Table 1. Studies included for the question “In which age groups should children with SRC be managed differently from adults?”
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Anderson,
Catroppa,
Morse et al.,
2000 11
Prospectivelongitudinal
(n=124)
Mild/ Mod/
Severe TBI
Young 37yrs; Old 812yrs
Developmental
Intellectual (WPPSI-WISC
III); Adaptive (VinelandPreinjury); Measured
acute (0-3 months) and
12 months post
Age at injury was not
predictive of outcome for
children with
mild/moderate TBI, but was
for severe.
3
Anderson,
Morse, Klug et
al., 1997 12
Prospectivelongitudinal
(n=73)
Severe/
Mild-Mod/
Non-injured
controls
2-7yrs
continuous
variable-one
group
Age-continuous
Demographic – Medical;
Adaptive (Vineland
Preinjury); Personality;
Family function;
Intellectual (WPPSI-R,
WISC-III, Bayley Scales);
Expressive/Receptive
Language; Memory
(Measured at acute and
12 months post)
Early age at injury
associated with 12 month
outcome only for memory.
3
Babcock,
Byczkowski,
Wade et al.,
2013 13
Retrospective
analysis of a
prospective
observational
study
(n=406)
Mild TBI/
Concussion
Children vs.
Adolescents
5-10yrs;
11-18yrs
Developmental
Demographics; TBI
history; Medical data;
RPQ
Adolescent age was one
predictor of PPCS (headache
predictor)
3
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Baillargeon,
Lassonde,
Leclerc, et al.,
2012 14
Cross-sectional
study
(n=96)
Concussion
(Sport)
9-12yrs;
13-16yrs;
adults
Developmental
Neuropsychological (NHL
Battery and Brown
Peterson Test measuring
working memory); ERP;
EEG; PCSS
"...adolescents are more
sensitive to the
consequences of
concussions than are
children or adults." (ERP and
Working Memory)
3
Bakhos,
Lockhart,
Myers, et al.,
2010 15
Retrospective
review;
Epidemiological
, stratified
probability
sample
(n=502,78
4)
Concussion
Pre-high
school 813yrs;
High school
14-19yrs
Educational
Type of sport
ED visits for concussion in
older group (65%); for
younger group (35%)- all
causes 2001-2005
3
Barlow,
Crawford,
Stevenson, et
al., 2010 16
Prospective,
consecutive
controlledcohort study
(n=670)
mTBI/
Concussion
vs. ECI
0-18yrs;
Under 6yrs;
Over 6yrs
Educational
PCSI Total-parent report;
RPQ – Parent Report;
Family functioning,
Maternal psych
adjustment (Brief
Symptom Inventory)
Asymptomatic mTBI group
was younger than
symptomatic group;
"Children > 6yrs more likely
to remain symptomatic";
Mediated by severity:
School-aged children with
mTBI and LOC may have
longer recovery.
3
Blume,
Vavilala, Jaffe,
et al., 2012 17
Prospectivecohort study
(n=402, 60,
122
respectivel
y)
Mild vs.
Mod/Severe
vs. control
(arm injury)
5-12yrs;
13-17yrs.
Developmental
Physical – Headache
ratings by parents, and
adolescents
Headache associated with
greater age. Girls and
adolescents at greater risk
for Headache after TBI
3
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Browne &
Lam, 2006 18
Retrospective
case series
(n=592)
Sport and
Recreation in
ED: Mild/
Mod/ Severe
concussive
head injury
(AAN grades)
0-4yrs;
5-9yrs;
10-16yrs.
Developmental
Injury/ medical
characteristics, sport,
demographics
Children and adolescents
who suffered a concussive
head injury while playing
organized sports (compared
to other leisure activities)
were likely male and older
than 10 years. The most
severe were also in that
group.
4
Corwin,
Zonfrillo,
Master, et al.,
2014 19
Retrospective,
exploratory
cohort
(n=247)
Concussion
5 -12yrs; 1314yrs; 1516yrs.
Developmental
Symptoms, days to
clearance, injury
mechanisms
Oldest group took a longer
time to return to school fulltime and youngest group
took longest to recover but
no statistically significant
differences.
3
Covassin,
Elbin, Harris,
et al., 2012 20
Cohort study
(n=296)
Concussionsport
High school
vs. College
Educational
Cognitive-Memory;
Physical-Postural
Stability (ImPACT &
BESS)
High school athletes worse
on visual/ verbal memory;
BESS results had age-sex
interaction. Male high
school worse BESS than
college; opposite for female.
3
Eisenberg,
Andrea,
Meehan, et
al., 2013 21
Prospective
cohort study
(n=280)
Concussion
11-22yrs:
11-12yrs vs.
>13yrs
Developmental
(Pubertal
status)
Post-concussion
symptoms (RPQ)
Those 13 and above =
predictor of prolonged
recovery
3
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Field, Collins,
Lovell, et al.,
2003 22
Prospective
cohort study
College
(n=371);
High
School
(n=183)
Concussion
(Sport)
High school
vs. College
Educational
Neurocognitive (HVLT;
SDMT; Trails; COWAT);
PCSS
Prolonged memory
dysfunction compared to
College
3
Grubenhoff,
Kirkwood,
Gao, et al.,
2010 23
Prospective,
observational,
cohort study
(n=348)
Mild TBI
(blunt head
trauma) vs.
controls
(minor
extremity
injury)
6-8yrs;
9-11yrs;
12-14yrs;
15-18yrs
Developmental
SAC (cognitive and
symptoms)
SAC differentiated only the
12-14yr group from
controls. Graded symptom
checklist differentiated all
groups from controls
3
Hunt &
Ferrara, 2009
Cross-sectional
study between
groups design
(n=198)
Normals
4 groups:
9th through
12th grades
Educational
SAC; Trails; Digit Span,
Symbol Digit; Hopkins
Verbal Learning; Finger
tapping, Head Injury
Scale (symptoms)
11th-12th graders stronger
on information processing
attention and motor
dexterity than 9th graders.
Recommend testing
entering 9th grade and then
entering 10th.
3
24
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Jinguji,
Bompadre et
al., 2012 25
Prospective
cohort study
(n=214)
Normal
athletes
13-15yrs vs.
16-19yrs.
Kerr,
Zuckerman et
al., 2016 26
Epidemiological
(n=3000+)
Football
athletes
Kontos, Elbin
et al., 2013 27
Prospective
cohort study
(n=488)
Sports
concussion
youth tackle
football
males
Measures
Age-Related Findings
Level of
Evidence
Developmental/
educational
(high school
young and old)
Younger group had fewer
symptoms; concentration
testing unreliable; lowest
immediate memory scores
in older boys; lowest
concentration in younger
boys; for balance- younger
females better than younger
males.
3
(3 groups) 514yrs=
Youth;
Secondary
School;
College
Educational/
sport level
Youth and high school
athletes had higher
probability of recovery
taking greater than 30 days
compared to college. Youth
had higher probability of
return in less than 24 hours
compared to high school.
More concussion symptoms
reported in high school &
college than in youth.
3
8-10yrs vs.
11-12yrs
Sport,
developmental
Older 11-12yr olds were 2.9
times more likely to sustain
concussion.
3
Athletic Exposure;
Incidence Rate
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Lee, Odom et
al., 2013 45
Retrospective
analysis
(n=184)
Concussed
athletes
13-16yrs vs.
18-22yrs (92
matched)
Educational(mostly High
school v College
but some in
middle school)
Post Concussion
Symptom Checklist on
ImPACT
No difference in symptom
presence, severity, total at
baseline or post-concussion.
No diff in return to baseline
scores.
3
Lichtenstein,
Moser et al.,
2013 28
Majerske &
Mihalik, 2008
Retrospective
analysis
(n=502)
Normal
athletes
10-12yrs vs.
13-18yrs
Developmental
ImPACT
Younger group had more
"invalid" test results.
3
Retrospective
cohort
(n=95)
Concussed
athletes
13-15yrs v
16-18yrs
Developmental
(adolescents)
ImPACT PCSS
Younger group had more
visual and verbal memory
deficits than older group
after concussion.
3
McKay,
Brooks, et al.,
2014 29
Prospective/
cross sectional
cohort
(n=704)
Baselines
Bantam (1314yrs);
Midget (1517yrs)
Sport level
ImPACT
16-17yr olds stronger in
visual motor processing and
impulse control than
younger group. Females
more symptoms reported.
3
Valovich
McLeod, Bay,
et al., 2012 42
Descriptive
epidemiology
study
(n=1134)
Healthy
baselines
9th, 10th,
11th, 12th
grades
Educational (by
grade)
SCAT2 Total Symptom
Score; SAC; BESS
Males score lower; 9th
grade lower than 11th
grade; history of concussion
were lower; Adolescents
display variable SCAT
results, need to administer
baselines.
3
46
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Meehan,
Mannix, et al.,
2014 30
Prospective
cohort study
(n=531)
Patients of
sports
concussion
clinic
7-26yrs
Age was a
continuous
variable
PCSS; Age, sex,
concussion history and
variables; ImPACT index
scores
Overall symptom burden
was only independent
variable to predict
prolonged symptoms.
3
Meehan,
Mannix, et al.,
2013 31
Prospective
cohort study
(n=182)
Patients of
sports
concussion
clinics
7-26yrs
Age was a
continuous
variable that
was examined
PCSS; Age; concussion
history; ImPACT scores;
demographics
PCSS related to prolonged
recovery- age and amnesia
not related to prolonged
recovery (longer than 28
days).
3
Moser, Schatz,
et al., 2016 32
Retrospective
cohort
(n=30)
Healthy
baselines
10-12yrs
Educational,
middle school
ImPACT index scores,
PCSS
Verbal Memory/ Visual
Motor Speed stable on one
year test-retest. Visual
Memory, Reaction Time,
Symptom Checklist less
reliable. Conclude to test
yearly in this age group
contrast to high school
athletes.
3
National
Electronic
Injury
Surveillance
System
(NEISS), 2007
Epidemiological
Samples
from 96
hospitals
All injuries in
youth, not
just
concussion
0-4yrs;
5-14yrs;
15-24yrs.
Developmental
Estimates of injuries in
different product and
cause categories
Estimates of injuries in
different product and cause
categories.
3
33
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Olsen, 2012 34
Prospective
cohort study
(n=852)
Healthy
youth
athletes
11-13yrs vs.
17-18yrs
Developmental
BESS
No differences between
genders or age cohorts
3
QuatmanYates,
Hugentobler,
et al., 2014 35
Retrospective
medical review
and prospective
cohort
(n=20)
Children and
adolescents
referred for
postural
control
Physical
Therapy
8-13yrs;
14-18yrs
Developmental
BESS
Age may influence BESS
scores. BESS not easy to
interpret and use in youth.
Need narrow age bands for
BESS and then establish
norms.
3
Ransom,
Vaughan, et
al., 2015 36
Prospective
cohort study
(n=349)
Concussed
youth and
parents
Educational
Questionnaire,
symptoms
Parent and student reports
of academic difficulties were
greatest for 9-12yr olds.
3
RegisterMihalik,
Kontos, et al.,
2012 37
Prospective
cohort study
(n=40)
Healthy
active
athletes
Kinder-5yr;
6-8 middle;
9-12 high
school.
High school
vs. collegiate
athlete
Educational
ImPACT and paperpencil
neuropsychological tests
Baseline measures need to
be readministered with age.
Greatest improvement in
scores between first and
second administration.
3
Reynolds &
Fazio, 2016 38
Retrospective
(n=2723)
Healthy
athletes with
no more
than 1
concussion
in history
10-12yr olds
Developmental
ImPACT
10yr olds significantly
different from 11 and 12yr
olds; 11 and 12yr olds
different from each other on
Visual Memory, Visual
Motor Speed, Reaction
Time, and Impulse Control
3
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Sady, Vaughan
et al., 2014 39
Prospective
cohort study
(n=633)
Concussed
and
uninjured
5-7yrs
younger
child;
8-12yrs
older child;
13-18yrs
adolescent
Developmental
PCSI: Parent and selfreports
"…greater discriminability
from parent reports."
3
Schneider,
Emery, et al.,
2010 40
Pooled data of
three
prospective
cohort studies
(n=4193)
Youth ice
hockey
players
9-17yrs.
Males=11-12
and 13-14;
Females= 910, 11-12,
13-14, 1517yrs.
Sport level
SCAT and demographics
"The SCAT may need to be
repeated regularly due to
altered stages of
development which may
affect performance."
Bantam and Midget females
reported more symptoms
(13-17yrs).
3
Snyder, Bauer,
et al., 2014 47
Prospective,
cohort
(n=761)
Baselined
children
9-10yrs;
11-12yrs;
13-14yrs;
15-16yrs;
17-18yrs
Age-continuous
groups
SCAT2
Teens perform higher on
SCAT2 than younger (9-11).
Utility of SCAT2 for 9-11yr
olds questioned.
3
Tonks,
Williams et al.,
2011 41
Prospective
TBI
(n=28);
Controls
(n=89)
Youth TBI
and matched
controls
Two TBI
groups with
matched
controls: 1)
8-10yrs; 2)
10-16yrs.
Developmental
D-KEFS; sociobehavioural assessment;
Only 10-16yo children with
TBI scored lower on
neuropsychological tests; All
children with TBI had more
socioemotional difficulties.
3
Paper
Study Type
N
Brain Injury
Status
Age Groups
Classification
Type
Measures
Age-Related Findings
Level of
Evidence
Williams,
Crowe, et al.,
2016 43
Prospective,
cross-sectional
(n=832)
Baselined
youth
9-17yrs:
Late
childhood
(9-12yrs);
Young
adolescence
(12-15yrs);
Late
adolescence
(15-17yrs)
Developmental
CogSport for kids
Biggest change in baseline
test results in the 9-12yr
range. Stable performance
by 15yrs.
3
Zemek,
Barrowman,
et al., 2016 44
Prospective,
multicenter
cohort
(n=3063)
Initial
enrolment
Pediatric
patients in
ED’s in
Canada;
validation
cohort =883;
derivation
cohort =1701
5-7yrs; 812yrs; 1318yrs
Developmental
PCSI; Child-SCAT; ACE
12 point risk score for
prediction of PPCS. Female
sex, and age 13yrs or older
associated with PPCS.
3
ACE, Acute Concussion Evaluation; BESS, Balance Error Scoring System; COWAT, Controlled Oral Word Association Test; D-KEFS, Delis-Kaplan Executive Function System; ECI, Extracranial Injury;
ED, Emergency Department; EEG, Electroencephalography; ERP, Event Related Potentials; HVLT, Hopkins Verbal Learning Test; ImPACT, Immediate Post-Concussion Assessment and Cognitive
Test; LOC, Loss of Consciousness; mTBI, Mild Traumatic Brain Injury; NEISS, National Electronic Injury Surveillance System; NHL, National Hockey League; PCSS/PCSI, Post Concussive Symptom
Scale/Post Concussion Symptom Inventory; PPCS, Persistent Postconcussive Symptoms; RPQ, Rivermead Postconcussion Symptoms Questionnaire; SAC, Standardized Assessment of
Concussion; SCAT, Sport Concussion Assessment Tool; SDMT, Symbol Digits Modality Test; TBI, Traumatic Brain Injury; WISC, Wechsler Intelligence Scale for Children; WPPSI, Wechsler
Preschool Scale of Intelligence