1. Concussion What do parents know? Dr. Kirstin Weerdenburg, MD FRCPC Associate Staff Physician Pediatric Emergency Medicine The Hospital for Sick Children, Toronto, ON

3. Outline Background Diagnosis & Management Parental knowledge research Information resources

4. Is concussion a problem? ~144,000 children/year present to Emergency Departments in the US CDC estimates 1.6-3.8 million sports-related concussions occur annually in the US WHO estimates 6 concussions per 1000

5. Is concussion a problem? Are these underestimates? – Many more children are treated by other health care providers or not at all – Head injuries/concussions also can occur during play, not in sport

6. What is a concussion? *Don’t need to lose consciousness*

7. What is a concussion? Brain-related signs/symptoms: – Headache – Dizziness – Vision changes – Confusion – “Feeling foggy” – Sensitivity to light/sound – Feeling sick – Sleep disturbances – Mood changes – Difficulty concentrating/remembe ring *Don’t know when each child will recover*

8. How is concussion diagnosed? Zurich 4 th International Consensus Statement on Concussion - cornerstone reference on diagnosis and management in the clinical setting Unfortunately, there are no tests that can diagnose concussion, not even CT/MRI

9. How is concussion managed? Immediately remove the child from play/sport Assessed by a licensed health care provider trained in the evaluation and management of concussion Graduated Return-to-Play/School

10. Why do we care about concussion in children? Higher risk for: – Post-concussive syndrome – various symptoms may last for weeks or months after the concussion – Second impact syndrome – second concussion occurs before healing from a first concussion has occurred, very rare but may result in death

11. What should parents know? Identify the possibility a concussion has occurred Remove child from play/sport and receive an assessment from a physician Follow Return-to-Play guidelines

12. What do parents know? Previous studies have shown: – Majority of parents have knowledge of concussion and that it is a brain injury, but their children were involved in high-risk contact sports – One quarter of adults were not aware of any symptoms or only one symptoms of concussion

13. What do parents know? Limited evidence on: – General parental awareness of concussion as a brain injury, which may lead them obtain information on recognition and management – Parental knowledge of concussion regardless of whether or not they are involved in sport – Parental knowledge of management and Return- to-Play guidelines

14. Our Research

15. What we wanted to learn more about? How did parental suspicion of concussion compare to physician diagnosis? What factors were consistent with parental suspicion of concussion and with physician diagnosis?

16. What we wanted to learn more about? How often are parents informed that concussion is a brain injury? How often are parents aware of correct management actions?

17. How we answered these questions? Asked parents of children age 5-17 years that came to our Emergency Department: – If their child had a head injury? – After describing the study, if they would like to participate by completing a survey? To determine physician diagnosis we looked in the child’s health record

18. How we answered these questions? Survey items: – Parental demographics – Child’s sport participation – Parental knowledge of concussion and its management – Child’s history of concussion – History of presenting head injury

19. What did we find? Head injuries (Dec 2012-Oct 2013) = 1979 Potentially eligible = 577 Enrolled = 495 Excluded = 1402 Refused consent = 82

20. What did we find? Parental demographics Female gender70% Age 31-50 years80% Completed post-secondary education85% Involved in an organized sport in the past or present 73% Experienced a concussion in their self or immediate family member 18%

21. What did we find? Child demographics Average age10.1 years Male gender62% Head injury occurred during recreational play vs. sport 70% vs. 30%

22. What did we find? Ability of parents to identify children with concussion compared with physicians was moderately limited – Children >10 years had increased odds of parent suspicion of concussion consistent with physician diagnosis – Children >10 years, past history of concussion and participation in contact sports had increased odds of parent suspicion of concussion

23. What did we find? 79% of parents recognized concussion as a brain injury 58% of parents more accurately recognized concussion as a brain injury without bleeding

24. What did we find? Consequences: – 71% were aware that their child might miss activities for weeks to months – 67% were aware that their child might miss school

25. What did we find? Management: – 92% of parents responded that they would stop their child from play and see a doctor Did not differ in children with sport and non-sport mechanisms – Only 32% were aware of Return-to-Play guidelines This awareness was significantly higher in children injured with in a sport (37%) vs. non-sport (24%)

26. What did we find? – Internet was the most common (43%) – Physician was the second most common (40%) – School was reported as a source in 15% Information sources:

27. What do these findings mean? Most parents recognized concussion as a potentially significant injury with the potential for short- and long-term consequences – Due to media attention on concussion? (Sidney Crosby, NFL)

28. What do these findings mean? Many parents reported that they knew to remove their child from play/sport and undergo physician assessment which is reassuring

29. What do these findings imply? Very important to encourage a high-degree of knowledge in recognizing this injury in parents May result in lower threshold of parents to remove child from play/sport and seek medical attention leading to early detection and correct management

30. What do these findings imply? Major role of physician, after confirming the diagnosis of concussion, is to provide information on longer-term management (Return-to-Play guidelines)

31. How can we improve a parent’s ability to recognize concussion? Knowledge Empowerment

32. How can we reach parents that do not seek medical attention? How can we further educate parents and their children? How can we provide the most accurate recommendations?

33. Knowledge Empowerment Multiple settings (schools, gym class) By other professionals (teachers, coaches) To parents of children of different age groups Multiple languages Increase children’s ability to suspect concussion in themselves as well

34. Knowledge Empowerment What can you do now? – Provide parents and children with information &/or links to existing excellent and credible parent-friendly web-based resources

35. Resources www.parachutecanada.orgwww.cdc.gov/HeadsUp/

36. Resources www.aboutkidshealth.ca

37. Resources DocMikeEvans - YouTube

38. Take Home Message Parents should have a key role in: – Identifying the possibility a concussion has occurred – Removing the child from play/sport and receive an assessment from a physician – Following Return-to-Play guidelines

39. Acknowledgements Dr. Kathy Boutis Dr. Suzan Schneeweiss Ellen Koo Pediatric Research Academic Initiative in SickKids Emergency (PRAISE) program & Johanna Crudden Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP)

40. Questions?