In 2011, the American Camp Association published “Concussions: What Camps Can Learn from the Zachery Lystedt Law” in the Winter issue of The CampLine. That article, written with the assistance of Dr. Stanley Herring, MD, examined what camps could learn from the emerging state laws requiring that athletes under the age of eighteen who were suspected of having sustained a concussion must be removed from practice or a game — and not allowed to return until they obtained a written return-to-play authorization from a medical professional trained in the diagnosis and management of concussions. The article examined that, while camp programs are generally not held to the requirements of state concussion laws (unless they conduct a youth sports program, such as a soccer or football camp), the practices and safety measures contained within them were still important to consider in the camp environment.

Much has changed in the ensuing years, warranting an update for the camp community. Every state and the District of Columbia has now enacted laws to protect young athletes from the risks associated with concussions in sport. While state laws vary, they generally have the same three foundational directives.

1. Education of Coaches, Parents, and Athletes: Schools/sports leagues must inform and educate coaches, athletes, and their parents and guardians about concussion through training and/or a concussion information sheet.
2. Removal from Play: An athlete who is believed to have sustained a concussion or who exhibits signs, symptoms, or behaviors consistent with the injury must be removed from play (including practices, games, etc.) immediately.
3. Permission to Return-to-Play: An athlete can only return-to-play (or any practice activity) after at least 24 hours and only then with written clearance from an appropriate health care provider who is trained in concussion management.

The differences between state laws vary regarding what sport programs must comply, what penalties exist for those who do not comply, and what medical providers are approved to make return-to-play decisions. 

Return-to-Play Authorized Decision Makers: 

• Seven states (AL, DE, KS, ME, ND, RI, and TX) designate the written clearance to come only from a licensed physician. 
• Twelve other states  (AZ, CO, CT, ID, IA, LA, MA, NC, NM, PA, SC,and TN) also include language to specifically allow for physician assistants, nurse practitioners, and/or neuropsychologists.  
• Ten states (AZ, CT, IA, MA, ME NE, NM, NV, PA, and SC) have language to specifically include athletic trainers.
• Two states (IA and NV) name physical therapists.   
• Thirty of the laws include language to designate a health care provider specially trained in the evaluation and management of concussion but do not specifically name who those providers are. 

Organizations that Must Comply: 
Most youth sport concussion laws are only applicable to school-sponsored sport programs, as many states do not have direct oversight capability of privately run youth sport organizations. However, there is growing legal precedent and an increased standard of care for immediate recognition and appropriate management of concussions at all levels of sport.1 

Penalty for non-compliance: As penalties vary greatly across the country, refer to each state’s law for details: www.knowconcussion.org/resource/concussion-legislation-map/ 

Implications for the Camp Environment
While no state laws are explicitly applicable to camps (unless a camp conducts a youth sports program, such as a soccer or football camp), the practices and safety measures protect the health of those who participate in activities that might lead to concussion or other forms of head injury. Thus, camps should consider applying their own state laws to their programs as well. (As always, the American Camp Association recommends that camps seek legal counsel when developing their own policies and procedures.)

Consider for example: 

1. Have you identified the activities in your program that present risk of head injury and potentially concussion? These might include activities such as those involving motorized vehicles; boarding; in-line skating; hockey; adventure/challenge activities that involve rock climbing, rappelling, spelunking, high ropes (including zip lines), or vertical climbing walls/towers; all horseback riding activities, including pony rides; and bicycling — to name a few.
2. What training can be provided  to front-line staff to help them recognize the signs and symptoms of a concussion immediately when it occurs during an activity?
3. Once identified by front-line staff, how quickly can you get the patient to qualified medical care for an evaluation of concussion (or other traumatic head injuries)?
4. If the patient is diagnosed with a  concussion, what are the steps you will take (with medical professionals and the parents) to ensure that the patient is properly cared for and not allowed to return to any kind of activity (as deemed by the medical professional) that would hinder recovery? Does the patient go home? Do they stay in camp? Etc.
5. Repeated mild traumatic brain injuries (TBI) occurring over an extended period of time can result in cumulative neurological and cognitive deficits, and repeated mild TBIs occurring within a short period of time, can be catastrophic or fatal. It is important for camps to consider all of these issues and create a culture where head injuries are minimized; where accidents involving head injuries are evaluated and handled by professionals trained in the diagnosis and management of concussions; and return-to-activity decisions are made by those medical professionals in partnership with parents.

Resources

• Centers for Disease Control and Prevention
    o Heads Up  - All Concussion-related resources http://www.cdc.gov/HeadsUp/
    o Online Training Courses: www.cdc.gov/headsup/resources/training.html 
    o Traumatic Brain Injury and Concussion Data and Statistics: www.cdc.gov/traumaticbraininjury/data/index.html 
• State Concussion Laws for Youth Athletes: www.knowconcussion.org/resource/concussion-legislation-map/ 
• Get a Heads Up on Concussion in Sports Policies Information for Parents, Coaches, and School & Sports Professionals. Centers for Disease Control and Prevention: 
   www.cdc.gov/headsup/pdfs/policy/headsuponconcussioninsportspolicies-a.pdf

Footnotes: 1KnowConcussion.org: Retrieved from www.knowconcussion.org/resource/concussion-legislation-map/