Children who sustain concussions may require 3 months or longer to achieve optimal functioning across physical, cognitive, socioemotional, and resilience domains, with female children showing particularly prolonged recovery trajectories, according to new research.

The prospective cohort study, conducted by researchers from the Pediatric Emergency Research Canada network, challenges the commonly cited 4-week recovery window for pediatric concussion by examining recovery through a more comprehensive lens compared with traditional symptom-focused approaches.

“The findings of this cohort study suggest that children who sustain concussion may need 3 months or longer to be considered optimally recovered across physical, cognitive, socioemotional, and resilience domains,” the study authors wrote. “Clinically, these findings may help to explain why some children, especially [female children], take longer to feel as though they are well even though subjective and objective assessments of symptoms or specific functions indicate absence of problems,” they added.

Comprehensive Approach to Recovery Assessment

The study enrolled 967 children aged 8 to 17 years (median age = 12.3 years, 58.1% male), including 633 with concussion and 334 with orthopedic injury (OI) as a control group. Participants were assessed approximately 10 days, 3 months, and 6 months postinjury using a comprehensive optimal functioning measurement encompassing 11 validated variables across four domains:

• Motor-physical functioning

• Cognitive functioning

• Socioemotional functioning

• Resilience and social support.

Rather than focusing solely on postconcussive symptoms (PCS), the researchers created a holistic recovery metric requiring participants to meet high standards of performance and absence of impairment across all domains. Participants with incomplete assessments (greater than 30% missing measures) were excluded from score derivation.

Key Findings

Children with concussion demonstrated slower recovery compared with those who sustained orthopedic injuries, particularly within the first three months. While both groups reached similar levels of optimal functioning by six months, early assessments revealed that children with concussion had significantly lower functioning scores.

Time was identified as the strongest factor influencing recovery, followed by the type of injury and the child’s sex. Interactions between these variables were statistically meaningful, but no added impact was seen when all three were considered together.

At the 10-day follow-up, both male and female children with concussion were less likely to be functioning optimally compared with peers who had orthopedic injuries. This disparity persisted among female children at the 3-month mark, whereas male children had largely recovered by then. By six months, optimal functioning was comparable across all groups.

Notably, male children with concussion recovered more rapidly than female children, showing higher rates of optimal functioning at both three and six months. In contrast, children in the orthopedic injury group did not show any sex-based differences in recovery.

Lead study author Miriam H. Beauchamp, PhD, and colleagues commented: “As with studies focusing specifically on PCS, these findings can be interpreted with a reasonably optimistic view of concussion in which sequelae tend to be transient, with most children expected to make a full recovery in the long term. Previous reports suggest PCS resolve within 2 weeks with only one-third of participants reporting persisting symptoms after 1 month and no associations with intellectual functioning. However, the comprehensive and long-term approach in this study suggests that complete recovery for children, ie, they are considered and perceive themselves as functioning optimally across domains, may take well beyond the 1-month span typically cited for PCS resolution (and up to 6 months in females).”

Sex Differences in Recovery

The researchers found pronounced sex differences in recovery trajectories postconcussion that weren't observed in the orthopedic injury group. They noted that these differences likely reflected biological effects rather than psychological reporting bias, given that sex differences were more apparent following concussion and disappeared by 6 months postinjury. This interpretation was supported by prior findings from the same cohort demonstrating associations between sex and brain structure and connectivity following pediatric concussion.

Clinical Implications

The researchers emphasized that their findings have direct clinical relevance, suggesting that health care providers should adopt comprehensive assessment approaches and extend follow-up periods, particularly among female patients.

“Most children reach optimal functioning within 3 to 6 months; this information should be included in anticipatory guidance and reassurance to families,” the study authors concluded.

The study was funded by the Canadian Institutes of Health Research and conducted at five Pediatric Emergency Research Canada network sites between September 2016 and July 2019. Data were analyzed from January 2024 to January 2025.

Source: JAMA Network Open