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UPDATED 2/21/13 3 p.m.

Editor’s Note: This is the first of a two-part series looking at head concussions among Hawaii student athletes. Read part 2 on why the injury is so prevalent in school sports.

Cathy Todd draws a single sheet of paper from her purse and slides it across the table, pointing to a diagram. It’s a detailed picture of the human brain, courtesy of WebMD, along with a bullet-point list describing the brain’s parts.

“You see this?,” she asks, tapping her finger on one of the organ’s dark grooves. It’s the temple, the side of the head between the forehead and ear. “That’s where she got hit.”

Todd is referring to her daughter — a 16-year-old Punahou cheerleader who during an October 2011 practice session hit her head on a teammate’s shoulder while trying to do a tumble.

She saw a few stars but didn’t think much of it. So she braced herself to do the stunt again — less than 15 minutes later.

The same thing happened: her temple collided with a teammate’s shoulder.

More stars ensued, triggering symptoms that Todd says still affect her daughter a year and a half later. She still struggles with bouts of headaches, confusion, indecisiveness and emotional instability, Todd said.

Todd’s daughter is one of the hundreds — some say thousands — of Hawaii high school athletes who suffered concussions during the 2011 school year. (See table below.)

Experts say it’s difficult to determine exactly how many Hawaii students actually suffer concussions because many are are never reported.

“I can’t even guess how many go unreported,” said Ross Oshiro, who coordinates the Department of Education’s . “I don’t see the numbers leveling off for at least another couple of years. We’re still on that track of raising awareness.”

involving the National Football League and former players who say they’re at risk of long-term brain disease because of repeated head trauma have thrust the issue into the national limelight.

Hawaii lawmakers have proposed legislation aimed at enhancing concussion awareness in schools, but interviews with medical professionals suggest that more needs to be done. Kids like Todd’s daughter still fall through the cracks, winding up with unexpected concussions and long-lasting, even life-changing, repercussions. Todd herself has become an advocate for head-injury prevention working with medical professionals and the DOE to boost awareness.

Todd’s daughter, doctors said, got a second concussion before her first one was able to heal.

Getting one concussion is bad enough. But it’s the second one that can be especially catastrophic, experts say.

And studies show that athletes who have suffered one concussion are to sustain a second one.

Concussions are traumatic brain injuries caused by a that can change the way the brain normally works. They can cause confusion, blurred vision, memory loss, nausea and, sometimes, unconsciousness.

is increasingly revealing long-term consequences of sports-related concussions, particularly those .

Todd sighs, citing functions of the brain lobes surrounding the temple: problem-solving, judgment, motor function, memory, hearing. “It was as if she was in a fog all the time,” she said.

Todd regrets not knowing more about concussions at the time of the incident. But more importantly, Todd wishes her daughter had known to identify the first injury, to step away and rest, to seek medical attention.

“My daughter was so unprepared,” Todd said. “She didn’t realize anything was wrong.”

Preventative Policies a Work in Progress

State data show that the number of reported concussions among Hawaii students has more than quadrupled between the 2007 and 2011 school years.

School Year	Number of concussions reported to DOE
2007-2008	213
2008-2009	311
2009-2010	314
2010-2011	446
2011-2012	895

Oshiro attributes the dramatic increase in reported concussions to heightened awareness among athletes, coaches, parents and athletic trainers as to what to do when the injury occurs. Local medical professionals credit the DOE’s , launched in 2011, for shedding light on concussion and for treating the injury.

The program has also streamlined the reporting process, making it easier for students to notify their coaches if they’ve experienced a concussion, officials say.

More recently, Gov. Neil Abercrombie last July signed into law , which required the DOE and to develop a concussion awareness program with guidelines for concussion management. Private schools — many of which fall under the — also participate in the program.

The program involves educating student athletes, parents, sports officials, school faculty and staff and school administrators on concussion symptoms and treatment. Coaches and athletic trainers need to attend annual educational sessions, too.

The law also requires removing a student from any athletic activity if he or she demonstrates any signs or symptoms of a concussion. And any student with a concussion needs to get a doctor’s approval before returning to the sport.

The national spokeswoman Courtney Lenard told Civil Beat that Hawaii’s law is on par with , the bulk of which was passed within the last two years.

But where Hawaii’s law stands out, Lenard said, is a provision that requires a school-employed athletic trainer to monitor a student athlete’s return to physical activity following a concussion.

The state high school athletics association also requires a certified athletic trainer at all state tournaments. Hawaii is also the only state to mandate that every public high school have at least one athletic trainer, according to Oshiro.

Coaches each year also have to take and pass the National Federation of State High School Associations’ . They aren’t allowed to coach if they fail the test, Oshiro said.

But more could be done, said Cora Speck, Injury Prevention and Research coordinator at Queen’s Medical Center.

The next step is ensuring that all stakeholders — including doctors, coaches, teachers and principals — are in communication with each other once a student has a concussion, she said.

“If an athlete has a concussion, comes to Queen’s, and his doctor gives him a piece of paper which says he can’t compete, then what are the chances he’s actually going to follow through on the best practices?” Speck said. “They’re fairly small.”

Speck suggested creating a hotline or website that school officials and parents can access for doctors’ assessments and status updates. The forum would also ensure that students manage their concussions appropriately.

And state lawmakers this session are also considering a that would would expand the concussion education program in various ways, including broadening its scope to include all head injuries. The House minority caucus, which introduced the bill, also wants to extend it to 19-year-olds to ensure that all high school students benefit from the program. (Act 197 is designated for student athletes ages 14 through 18.)

Rep. Beth Fukumoto said the caucus looked to legislation in other states such as New Jersey when drafting the bill.

But Oshiro criticized parts of the proposal, especially the provision that would extend the program to all types of injuries. Head injuries, he said, range from a face laceration to a nose fracture.

“If you start putting everything under the sun into this, people aren’t going to hear the message,” he said.

But Fukumoto said it’s unlikely the measure will become law. The proposal has already been referred to three committees.

Concussions’ Link to Brain Disease Garners National Attention

Sports-related concussions have come under scrutiny in recent years, particularly in light of ongoing legal disputes involving the NFL and former players are believed to have developed Chronic Traumatic Encephalopathy (CTE). CTE is a degenerative brain disease — similar to Alzheimer’s — whose known symptoms include depression and dementia.

As many as 15 percent of all second-impact concussions develop into “persistent disabling problems,” according to Speck.

A notable number of former NFL players have committed suicide in recent years, with many experts — including researchers at — attributing the deaths to symptoms stemming from CTE.

Football legend Dave Duerson, who killed himself in February 2011 and was found to be suffering from CTE, left a suicide note asking that his brain be donated to Boston University for research.

And San Diego football icon Junior Seau last May committed suicide, with Boston researchers concluding this January that at the time of his death.

According to the Associated Press, have also filed lawsuits against the NFL, accusing the league of downplaying concussions and failing to educate them on how to manage the injury. The lawsuits last year were consolidated into one master complaint.

The increased attention to sports-induced concussions has marked a paradigm shift in the way coaches and athletes approach the injury. Only now are advocates urging schools to proactively address concussions, such as “when in doubt, sit it out” policies.

The number of sports-related traumatic brain injuries treated in hospitals has been on the rise since the early 2000s, according to the CDC’s Lenard. Experts estimate that between 1.6 million and 3.8 million sports-related concussions occur in the U.S. each year.

And more than of all sports-related traumatic brain injury emergency room visits involved kids ages 10 through 19, according to CDC data.

Young athletes are more vulnerable than adults to lasting sports-related brain damage because their brains are still developing, according Linda Rosen, chief of the state ’s Emergency Medical Services and Injury Prevention Systems branch. Children also have less access than professional athletes to high-quality protective gear, experts say.

In Hawaii, the number of youth traumatic brain injuries treated in emergency departments or hospitals has also increased in recent years, according to data acquired from the DOH’s Injury Prevention and Control program and .

In 2011, roughly 3,700 Hawaii children ages birth through 18 were treated for traumatic brain injuries either in emergencies departments or hospitals. In 2007, the number was 2,600.

Hawaii’s youth concussion rates are on par with those in other states, Oshiro said.

Still, Elzy Kaina, a nurse at the , pointed out that many Hawaii youth play sports year-round because of the good weather, perhaps heightening the likelihood of long-term brain damage. Continuous play impedes concussion recovery, and rest is integral to the healing process.

Hawaii students who have suffered concussions takes 23 days on average to recover, DOE data show. According to Oshiro, activity as simple as playing on a smart phone can interfere with a youth’s brain recovery.

Punahou Cheerleader’s Brain Still Recovering

Todd’s daughter began cheerleading competitively for Punahou when she was 12-years-old and did gymnastics as a kid. She never learned much about concussions, Todd said.

It wasn’t until after practice that Todd’s daughter told Punahou’s athletic trainers she was feeling strange. The trainers diagnosed the injury as a minor concussion and later instructed Todd on signs to look out for. They also sent a notice to the daughter’s teachers informing them of the injury. And if symptoms didn’t go away within three days, they said, call a doctor.

Two days later a teacher sent Todd’s daughter to the school nurse. She wasn’t focusing, Todd said, she was out of it.

Todd and her family have been battling the aftermath of those two concussions ever since. Todd’s daughter has met with a therapist, neurologists and psychiatrists, one of whom now prescribes her anti-depressants.

Her symptoms — difficulty concentrating, mood swings and depression, to name a few — came and went.

They’re still coming and going.

Todd acknowledges that her daughter’s injuries likely weren’t the only thing that put her into a funk. Granted, her daughter is going through the same issues most teenagers experience.

Still, the doctors agree that she might be better able to cope with her volatile emotions and other psychological problems if it weren’t for the traumatic brain injuries, Todd said.

But ascertaining exactly how big a role the concussions are playing in her daughter’s ongoing psychological issues is all but impossible, according to Todd. Doctors typically discourage doing CT scans on people whose brains are still developing — and without a scan, it’s difficult to determine if the brain is working in a way it shouldn’t.

Todd said the time stretches during which her daughter is back to normal are longer, indicating her brain is healing.

But it’s just as hard to determine how close she is to recovery.

“It’s not like looking at a bruise and seeing your bruise is going away,” Todd said.

Doctors estimate that it could take as long as three years for her brain to fully heal.

Advocates Call for Increased Awareness

In order to raise awareness, Todd would like to see schools and club sports implement a more rigorous version of the state education program enacted last year.

Every school’s athletic officials should hold a bimonthly or weekly class for all student athletes to discuss topics including traumatic brain injuries, sportsmanship and athletic wellness, Todd said. She also suggested that Punahou educate and prepare parents on concussion management before sports seasons begin.

UPDATE But Punahou athletes in high-risk sports — including cheerleading — complete the and receive concussion education and counseling, according to Punahou spokeswoman Carlyn Tani. The assessment guides athletes through the for concussion management.

And in addition to participating in the state-mandated concussion awareness program, all Punahou coaches get annual preseason training on concussion management, Tani said. The school also provides preseason informational sessions to parents whose children are involved in high-risk sports. Punahou has had the policies in place for five years, according to Tani.

Rehab Hospital’s Kaina also advocates for improving concussion education among primary care physicians. Not all doctors are well-versed enough in the injury, especially because concussion science is relatively new, Kaina said.

Advocates such as Oshiro are also pushing for expanding awareness among youth sports organizations.

Caesar Ursic, medical director of trauma services at Queen’s, said extending initiatives to younger athletes is a critical part of the solution.

“We have to start at the younger ages,” Ursic said. “It’s a mistake just to concentrate on high school … The smaller they are the more vulnerable to these kinds of traumas. They’re still developing, developing in ways that you don’t get a second chance.”