyone in their lives about the realities of concussion is Gioia's mission: He wants kids off the playing field — and often out of the classroom as well — after even a minor concussion (see "Responding to head injury").
"About a decade ago, I started seeing more kids with ‘mild' traumatic brain injuries," says Gioia, who directs the Safe Concussion Outcome Recovery and Education (SCORE) program at Children's. "But for children and families going through this, concussion doesn't feel mild; it can be a life-altering event they're struggling through."
Since then, Gioia has taken a public health approach to helping those children and parents. He has conducted research on concussion's impact on kids' lives, including their academic performance. He has developed tools to help coaches, parents and others respond appropriately after an injury. And he has lobbied for state and federal legislation that would keep kids safe and help ensure their speedy recovery from concussion.
Gioia spends much of his time seeing his young patients. But soon after he arrived at Children's in 2002, he realized it didn't matter how great a clinician he was if children with concussions weren't coming in for care in the first place. Understanding of these injuries was seriously lacking, he says — even among physicians and other health professionals.
Armed with funding from the U.S. Centers for Disease Control and Prevention, Gioia and collaborators developed a series of toolkits designed to educate physicians, schools and those involved in youth and high school sports. Gioia was one of the primary authors of the "Heads Up: Brain Injury in Your Practice" toolkit, which includes a standardized form for evaluating acute concussion plus a care plan.
The toolkits and other materials are available online, where there are also a list of frequently asked questions and a video aimed at coaches and parents. Coaches can also order a sticker designed to go on the back of a clipboard, which lays out signs of concussion and a response plan.
Gioia's latest project is a smartphone app that walks parents, coaches and anyone else through what they should do if they suspect a child has a concussion. The "Concussion Recognition and Response" app even logs the users' responses, so that information can be emailed to parents or the child's pediatrician.
"We're not asking you to diagnose; we're asking you to respond," says Gioia. "It's like calling 911 if a friend starts to breathe heavily, sweat profusely and clutch his chest. You and I aren't qualified to diagnose a heart attack, but we can recognize possible signs and take action."
Gioia has also joined with former San Francisco 49er Steve Young in a Safe Kids webcast on sports safety.
Concussion in the classroom
These days Gioia's message has a new twist: Sometimes it's not enough just to pull kids off the soccer field or basketball court after they've had a blow to their heads. In some cases, kids may need to take a time-out on academics, too.
In one study, which he's preparing for publication, he and his colleagues found that almost 90 percent of patients with concussions reported that their symptoms worsened when they went back to school. Exerting their brains too soon after their injuries made their headaches worse, tired them out and left them irritable and unable to concentrate. In another study, the researchers found that math is the hardest subject to manage post-concussion.
The more students continue to over-exert their brains, says Gioia, the more likely they are to worsen their symptoms and delay their recovery.
"I tell people it's like jumping up and down on a bad knee," says Gioia, who began his career as a school psychologist. "If you do that day in and day out, you're not going to allow that knee to recover."
These findings underscore the importance of focusing not just on helping student athletes get back in the game but also managing their return to school very carefully, says Gioia. Schools need to understand concussion and how it can affect academic performance and then put appropriate supports in place, he says.
Depending on the severity of the injury, says Gioia, parents should consider keeping their children out of school for a day or two and monitoring kids at home to see how well they can manage basic activities. If they're sleeping 12 hours a day or can't concentrate for more than a few minutes, says Gioia, they should not go back to school. Once children do return, teachers should allow them to put their heads down on their desks or take breaks during class. For more serious cases, home- or hospital-based instruction might be required.
"We don't put kids with sprained knees in wheelchairs; we allow them to walk and do things up to the point where their symptoms start to worsen," says Gioia. "It's the same thing with school."
A legislative imperative
In addition to raising awareness, legislative action is another priority for Gioia, who credits growing up with a politically active mother in New York City for his activism.
At the state level, Gioia has offered testimony in Maryland's General Assembly, Virginia's General Assembly and Washington, D.C.'s City Council. His goal? To get every state to pass legislation based on three core principles.
First, the legislation would require states to create programs to educate kids, parents, coaches and schools about concussion. It would require schools to adopt a "when in doubt, sit it out" rule, so that players showing signs of concussion — stumbling, looking glassy-eyed or having trouble remembering plays, for example — get pulled from the field. And it would require that kids with concussions return to the game only after they've been evaluated by a neuropsychologist or other health-care professional trained in concussion management.
Gioia has also testified before Congress in support of federal legislation that would not only address student athletes' safety but also make it possible for them to receive support in school for sitting out of sports until they recover. His testimony before the House Committee on Education and Labor last year prompted coverage by CNN, The Wall Street Journal, The New York Times and other media outlets.
That advocacy is already paying off. In Maryland, for example, a law passed last May requires the state's department of education to develop policies and education programs for student athletes, parents, coaches and school staff.
Christopher C. Giza, MD, who worked with Gioia on an evidence-based sport concussion guideline for the American Academy of Neurology, applauds Gioia's public health approach.
"When you're providing clinical care to patients one on one, there's a limit to how big an effect you can have," says Giza, an associate professor of pediatric neurology and neurosurgery at Mattel Children's Hospital at the University of California Los Angeles. "When you reach out to policymakers, educate the general public and educate other professionals, there's a ripple in a pond kind of effect. Your effort can spread to thousands or even hundreds of thousands of people."
People often ask Gioia if he'd like to see young people's participation in football and other potentially dangerous sports banned. Not at all, says Gioia, calling himself a proponent of "reasonable protection" rather than overprotection. Besides, he laughs, "you don't want to know what the world would be like if we cut out these activities!"
Rebecca A. Clay is a writer in Washington, D.C.
More information on Dr. Gioia's outreach is available online.
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