The incidence of traumatic brain injury (TBI) and concussion in America’s youth is likely underreported. Still today, some children are told to “walk off” a blow to the head or shake off having had their “bell rung.” Though the nation’s athletic community is more cognizant of these issues than ever before, brain injuries require improved prevention, detection, and treatment efforts.

Physicians and scientists are beginning to understand the mechanisms underlying the short-term effects of these devastating injuries, but many questions remain unanswered. What happens when children suffer from repeated head injuries? How do structural brain changes correlate with emotional and behavioral symptoms? Are younger victims likely to suffer in more severe, emotional ways than adults?

It is this last unanswered question that is highlighted in a recent study in the Journal of Adolescent Health. The study determined that nearly half of all newly admitted adolescents in the New York City penal system harbored a history of TBI. In this 2012 study of 300 male and 84 female 16- to 18 year-old inmates, researchers determined TBI prevalence by screening newly arrived inmates using a validated adult TBI screening tool. Though the study is focused on injury surveillance and reduction, the exposure of this data presents a critical opportunity to discuss mental health, substance use, and violence amongst America’s youth.

To play devil’s advocate, it is critical to realize this study did not complete a physical exam on all participants at the time of their concussion, nor did it locate medical records outside of the prison system to investigate the type of injury each child sustained. The researchers gathered data from self-reported questionnaires. Though such surveys can be accurate and provide a population health analysis, it is not possible to draw conclusions regarding brain injury and emotional consequence from this data.

Nonetheless, the results surprised the TBI community. Not only was the rate of brain injury significantly higher than in the general population for the same age group, and it was also higher than previous estimates in similar samples.

From 2009-2010, brain injuries in youth (age 24 or younger) accounted for nearly 162 per 100,000 hospitalizations and 4,064.4 per 100,000 emergency department (ED) visits. Of course, not every child who visits the ED for TBI requires hospitalization, but this recent finding should call into question whether physicians, parents, and the health care system as a whole are effectively identifying TBI in children, and whether barriers to adequate health care access inhibit certain populations of youth from receiving proper diagnoses.

While the debate surrounding the true definition of TBI will continue, what is certain is the lack of knowledge regarding the long-term effects of TBI in youth. Information about the neurologic and psychological changes that may befall young TBI victims is scarce.

Here is what we know: The rate of brain injury in kids is rising, fast. There is definitively a post-concussion time period during which children suffer from recoverable cognitive and emotional changes. The more concussions a child gets, the more likely they are to suffer long-term consequences. Beyond that, the rest is hypothesis and speculation. As researchers follow young TBI victims for longer periods of time and gather more data, the water will clear and more will be known, but for now, the best treatment remains prevention.

In adults, more information exists about the long-term consequences of TBI. Though the chronic effects of TBI are individualized, certain commonalities exist. Thinking and cognition can be inhibited, with executive function demonstrating particularly notable challenges. Executive function in the brain supports complex processes including coordinating events, decision-making, and adapting to changes. Mood and behavior changes are also noted in TBI victims. The effects vary individually, but can manifest as changes including rapidly changing emotions, aggression, and lack of motivation.

Take the U.S. military, for example. The nation has been at war for over 10 years and service members have sacrificed their bodies and minds. The rates of post-traumatic stress (PTS), depression, and substance abuse are on the rise, and TBI is in the mix—are they related?

In the teen-focused study, more than 55% of head injuries reported were associated with an assault. This extends the consideration of TBI to include effects of PTS as well. Suffering a brain injury as a result of gang violence or an abusive home is very different than one on the football field. Yes, both injuries are experienced during a traumatic event; however, the psychological penumbra is very different. Thus, caution must guide any assumptions that adolescents who suffer a TBI are all predisposed to emotional lability, anger, or depression.

It is not difficult to imagine that incarceration is a traumatic experience in itself. Add a recent assault or battery and the mind is simply tired, fatigued, and abused. Should it change the way all adolescents in prison are treated? Absolutely. While the march of science continues, every effort that can be made should be made to understand the plight of this young population to offer hope and opportunity to stay out of prison.

It is clear that these changes, when occurring in our youth populations, have the potential to make the social challenges of adolescence even harder to navigate and make an adolescent even more likely to make decisions that land him or her in jail. However, the dearth of knowledge surrounding the long-term effects of brain injury in youth calls for further investigation, not for extrapolation.

The data from this study is critical. Not because it implies any causality—it does not. The study plainly demonstrates that TBI is a real problem for young Americans.

Most importantly, the study brings to light the need for improved mental and cognitive health for all of America’s youth, and makes a clear argument for a study focused on the definition and long-term consequences of brain injury in children.