Words in Italics throughout the Child SCAT3 are the instructions given to the child by the tester.
Sideline Assessment - Child-Maddocks Score
To be completed on the sideline/in the playground, immediately following concussion. There is no requirement to repeat these questions at follow-up.
Sideline Assessment - Child-Maddocks Score
On the day of injury
- the child is to complete the Child Report, according to how he/she feels now.
In situations where the symptom scale is being completed after exercise, it should still be done in a resting state, at least 10 minutes post-exercise.
On all subsequent days
- the child is to complete the Child Report, according to how he/she feels today, and
- the parent/carer is to complete the Parent Report according to how the child has been over the previous 24 hours.
Standardized Assessment of Concussion - Child Version (SAC-C)
Ask each question on the score sheet. A correct answer for each question scores 1 point. If the child does not understand the question, gives an incorrect answer, or no answer, then the score for that question is 0 points.
"I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember. in any order."
"I am going to repeat the same list again. Repeat back as many words as you can remember in any order. even if you said the word before."
Complete all 3 trials regardless of score on trial 1 &2. Read the words at a rate of one per second. Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the child that delayed recall will be tested.
Concentration - Digits Backward:
"I am going to read you a string of numbers and when I am done, you repeat them back to me backwards, in reverse order of how I read them to you. For example, if I say 7-1. you would say 1-Z"
If correct, go to next string length. If incorrect, read trial 2. One point possible for each string length. Stop after incorrect on both trials. The digits should be read at the rate of one per second.
Days in Reverse Order:
"Now tell me the days of the week in reverse order. Start with Sunday and go backward. So you'll say Sunday. Saturday ... Go ahead"
1 pt. for entire sequence correct
The delayed recall should be performed after completion of the Balance and Coordination Examination.
"Do you remember that list of words I read a few times earlier? Tell me as many words from the list as you can remember in any order."
Circle each word correctly recalled. Total score equals number of words recalled.
These instructions are to be read by the person administering the child SCAT3, and each balance task should be demonstrated to the child. The child should then be asked to copy what the examiner demonstrated.
Modified Balance Error Scoring System (BESS) testing
This balance testing is based on a modified version of the Balance Error Scoring System (BESS)'-A stopwatch or watch with a second hand is required for this testing.
"I am now going to test your balance. Please take your shoes off, roll up your pant legs above ankle (If applicable), and remove any ankle taping (if applicable). This test will consist of two different parts."
(a) Double leg stance:
The first stance is standing with the feet together with hands on hips and with eyes closed. The child should try to maintain stability in that position for 20 seconds. You should inform the child that you will be counting the number of times the child moves out of this position. You should start timing when the child is set and the eyes are closed.
(b) Tandem stance
Instruct the child to stand heel-to-toe with the non-dominant foot in the back. Weight should be evenly distributed across both feet. Again. the child should try to maintain stability for 20 seconds with hands on hips and eyes closed. You should inform the child that you will be counting the number of times the child moves out of this position. If the child stumbles out of this position. instruct him/her to open the eyes and return to the start position and continue balancing. You should start timing when the child is set and the eyes are closed.
Balance testing -types of errors -Parts (a) and (b)
- Hands lifted off iliac crest
- Opening eyes
- Step, stumble, or fall
- Moving hip into> 30 degrees abduction
- Lifting forefoot or heel
- Remaining out of test position > 5 sec
Each of the 20-second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the child. The examiner will begin counting errors only after the child has assumed the proper start position. The modified BESS is calculated by adding one error point for each error during the two 20-second tests. The maximum total number of errors for any single condition is 10. If a child commits multiple errors simultaneously, only one error is recorded but the child should quickly return to the testing position, and counting should resume once the subject is set. Children who are unable to maintain the testing procedure for a minimum of five seconds at the start are assigned the highest possible score, ten, for that testing condition.
OPTION: For further assessment, the same 2 stances can be performed on a surface of medium density foam (e.g., approximately 50cmx40cmx6cm).
Use a clock (with a second hand) or stopwatch to measure the time taken to complete this task. Instruction for the examiner-Demonstrate the following to the child:
"The child is instructed to stand with their feet together behind a starting line (the test is best done with footwear removed). Then, they walk in a forward direction as quickly and as accurately as possible along with a 38mm wide (sports tape). 3-meter line with an alternate foot heel-to-toe gait ensuring that they approximate their heel and toe on each step. Once they cross the end of the 3m line, they tum 180 degrees and return to the starting point using the same gait. A total of 4 trials are done and the best time is retained. Children fail the test if they step off the line, have a separation between their heel and toe, or if they touch or grab the examiner or an object. In this case, the time is not recorded and the trial repeated, if appropriate. "
Explain to the child that you will time how long it takes them to walk to the end of the line and back.
Upper limb coordination
Finger-to-nose (FTN) task:
The tester should demonstrate it to the child.
"I am going to test your coordination now. Please sit comfortably on the chair with your eyes open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow and fingers extended). When I give a start signal. I would like you to perform five successive finger to nose repetitions using your index finger to touch the tip of the nose as quickly and as accurately as possible."
Scoring: 5 correct repetitions in< 4 seconds= 1
Note for testers: Children fail the test if they do not touch their nose, do not fully extend their elbow or do not perform five repetitions. Failure should be scored as 0.
References & Footnotes
- This tool has been developed by a group of international experts at the 4th International Consensus meeting on Concussion in Sport held in Zurich, Switzerland in November 2012. The full details of the conference outcomes and the authors of the tool are published in The BJSM Injury Prevention and Health Protection, 2013, Volume 47, Issue 5. The outcome paper will also be simultaneously co-published in other leading biomedical journals with the copyright held by the Concussion in Sport Group, to allow unrestricted distribution, providing no alterations are made.
- McCrory P et al., Consensus Statement on Concussion in Sport -the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. British Journal of Sports Medicine 2009; 43: i76-89.
- Maddocks, DL; Dicker, GD; Saling, MM. The assessment of orientation following concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5(1): 32-3.
- McCrea M. Standardized mental status testing of acute concussion. Clinical Journal of Sport Medicine. 2001; 11: 176-181.
- Guskiewicz KM. Assessment of postural stability following sport-related concussion. Current Sports Medicine Reports. 2003; 2: 24-30.
- Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond-Tooke, G.&McCrory, P. Normative values for 16-37 year old subjects for three clinical measures of motor performance used in the assessment of sports concussions. Journal of Science and Medicine in Sport. 2010; 13(2): 196-201.
- Schneiders, A.G., Sullivan, S.J., Kvarnstrom. J.K., Olsson, M., Yden. T.&Marshall, S.W. The effect of footwear and sports-surface on dynamic neurological screen-ing in sport-related concussion. Journal of Science and Medicine in Sport. 2010; 13(4): 382-386
- Ayr, L.K., Yeates, K.O., Taylor, H.G.,&Brown, M. Dimensions of post-concussive symptoms in children with mild traumatic brain injuries. Journal of the International Neurol psychological Society. 2009; 15:19-30.
CHILD ATHLETE INFORMATION
Any child suspected of having a concussion should be removed from play. and then seek medical evaluation. The child must NOT return to play or sport on the same day as the suspected concussion.
Signs to watch for
Problems could arise over the first 24-48 hours. The child should not be left alone and must go to a hospital at once if they develop any of the following:
- New Headache, or Headache gets worse
- Persistent or increasing neck pain
- Becomes drowsy or can't be woken up
- Can not recognize people or places
- Has Nausea or Vomiting
- Behaves unusually, seems confused, or is irritable
- Has any seizures (arms and/or legs jerk uncontrollably)
- Has weakness, numbness or tingling (arms, legs or face)
- Is unsteady walking or standing
- Has slurred speech
- Has difficulty understanding speech or directions
Remember, it is better to be safe.
Always consult your doctor after a suspected concussion.
Return to School
Concussion may impact on the child's cognitive ability to learn at school. This must be considered, and medical clearance is required before the child may return to school. It is reasonable for a child to miss a day or two of school after concussion, but extended absence is uncommon. In some children, a graduated return to school program will need to be developed for the child. The child will progress through the return to school program provided that there is no worsening of symptoms. If any particular activity worsens symptoms, the child will abstain from that activity until it no longer causes symptom worsening. Use of computers and internet should follow a similar graduated program, provided that it does not worsen symptoms. This program should include communication between the parents, teachers, and health professionals and will vary from child to child. The return to school program should consider:
- Extra time to complete assignments/tests
- Quiet room to complete assignments/tests
- Avoidance of noisy areas such as cafeterias, assembly halls, sporting events, music class, shop class, etc
- Frequent breaks during class, homework, tests
- No more than one exam/day
- Shorter assignments
- Repetition/memory cues
- Use of peer helper /tutor
- Reassurance from teachers that student will be supported through recovery through accommodations, workload reduction, alternate forms of testing
- Later start times, half days, only certain classes
The child is not to return to play or sport until he/she has successfully returned to school/learning. without worsening of symptoms. Medical clearance should be given before return to play.
If there are any doubts, management should be referred to a qualified health practi-tioner, expert in the management of concussion in children.
Return to sport
There should be no return to play until the child has successfully returned to school/learning, without worsening of symptoms. Children must not be returned to play the same day of injury. When returning children to play, they should medically cleared and then follow a step wise supervised program, with stages of progression.