There has been a huge amount of publicity over the last 5 years regarding concussion, due to increased recognition of head injury at the NFL level. Some of the work that Dr. Constantine has done has increased recognition of sports-related concussion in the media. This work has led to many legislative changes, including big changes in the Pennsylvania state law. Despite the fact that there is a long way to go, all of this has led to improved safety standards and we are moving in the right direction. However, there are some challenges with respect to pediatric concussions. It is understood that athletes cannot be trusted to explain what is wrong with them. So, often times, a fundamental problem of dealing with this injury can be the players concealing their symptoms. Athletes often lie about their symptoms, not only at the professional level but also at all ages. This may include younger children who will not say if they have a headache because if they admit to the headache, they will not be able to attend the following game.

This concealment starts at an early age and culminates in professional sports. An USA Today article published on Dale Earnhardt describes the common issue of the athlete being the last person to admit that something is wrong with him or her. In motor sports especially this is a problem because a driver may be inches apart from another driver’s wheel going 220 mph. Some of the other drivers do not want to be on the track with someone who has a concussion. To put it mildly, the diagnosis can be tricky, and the misdiagnosis of injury is very common. For example, labs can elaborate a disease but diagnosing a concussion is more like trying to interpret the moods of an Irish setter that this presents an enormous challenge.

The reason that I got into management of concussions over 25 years ago was because of this dilemma of having people who were understood to be injured, but would not admit that they were injured and to find technology that could prove this. Initially, I started at the NFL level with the Pittsburg Steelers, but our major concern now is obviously with children since they are a precious commodity. Most concussions occur in children, and even though a very small number of child athletes make it to the college or professional level, almost everybody plays sports as a kid. Their exposures/risk of concussion is therefore higher and it has been found that their brains are more vulnerable than adults. Some of the work that Dr. Cantu and others have done over the years solidifies that brain injuries can seriously interfere with a child’s development leading to serious problems in school. Dr. Joy discussed that children will often deny their symptoms, even after they are educated on what symptoms to look for and how to report them. It is important to always be cognizant of this fact.

There is also the issue of second impact syndrome [1], which is a very disturbing rare condition that many people believe is something we need to be careful about in children. There are a number of videos showing kids playing tackle football. First of all, there can be a long discussion about whether or not kids should be playing tackle football and ramming into another child at high speeds since he probably does not have the strength to hold his head erect. But, this happens all the time. I work a lot in these sports in Pennsylvania and particularly in western Pennsylvania in the Pittsburg area. In this area, people start playing tackle football at age 6. Now when I was a kid, it was age 8 and philosophically, I have a problem with that. For example in baseball, kids in t-ball are learning skills on how to hit off the tee. But for kids this age in football, they get thrown into situations where they can have a significant impact on their health. This is why working with children is so important for the sake of their safety as well as for their physical and psychological well-being.

From the standpoint of being a neuropsychologist, these are some of the symptoms that have been found in athletes, specifically high school and college athletes. Other researchers have done similar studies and have found pretty much the same thing [2]. Headaches are always the number one symptom seen in most of the concussion studies. Symptoms of feeling slowed down/sluggishness, difficulty concentrating, fogginess, and memory dysfunction have to do with the cognitive systems in the brain. This area specifically is where neuropsychological assessment is particularly useful because these symptoms are things that athletes are not very good at reporting or being aware of. This cries out for a tool that can help manage the cognitive aspects of injury. Setting the research bias aside, the symptoms that athletes are likely to have in terms of these four general systems must be thought about. This was done by factor analysis and what is observed is that the system constellations hanging together have more of the migraine type of symptoms.