Earlier this year, my 11-year-old daughter got a concussion.She was sledding with her sisters on our property and hit her head against a tree. I saw the incident: Her sled turned midway through the run (they had built their own track) so she was going backwards, gaining speed. I could tell the way she hit the tree – with a whiplash-like velocity – that the impact was not your average bump to the head. A concussion is caused by the internal movement and distortion of the brain as it bounces around inside the cranium after an impact. This is different than, for example, getting hit in the head by a ball. In that case, the injury is caused by the force of the ball being directly transmitted to your skull. Science is taking big steps toward understanding the effects of concussion and, although much more research still has to be done, the results so far are worrisome. Until quite recently, it was thought that concussion from accidents in contact sports (such as American football) was a temporary malfunction rather than a permanent injury. This changed in 2005 when research by Dr. Bennet Omalu, a pathologist at the county coroner’s office in Pittsburgh, discovered a link between concussion and a degenerative brain disease called chronic traumatic encephalopathy, or CTE. His research showed that one out of five concussions leads to post-concussion syndrome, “a period of cognitive impairment that may last months, in which patients have headaches, unsteadiness and other problems.” In some cases it seems likely that repeated concussions lead to CTE. The results of his research with retired football players and subsequent fight between Dr. Omalu and the NFL is the subject of a recent film called “Concussion.” Although my daughter did not pass out or have other obvious symptoms of a concussion (such as vomiting or nausea, dizziness, confusion, or loss of memory) I didn’t rule it out. My experience with concussions is very limited - I have never had one nor have any of my four daughters. They are athletic but have chosen recreational sports such as swim team and dance as opposed to higher impact sports, like hockey, for example. I figured our risk for concussion was low. The girls ski and ice skate (wearing helmets) and we have never had an incident with sledding (no helmets) until that Saturday afternoon. We took it easy the next day and although she said her head hurt a little she seemed fine. When she came home from school that following Monday she complained of a headache. I figured this could be because she was recently sick with a bad cold and still had congestion – it could be sinus-related. Or, it could be a symptom of a concussion. As someone who tends to not worry too much, I decided to wait another day and see if she still had a headache. It was after school on Tuesday that I called the nurse at our pediatrician’s office. My daughter had gone to her swim team practice and I got a text from her saying she had to sit out after a half hour because of a terrible headache. The nurse recommended total “brain rest,” which meant no homework, no reading or writing, and no screen time. If her headache went away after that, it was most likely a concussion and we should come in the following morning to see a doctor. My daughter groaned, concerned about her grades and falling behind at school. Two hours later, she no longer had a headache. We were relieved and concerned at the same time. We knew she almost certainly had a concussion, but what now? A recent report in The Economist says that the underlying biology of a concussion is becoming clearer. This mostly relates to the release of certain chemicals when axons (the filamentous connections between nerve cells) are damaged. One main challenge is to try to understand whether a particular injury is likely to have long-term consequences. Certain proteins are released into the brain after head injuries and developing a test to find the presence of those proteins might provide a way to determine an injured player or person’s prognosis. This would help athletes, coaches and, I would argue, parents, to determine when a player should return to the field, or a child to regular activities and recreational sports. At the doctor’s office, my daughter was subjected to a series of neurological tests that required her to do things like touch her nose then touch the doctor’s extended index finger in rapid succession. The idea is not to tell us conclusively that she has a concussion, rather it rules out other bigger problems like bleeding or swelling in her brain. It is estimated that 4-5 million people suffer from concussions each year (those are the reported ones, most likely there are many more) and there is an emerging trend among younger, middle school athletes. Many young people return to playing sports long before their brain has had time to heal. Even more don’t report symptoms because they fear a loss of standing in their sport. According to the Economist, a survey of American university athletes in 2014 found that 20% believed they had suffered a concussion but almost 80% of those decided to continue to play rather than seek medical attention. The point is that adult athletes can make up their own minds about what risks they want to take, but children cannot. The Economist suggests that it is therefore children who should attract the greatest attention. They cite a 2012 study by Andrew Mayer at the University of New Mexico in Albuquerque that subtle brain changes in children who have sustained a concussion persist for months after the injury, even when there are no longer any obvious symptoms. They also cite a study, perhaps even more worrisome, which found that children who had sustained a single sports-related concussion still had impaired brain function two years later. Ten-year-olds with a history of concussion performed worse on tests of working memory, attention, and impulse control than their uninjured counterparts. We left the doctor’s office with the information that my daughter had to manage her own symptoms, meaning if she felt a headache, she needed to back off and stop reading/screentime/physical activities and rest up. We were given a piece of paper outlining recent rules to live by to help her gradually integrate back into sports and activities. With each small step (24 hours symptom-free) she could ramp up her activity. If symptoms returned, we had to go back to the previous step and do less, or with less intensity. It’s been three months now and my daughter still has headaches. We've become paranoid about letting her do normal things like wrestling with her Dad and sisters, going skiing, or even doing Pacers during her middle school P.E class. What if it’s too much? What if she regresses and suffers from memory loss or can’t concentrate? Soccer season will start up in another month or so and I'm worried. I don’t want my child to get hit in the head while she is still healing and yet we don’t really know how long it will take to fully heal. Our doctor says it could take months and that she should be fine, but it’s the cumulative effect that we need to watch out for. If she gets another concussion, she runs the risk of doing permanent damage to her brain. The good news is we know more now and concussion is not the invisible injury it once was. The teachers and administrators at my daughter's middle school were extremely supportive of her and let her stop working at the onset of a headache, encouraged her to sit out of PE, and to take a break during long periods of iPad use. For this I was grateful. But how can we prevent children from sustaining a concussion in the first place? I don’t know the answer to that; perhaps less emphasis on contact sports? Better testing for possible concussions after a head injury? More accountability for concussion management and time for athletes to heal? All I know for sure is that I will now require my children to wear helmets when sledding. Perhaps they will start a new trend.