Predicting Psychological Distress after Pediatric Concussion

Plasma Biomarkers of Traumatic Brain Injury in Adolescents With Sport-Related Concussion

Importance

Blood-based biomarkers may clarify underlying neuropathology and potentially assist in clinical management of adolescents with sport-related concussion (SRC).

Objective

To investigate the association between SRC and plasma biomarkers in adolescents.

Design, Setting, and Participants

Prospective cohort study in Canadian sport and clinic settings (Surveillance in High Schools and Community Sport to Reduce Concussions and Their Consequences study; September 2019 to November 2022). Participants were a convenience sample of 849 adolescent (ages 10-18 years) sport participants with blood samples. Data were analyzed from February to September 2023.

Exposures

Blood collection and clinical testing preseason (uninjured) and post-SRC follow-ups (ie, ≤72 hours, 1 week, and biweekly until medical clearance to return to play [RTP]).

Main Outcomes and Measures

Plasma glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase-L1 (UCH-L1), neurofilament light (NfL), and total tau (t-tau) were assayed. Group-level comparisons of biomarker levels were conducted between uninjured and post-SRC intervals (postinjury day [PID] 0-3, 4-10, 11-28, and >28) considering age and sex as modifiers. Secondary analyses explored associations between biomarker concentrations and clinical outcomes (Sport Concussion Assessment Tool, Fifth Edition [SCAT5] symptom scores and time to RTP).

Results

This study included 1023 plasma specimens from 695 uninjured participants (467 male participants [67.2%]; median [IQR] age, 15.90 [15.13-16.84] years) and 154 participants with concussion (78 male participants [51.0%]; median [IQR] age, 16.12 [15.31-17.11] years). Acute (PID 0-3) differences relative to uninjured levels were found for GFAP (female participants: 17.8% increase; β = 0.164; 95% CI, 0.064 to 0.263; P = .001; male participants: 17.1% increase; β = 0.157; 95% CI, 0.086 to 0.229; P < .001), UCH-L1 (female participants: 43.4% increase; β = 0.361; 95% CI, 0.125 to 0.596; P = .003), NfL (male participants: 19.0% increase; β = 0.174; 95% CI, 0.087 to 0.261; P < .001), and t-tau (female participants: -22.9%; β = -0.260; 95% CI, -0.391 to -0.130; P < .001; male participants: -18.4%; β = -0.203; 95% CI, -0.300 to -0.106; P < .001). Differences were observed for all biomarkers at PID 4 to 10, 11 to 28, and greater than 28 compared with uninjured groups. GFAP, NfL, and t-tau were associated with SCAT5 symptom scores across several PID intervals. Higher GFAP after 28 days post-SRC was associated with earlier clearance to RTP (hazard ratio, 4.78; 95% CI, 1.59 to 14.31; P = .01). Male participants exhibited lower GFAP (-9.7%), but higher UCH-L1 (21.3%) compared with female participants. Age was associated with lower GFAP (-5.4% per year) and t-tau (-5.3% per year).

Conclusions and Relevance

In this cohort study of 849 adolescents, plasma biomarkers differed between uninjured participants and those with concussions, supporting their continued use to understand concussion neuropathology. Age and sex are critical considerations as these biomarkers progress toward clinical validation.

Psychological Predictors of Mental Health Difficulties After Pediatric Concussion

Children often experience mental health difficulties after a concussion. Yet, the extent to which a concussion precipitates or exacerbates mental health difficulties remains unclear. This study aimed to examine psychological predictors of mental health difficulties after pediatric concussion. Children (5 to <18 years of age, M = 11.7, SD = 3.3) with concussion were recruited in a single-site longitudinal prospective cohort study conducted at a tertiary children's hospital (n = 115, 73.9% male). The primary outcomes included internalizing (anxious, depressed, withdrawn behaviors), externalizing (risk-taking, aggression, attention difficulties), and total mental health problems, as measured by the Child Behavior Checklist at 2 weeks (acute) and 3 months (post-acute) after concussion. Predictors included parents' retrospective reports of premorbid concussive symptoms (Post-Concussion Symptom Inventory; PCSI), the child and their family's psychiatric history, child-rated perfectionism (Adaptive-Maladaptive Perfectionism Scale), and child-rated resilience (Youth Resilience Measure). Higher premorbid PCSI ratings consistently predicted acute and post-acute mental health difficulties. This relationship was significantly moderated by child psychiatric history. Furthermore, pre-injury learning difficulties, child psychiatric diagnoses, family psychiatric history, lower resilience, previous concussions, female sex, and older age at injury were associated with greater mental health difficulties after concussion. Pre-injury factors accounted for 23.4-39.9% of acute mental health outcomes, and 32.3-37.8% of post-acute mental health outcomes. When acute mental health was factored into the model, a total of 47.0-68.8% of variance was explained by the model. Overall, in this sample of children, several pre-injury demographic and psychological factors were observed to predict mental health difficulties after a concussion. These findings need to be validated in future research involving larger, multi-site studies that include a broader cohort of children after concussion.

A systematic review of pre-injury anxiety disorder and post-concussion outcomes in youth and young adult athletes

Pre-injury anxiety disorder may be a risk factor for poor outcomes following sportsrelated concussion. A systematic review was performed to characterize the relationship between pre-injury anxiety disorder and post-concussion symptom presentation and recovery time after sports-related concussions among children, adolescents, and young adults. A PRISMA-compliant literature search was conducted in Ovid MEDLINE, PsycINFO, EMBASE, and Scopus for articles published up to 25 January 2024. The initial query yielded 1358 unique articles. Articles that analyzed the relationship between pre-injury anxiety disorder and post-concussion symptoms and recovery time were included. A final cohort of 11 articles was extracted, comprising a total of 8390 study participants, of whom 921 had a history of pre-injury anxiety disorder. Pre-injury anxiety disorder was associated with prolonged time to return to sports activity and an increased incidence of physical, emotional, cognitive, and sleep-related symptoms. While the results of this review suggest an association between pre-injury anxiety disorder and post-concussion symptoms and recovery time, future studies should be more stringent regarding standardized anxiety disorder definitions, longitudinal assessment of post-concussion symptoms, anxiety disorder subtypes, and anxiety treatment history.

Applicability and clinical utility of the German rivermead post-concussion symptoms questionnaire in proxies of children after traumatic brain injury: an instrument validation study

BACKGROUND

The German Rivermead Post-Concussion Symptoms Questionnaire (RPQ) can be used to assess post-concussion symptoms (PCS) after traumatic brain injury (TBI) in adults, adolescents, and children.

METHODS

In this study, we examined the psychometric properties of the German RPQ proxy version (N = 146) for children (8-12 years) after TBI at the item, total and scale score level. Construct validity was analyzed using rank correlations with the proxy-assessed Post-Concussion Symptoms Inventory (PCSI-P), the Patient Health Questionnaire 9 (PHQ-9), and the Generalized Anxiety Disorder Scale 7 (GAD-7). Furthermore, sensitivity testing was performed concerning subjects' sociodemographic and injury-related characteristics. Differential item functioning (DIF) was analyzed to assess the comparability of RPQ proxy ratings for children with those for adolescents.

RESULTS

Good internal consistency was demonstrated regarding Cronbach's α (0.81-0.90) and McDonald's ω (0.84-0.92). The factorial validity of a three-factor model was superior to the original one-factor model. Proxy ratings of the RPQ total and scale scores were strongly correlated with the PCSI-P (ϱ = 0.50-0.69), as well as moderately to strongly correlated with the PHQ-9 (ϱ = 0.49-0.65) and the GAD-7 (ϱ = 0.44-0.64). The DIF analysis revealed no relevant differences between the child and adolescent proxy versions.

CONCLUSIONS

The German RPQ proxy is a psychometrically reliable and valid instrument for assessing PCS in children after TBI. Therefore, RPQ self- and proxy-ratings can be used to assess PCS in childhood as well as along the lifespan of an individual after TBI.

Smartphone App-Delivered Mindfulness-Based Intervention for Mild Traumatic Brain Injury in Adolescents: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Concussion in children and adolescents is a significant public health concern, with 30% to 35% of patients at risk for prolonged emotional, cognitive, sleep, or physical symptoms. These symptoms negatively impact a child's quality of life while interfering with their participation in important neurodevelopmental activities such as schoolwork, socializing, and sports. Early psychological intervention following a concussion may improve the ability to regulate emotions and adapt to postinjury symptoms, resulting in the greater acceptance of change; reduced stress; and recovery of somatic, emotional, and cognitive symptoms.

OBJECTIVE

The primary objective of this study is to assess the feasibility of conducting a parallel-group (1:1) randomized controlled trial (RCT) to evaluate a digital therapeutics (DTx) mindfulness-based intervention (MBI) in adolescents aged 12 to <18 years. The attention-matched comparator intervention (a math game also used in previous RCTs) will be delivered on the same DTx platform. Both groups will be provided with the standard of care guidelines. The secondary objective is to examine intervention trends for quality of life; resilience; self-efficacy; cognition such as attention, working memory, and executive functioning; symptom burden; and anxiety and depression scores at 4 weeks after concussion, which will inform a more definitive RCT. A subsample will be used to examine whether those randomized to the experimental intervention group have different brain-based imaging patterns compared with those randomized to the control group.

METHODS

This study is a double-blind Health Canada-regulated trial. A total of 70 participants will be enrolled within 7 days of concussion and randomly assigned to receive the 4-week DTx MBI (experimental group) or comparator intervention. Feasibility will be assessed based on the recruitment rate, treatment adherence to both interventions, and retention. All outcome measures will be evaluated before the intervention (within 7 days after injury) and at 1, 2, and 4 weeks after the injury. A subset of 60 participants will undergo magnetic resonance imaging within 72 hours and at 4 weeks after recruitment to identify the neurophysiological mechanisms underlying the potential benefits from MBI training in adolescents following a concussion.

RESULTS

The recruitment began in October 2022, and the data collection is expected to be completed by September 2024. Data collection and management is still in progress; therefore, data analysis is yet to be conducted.

CONCLUSIONS

This trial will confirm the feasibility and resolve uncertainties to inform a future definitive multicenter efficacy RCT. If proven effective, a smartphone-based MBI has the potential to be an accessible and low-risk preventive treatment for youth at risk of experiencing prolonged postconcussion symptoms and complications.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05105802; https://classic.clinicaltrials.gov/ct2/show/NCT05105802.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57226.

Association between days for concussion recovery and initial specialty clinic evaluation within 48 hours

BACKGROUND

Researchers have highlighted the importance of early access to concussion care within one week of injury in reducing recovery times. However, a persisting question for concussion researchers is "just how early is important?" The purpose of this study was to examine differences in recovery time as predicted by the number of days elapsed since injury (DSI) to initial evaluation among patients who had access to a specialty concussion clinic within seven days. We hypothesized that DSI group membership, even within seven days, would significantly predict risk of protracted recovery (i.e., beyond 21 days).

METHODS

In this archival study, retrospective data were gathered from electronic medical records between September 2020 to March 2022. Records of participants between ages 12-18, those diagnosed with a sports-related concussion based on initial clinic visit diagnosis by a medical provider and those who established care within seven days of injury at a large pediatric specialty concussion clinic were examined. Participants were divided into three DSI groups (patients seen in < 48 h: "acute", patients seen between 49 h < and < 96 h: "sub-acute", and patients seen between 97 < and < 168 h: "post-acute"). A general linear model was constructed to examine relationships between relevant concussion factors (e.g., Post Concussion Scale Score, neurodevelopmental history, psychiatric history, concussion history, migraine history, overall VOMS change score, cognitive testing, sex, age, race, and ethnicity) that were either significant in the preliminary analysis or in clinical judgement and recovery time. Adjusted odds ratios (OR) were derived from a binary logistic regression model, in which recovery time was normal (≤ 21 recovery days) or protracted (> 21 recovery days).

RESULTS

A total of 856 participants were eligible. Adolescents in the acute group (M = 15.12, SD = 8.04) had shorter recovery times in days compared to those in the sub-acute (M = 17.98, SD = 10.18) and post-acute (M = 21.12, SD = 10.12; F = 26.00, p < .001) groups. Further, participants in the acute (OR = 4.16) and sub-acute (OR = 1.37) groups who accessed specialty concussion clinics within 48 h were 4 times more likely to have a normal recovery and recovered approximately 6 days faster than the post-acute care group.

CONCLUSIONS

Earlier concussion care access predicted recovery times and was associated with lower risk for protracted recovery.

Association between sports-related concussions and the risk of self-injury thoughts and behaviors: Who, and under what circumstances?

BACKGROUND

Understanding the association between sport-related concussions and the risk of suicidal and non-suicidal self-injury thoughts and behaviors (SITBs), including non-suicidal self-injury (NSSI), suicidal ideation (SI), suicidal plan (SP), and suicidal attempt (SA), is crucial for suicide prevention. We aimed to identify the circumstances in which individuals with or without a concussion are vulnerable to SITBs.

METHODS

The cross-sectional study included 85,469 students from 63 Chinese university with a mean age of 19.6 years. Firstly, propensity score matching, and inverse probability of treatment weighting (IPTW) were used to match the concussion and non-concussion group based on a range of biological, social, and psychological factors. Subsequently, multivariable logistic regression and a decision tree algorithm were employed to evaluate the interaction and cumulative impact of these risk factors and concussion on the probability of SITBs.

RESULTS

In the unmatched sample, concussion exposures were associated with all SITBs, with NSSI (OR, 1.41), SI (OR, 1.10), SP (OR, 1.23), and SA (OR, 1.28). However, the matched and weighted sample only had a significant association with NSSI and SI. The decision tree model revealed that, in the unmatched sample, among individuals without depressive symptoms or childhood emotional abuse, the risk of concussion on SITBs increased from 45.5 % to 65.2 % (χ2, 9.370; adjusted P = .002) after experiencing sexual abuse and verbal bullying. In the matched sample, the risk increased from 46.2 % to 64.6 % (χ2, 6.848; adjusted P = .009).

CONCLUSION

Our study revealed that individuals who suffered concussions exhibited a significantly higher risk of SITBs.

Dose-Response Effect of Mental Health Diagnoses on Concussion Recovery in Children and Adolescents

BACKGROUND

Pre-existing mental health diagnoses may contribute to greater emotional symptom burden and prolonged recovery after concussion.

HYPOTHESIS

Youth with pre-existing mental health diagnoses will have greater emotional symptom burden, greater risk for delayed return to exercise, and more prolonged recovery from concussion than those without those diagnoses.

STUDY DESIGN

Prospective cohort.

LEVEL OF EVIDENCE

Level 3.

METHODS

A prospective registry of youth concussion was examined for differences in emotional symptom burden after injury to develop a predictive risk model for prolonged recovery. The impact of individual and total number of pre-existing mental health diagnoses (0, 1, 2, and 3+) was assessed, and multivariable logistic regression was performed to identify factors associated with prolonged recovery.

RESULTS

Among a cohort of 3105 youth with concussion, those with a history of mental health diagnoses, in a dose-response fashion, had greater postinjury emotional symptom burden (7 emotional symptoms vs 4; P < 0.01), visio-vestibular dysfunction (65% abnormal vs 56% abnormal; P < 0.01), later return to symptom-limited exercise (23 vs 21 days; P < 0.01), and overall longer concussion recovery (38 days, interquartile range [IQR] 18, 80) versus 25 days (IQR 13, 54; P < 0.01). Boys with prolonged recovery after concussion had greater emotional symptom burden than girls (5 emotional symptoms vs 3; P < 0.01).

CONCLUSION

Pre-existing mental health diagnoses are associated with greater postinjury emotional symptom burden and longer concussion recovery in a dose-response fashion. Visiovestibular deficits and delayed return to exercise are also associated with pre-existing mental health diagnoses and prolonged recovery. Boys with prolonged recovery from concussion experience greater emotional symptom burden than girls.

CLINICAL RELEVANCE

Addressing pre-existing mental health diagnoses is essential to concussion management. Boys with prolonged recovery from concussion may particularly benefit from interventions to address their higher emotional symptom burden. Interventions, including a home visio-vestibular exercise program and symptom-limited exercise, may contribute to improving time to concussion recovery.

CARE4Kids Study: Endophenotypes of Persistent Post-Concussive Symptoms in Adolescents: Study Rationale and Protocol

Treatment of youth concussion during the acute phase continues to evolve, and this has led to the emergence of guidelines to direct care. While symptoms after concussion typically resolve in 14-28 days, a portion (∼20%) of adolescents endorse persistent post-concussive symptoms (PPCS) beyond normal resolution. This report outlines a study implemented in response to the National Institute of Neurological Diseases and Stroke call for the development and initial clinical validation of objective biological measures to predict risk of PPCS in adolescents. We describe our plans for recruitment of a Development cohort of 11- to 17-year-old youth with concussion, and collection of autonomic, neurocognitive, biofluid, and imaging biomarkers. The most promising of these measures will then be validated in a separate Validation cohort of youth with concussion, and a final, clinically useful algorithm will be developed and disseminated. Upon completion of this study, we will have generated a battery of measures predictive of high risk for PPCS, which will allow for identification and testing of interventions to prevent PPCS in the most high-risk youth.

Improving outcome after paediatric concussion: challenges and possibilities

The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.

Saliva Cortisol as a Biomarker of Injury in Youth Sport-Related Concussion

Increasing rates of sport-related concussion (SRC) in youth impose a significant burden on public health systems and the lives of young athletes. Accurate prediction for those likely to develop persistent post-concussion symptomology (PPCS) using a fluid biomarker, reflecting both acute injury and recovery processes, would provide the opportunity for early intervention. Cortisol, a stress hormone released through the hypothalamic-pituitary-adrenal (HPA) axis following injury, may provide a missing physiological link to clinical recovery. This cohort study investigated the change in saliva cortisol following SRC and the association between cortisol and symptom burden in pediatric ice hockey players. Further, the association between cortisol levels and medical clearance to return to play was explored. In total, cortisol samples from 233 players were included; 165 athletes (23.6% female) provided pre-injury saliva and 68 athletes (19.1% female) provided post-SRC saliva samples for cortisol analysis. Quantile (median) regressions were used to compare cortisol between pre-injury and post-SRC groups, and the association between total symptoms (/22) and symptom severity scores (/132) reported on the Sport Concussion Assessment Tool (SCAT)3/SCAT5 and post-SRC cortisol (adjusting for age, sex, history of concussion, and time from injury to sample collection). Results demonstrated significantly lower saliva cortisol in post-SRC athletes compared with the pre-injury group (β = -0.62, 95% confidence interval [CI; -1.08, -0.16], p = 0.009). Post-SRC cortisol was not significantly associated with the SCAT3/SCAT5 symptom totals or symptom severity scores; however, females were found to report more symptoms (β = 6.95, 95% CI [0.35, 13.55], p = 0.040) and greater symptom severity (β = 23.87, 95% CI [9.58, 38.15], p = 0.002) compared with males. Exploratory time-to-event analysis revealed a point estimate suggesting a potential association between low cortisol levels and days to medical clearance to return to play. Although preliminary, these findings suggest that the HPA axis may be dysregulated post-SRC. Further, our exploratory analysis and case presentation of post-injury outliers highlight the need to further research cortisol as a prognostic biomarker to inform individualized sex-specific care after SRC.

Psychometric Properties and Validation of the General Anxiety Disorder 7-Item Scale Among Adolescents With Persistent Post-Concussive Symptoms

The General Anxiety Disorder 7-Item (GAD-7) scale is commonly used in primary care as a self-report measure of general anxiety symptoms with adult populations. There is little psychometric research on this measure with adolescent populations, particularly those with persistent post-concussive symptoms (PPCS). This study examined the psychometrics properties of the GAD-7 among youth with PPCS. We used baseline data from a randomized controlled trial of collaborative care for treatment of PPCS among 200 sports-injured adolescents 11-18 years of age (M_age = 14.7 years, standard deviation = 1.7). Eligible adolescents had three or more PPCS that lasted for ≥1 month and spoke English. Adolescents reported on their anxious (GAD-7 and Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]; RCADS) and depressive (Patient Health Questionnaire-9; PHQ-9) symptoms. Parents used the RCADS to report on their adolescents' anxious symptoms. The GAD-7 had good internal validity (Cronbach's alpha = 0.87), and significant (p < 0.001) correlations were detected between the GAD-7 and youth and parent report of anxiety on RCADS (r = 0.73 and r = 0.29) and PHQ-9 (r = 0.77) scores. Confirmatory factor analysis suggested a one-factor solution. These results suggest that the GAD-7 is a valid measure of anxiety with good psychometric properties for youth experiencing PPCS. ClinicalTrials.gov identifier: NCT03034720.

Psychometric Properties of the German Version of the Rivermead Post-Concussion Symptoms Questionnaire in Adolescents after Traumatic Brain Injury and Their Proxies

The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) assesses post-concussion symptoms (PCS) after traumatic brain injury (TBI). The current study examines the applicability of self-report and proxy versions of the German RPQ in adolescents (13-17 years) after TBI. We investigated reliability and validity on the total and scale score level. Construct validity was investigated by correlations with the Post-Concussion Symptoms Inventory (PCSI-SR13), Generalized Anxiety Disorder Scale 7 (GAD-7), and Patient Health Questionnaire 9 (PHQ-9) and by hypothesis testing regarding individuals' characteristics. Intraclass correlation coefficients (ICC) assessed adolescent-proxy agreement. In total, 148 adolescents after TBI and 147 proxies completed the RPQ. Cronbach's α (0.81-0.91) and McDonald's ω (0.84-0.95) indicated good internal consistency. The three-factor structure outperformed the unidimensional model. The RPQ was strongly correlated with the PCSI-SR13 (self-report: r = 0.80; proxy: r = 0.75) and moderately-strongly with GAD-7 and PHQ-9 (self-report: r = 0.36, r = 0.35; proxy: r = 0.53, r = 0.62). Adolescent-proxy agreement was fair (ICC [2,1] = 0.44, CI_95% [0.41, 0.47]). Overall, both self-report and proxy assessment forms of the German RPQ are suitable for application in adolescents after TBI. As proxy ratings tend to underestimate PCS, self-reports are preferable for evaluations. Only if a patient is unable to answer, a proxy should be used as a surrogate.

Examining Suicidality in Adolescents Who Have Sustained Concussions

Prior studies have reported an association between concussion and suicidality in high school students in the United States. However, when controlling for multiple life stressors in adolescence (e.g., bullying, substance use, poor grades), the relationship between concussion and suicidality was either attenuated or became nonsignificant in one study. Rather than assessing concussion as a possible risk factor for suicidality, this study examined predictors of ideation, planning, and attempts among youth who experienced concussion in the past year. The sample included 13,677 participants from the 2019 Youth Behavior Risk Survey, of whom 1,754 (13%) reported experiencing a concussion in the past year. Binary logistic regressions were conducted to predict ideation, planning, and attempts with modifiable stress factors, including physical activity, bullying, poor grades, insufficient sleep, binge drinking, marijuana use, illicit drug use, and depression. Among adolescents who experienced a concussion in the past year, 25% reported suicidal ideation (31% girls/19% boys), 20% reported suicide planning (25% girls/17% boys), and 15% reported a suicide attempt (17% girls/13% boys). In a multivariable model among girls with prior year concussion, being bullied (OR=2.37), illicit drug use (OR=2.80), current marijuana use (OR=2.47), and depression (OR=9.22) predicted suicidal ideation. Among boys with prior year concussion, being bullied (OR=2.29) and depression (OR=9.50) predicted suicidal ideation. Additional models were used to examine the association between having one or more modifiable stressors and suicidality, revealing that having three or more modifiable stressors was associated with a substantial increase in proportions of youth reporting suicidality. Among adolescents experiencing a concussion, treating depression and substance use, stopping bullying, and increasing physical activity may be associated with reduced risk for suicidality.

Association Between Concussions and Suicidality in High School Students in the United States

Importance

Prior research has shown a statistically significant association between sustaining a concussion and suicidality in adolescents, but this prior research controlled for relatively few variables predictive of suicidality.

Objective

To examine whether sustaining a concussion remained a significant predictor of suicidality after controlling for relevant covariates (e.g., sexual abuse/assault, bullying, substance use, depression), hypothesizing that the relationship between concussion and suicidality would become non-significant after controlling for these variables.

Design

This study involved secondary data analysis of the 2019 Youth Risk Behavior Surveillance (YRBS) System, a national cross-sectional study of adolescents. Analyses were stratified by gender.

Setting

A national sampling of U.S. high school students.

Participants

Eleven thousand two hundred sixty-two students in the YRBS database, including 5,483 boys and 5,779 girls.

Exposure(s)

Participants included in the analyses reported whether, in the last year, they experienced a concussion and/or suicidality.

Main Outcomes and Measures

The main outcome was suicidality (i.e., ideation, planning, attempt), which was predicted by concussion in an unadjusted analysis and by concussion along with other risk factors in a multivariable analysis.

Results

The final sample included 11,262 participants with available data on concussion and suicidality in the last year (14–18 years-old; 51.3% girls; 49.0% White). Per unadjusted odds ratios with 95% confidence intervals, there was a relationship between concussion and suicidal ideation [girls: OR = 1.46 (1.24, 1.73); boys: OR = 1.69 (1.41, 2.03)], planning (girls: OR = 1.39 [1.16, 1.66]; boys: OR = 1.76 [1.44, 2.14]), and attempt [girls: OR = 1.70 (1.32, 2.19); boys: OR = 3.13, (2.37, 4.15)]. These relationships became mostly non-significant after controlling for relevant risk factors for suicidality. The adjusted odds ratios showed no relationship between concussion and suicidal ideation [girls: OR = 1.11 (0.86, 1.44); boys: OR = 1.24 (0.92, 1.69)] or planning (girls: OR = 1.07 [0.82, 1.40]; boys: OR = 1.12 [0.82, 1.55]); but a significant relationship with suicide attempts in boys [OR = 1.98 (1.28, 3.04)], but not girls [OR = 1.05 (0.74, 1.49)].

Conclusions and Relevance

There was an association between concussion and suicidality in U.S. high school students; however, after controlling for other variables (e.g., depression, sexual abuse/assault, illicit drug use), there was no association between concussion and suicidality aside from a significant relationship between concussion and attempts in boys.

A Child Presenting with a Glasgow Coma Scale Score of 13: Mild or Moderate Traumatic Brain Injury? A Narrative Review

OBJECTIVE

The objective of this article was to compare children with traumatic brain injury (TBI) and Glasgow Coma Scale score (GCS) 13 with children presenting with GCS 14 and 15 and GCS 9 to 12.

DATA SOURCE

We searched PubMed for clinical studies of children of 0 to 18 years of age with mild TBI (mTBI) and moderate TBI, published in English language in the period of 2000 to 2020.

STUDY SELECTION

We selected studies sub-classifying children with GCS 13 in comparison with GCS 14 and 15 and 9 to 12. We excluded reviews, meta-analyses, non-U.S./European population studies, studies of abusive head trauma, and severe TBI.

DATA SYNTHESIS

Most children (>85%) with an mTBI present at the emergency department with an initial GCS 15. A minority of only 5% present with GCS 13, 40% of which sustain a high-energy trauma. Compared with GCS 15, they present with a longer duration of unconsciousness and of post-traumatic amnesia. More often head computerized tomography scans show abnormalities (in 9-16%), leading to neurosurgical intervention in 3 to 8%. Also, higher rates of severe extracranial injury are reported. Admission is indicated in more than 90%, with a median length of hospitalization of more than 4 days and 28% requiring intensive care unit level care. These data are more consistent with children with GCS 9 to 12. In children with GCS 15, all these numbers are much lower.

CONCLUSION

We advocate classifying children with GCS 13 as moderate TBI and treat them accordingly.

Perceptions of Symptom Duration are Associated With Emotional Distress and Functioning in Adolescents With Protracted Concussion Recovery

 

Adolescents with persisting post-concussive symptoms often report high levels of emotional distress, which can impact their daily functioning. The associations between modifiable factors, such as perceptions of recovery, and emotional distress have not been investigated in this age group.

Objective

To evaluate perceptions about recovery duration (e.g., “my symptoms will last a long time”, “my symptoms will be permanent rather than temporary”) and its associations with emotional distress and functioning in children and adolescents with a slower post-concussive recovery.

Methods

Participants (N = 49, 69% girls, 11–17 years old, M = 15.8 years old, SD = 1.8) were recruited from a concussion clinic on average 7.7 months after injury (SD = 2.5). Measures included the Illness Perception Questionnaire Revised (perceived duration of symptoms only) to evaluate recovery expectations, the Health and Behavior Inventory (self and parent reports) to evaluate current post-concussive symptoms (cognitive and somatic symptoms), the emotional distress subscale of the Strengths and Difficulties Questionnaire (SDQ—self-report), and the emotional functioning subscale of the Pediatric Quality of Life Questionnaire (PedsQL—self-report).

Results

Regression analyses (linear models with all covariates entered at once) suggested that greater expectations for symptom persistence were significantly associated with higher emotional distress on both SDQ and PedsQL subscales, after controlling for post-concussive symptom severity and other confounds. Emotional distress/functioning was not associated with perceptions of symptom duration reported by parents, severity of post-concussive symptoms (self- and parent reports), age, number of concussions, time since injury, or a history of mental health concern or diagnosis (parent-reported).

Conclusions

This study suggests that pessimistic attitudes for recovery duration may be more strongly associated with emotional distress than current post-concussive symptom severity or a history of mental health concern or diagnosis.

Neuropsychological and neuropsychiatric recovery from mild traumatic brain injury

PURPOSE OF REVIEW

Mild traumatic brain injury (mTBI) is a significant public health concern for children. This review summarizes recent literature on early symptoms and neuropsychiatric and neuropsychological outcomes following pediatric mTBI and highlights factors that predict prolonged recovery. Evidence-based recommendations for assessment and treatment are also discussed.

RECENT FINDINGS

Whereas most children recover within 1 month after mTBI, 10-30% of children experience lingering neuropsychiatric or neuropsychological symptoms 3 months or more after injury. For the subset who experience prolonged recovery, new or worsening emotional and behavioral symptoms are the most frequent concerns. Recent research has suggested that specific factors, including preinjury mental health concerns, female sex, and family characteristics, are associated with increased risk of experiencing prolonged recovery. Early management includes reassurance, brief rest (1-3 days), and gradual return to typical activities. When symptoms linger for more than 4 weeks, evaluation in a specialty clinic is recommended and multimodal therapies are considered. Active recovery models, which include gradual return to aerobic exercise and cognitive behavioral approaches, are promising for the management of prolonged symptoms.

SUMMARY

A minority of children with mTBI experience prolonged neuropsychiatric or neuropsychological concerns. While our understanding of pediatric mTBI is growing, and recommendations for assessment and management have been developed, many gaps remain.

Risk of Mental Health Problems in Children and Youths Following Concussion

IMPORTANCE

Concussion may exacerbate existing mental health issues. Little evidence exists on whether concussion is associated with the onset of new psychopathologies or long-term mental health problems.

OBJECTIVE

To investigate associations between concussion and risk of subsequent mental health issues, psychiatric hospitalizations, self-harm, or suicides.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study including children and youths aged 5 to 18 years with a concussion or orthopedic injury incurred between April 1, 2010, and March 31, 2020, in Ontario, Canada. Participants had no previous mental health visit in the year before the index event for cohort entry and no prior concussion or traumatic brain injury 5 years before the index visit. Data were collected from provincewide health administrative databases. Participants with concussion were included in the exposed cohort, and those with an orthopedic injury were included in the comparison cohort; these groups were matched 1:2, respectively, on age and sex.

EXPOSURES

Concussion or orthopedic injury.

MAIN OUTCOMES AND MEASURES

The primary outcome was mental health problems, such as psychopathologies and psychiatric disorders, identified from health care visits in emergency departments, hospitalizations, or primary care settings. Secondary outcomes were psychiatric hospitalizations, self-harm health care visits, and death by suicide (identified in health care or vital statistics databases).

RESULTS

A total of 152 321 children and youths with concussion (median [IQR] age, 13 [10-16] years; 86 423 [56.7%] male) and 296 482 children and youths with orthopedic injury (median [IQR] age, 13 [10-16] years; 171 563 [57.9%] male) were matched by age and sex. The incidence rates of any mental health problem were 11 141 per 100 000 person-years (exposed group) and 7960 per 100 000 person-years (unexposed group); with a difference of 3181 (95% CI, 3073-3291) per 100 000 person-years. The exposed group had an increased risk of developing a mental health issue (adjusted hazard ratio [aHR], 1.39; 95% CI, 1.37-1.40), self-harm (aHR, 1.49; 95% CI, 1.42-1.56), and psychiatric hospitalization (aHR, 1.47; 95% CI, 1.41-1.53) after a concussion. There was no statistically significant difference in death by suicide between exposed and unexposed groups (HR, 1.54; 95% CI, 0.90-2.61).

CONCLUSIONS AND RELEVANCE

Among children and youths aged 5 to 18 years, concussion was associated with an increased risk of mental health issues, psychiatric hospitalization, and self-harm compared with children and youths with an orthopedic injury.

Anxiety Is Associated With Diverse Physical and Cognitive Symptoms in Youth Presenting to a Multidisciplinary Concussion Clinic

INTRODUCTION

Pre-injury and post-injury anxiety are prevalent and important to consider in the medical management of concussions in youth. We examined the association between anxiety and other physical, cognitive, and emotional symptoms in injured adolescents and young adults undergoing an initial evaluation in a specialty concussion clinic.

METHODS

Participants were 158 adolescents and young adults presenting to a multidisciplinary concussion clinic for evaluation and treatment (54.4% girls and women; mean age = 17.3 years; SD = 2.9). Their median days post injury was 29 (interquartile range = 14-49; range = 7-349). They were divided into binary groups based on whether they had a pre-injury history of anxiety diagnosis or treatment and whether they were experiencing current anxiety in the week prior to the evaluation, and then compared on the Post-Concussion Symptom Scale.

RESULTS

Youth with a pre-injury history of anxiety reported greater post-concussion symptoms (Md total score = 36.0, IQR = 21.5-53.0) compared to youth with no pre-injury history of anxiety (Md total score = 20.5, IQR = 6.0-36.0; MW U = 1,520.00 p = 0.001, r = 0.26, small-medium effect size). They reported significantly worse headaches, nausea, balance difficulty, dizziness, vision problems, fatigue, concentration difficulty, irritability, nervousness, sadness, feeling more emotional, trouble falling asleep, and sleeping more than usual. Youth with high post-injury anxiety reported greater post-concussion symptoms (Md total score = 55.0, IQR = 33.0-62.5) compared to youth with low post-injury anxiety (Md total score = 19.0, IQR = 6.0-35.0; MW U = 681.00, p < 0.001, r = 0.49, large effect size). They reported significantly worse headaches, nausea, vomiting, dizziness, vision problems, fatigue, sensitivity to light, feeling mentally foggy, feeling slowed down, concentration difficulty, memory difficulty, irritability, sadness, feeling more emotional, drowsiness, trouble falling asleep, sleeping less than usual, and sleeping more than usual. Logistic regressions revealed that both pre-injury and post-injury anxiety were strong predictors of persistent post-concussion symptoms, with high post-injury anxiety presenting the strongest independent predictor, while attention-deficit hyperactivity disorder and pre-injury migraines were not significant predictors. Essentially all adolescents with high post-injury anxiety (97.1%) and nearly 9 of 10 adolescents with pre-injury treatment for anxiety (87.8%) met criteria for persistent post-concussion symptoms.

DISCUSSION

Pre-injury and post-injury anxiety are important risk factors for greater post-concussion symptoms among adolescents and young adults. Elevated post-injury anxiety was the strongest predictor of persistent post-concussion symptoms. Assessment of anxiety is important among adolescents presenting for concussion care and delivery of evidence-supported treatments for anxiety are important considerations for treatment planning for these youth.

Prevalence and risk factors for depression, anxiety and suicidal ideation in youth with persistent post-concussive symptoms (PPCS)

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

Association Between Preinjury Symptoms and Postconcussion Symptoms at 4 Weeks in Youth

OBJECTIVE

To investigate whether preinjury physical, emotional, cognitive, and sleep symptoms on the Post-Concussion Symptoms Inventory (PCSI) are associated with persistent postconcussion symptoms (PPCS) at 4 weeks and whether any associations are moderated by sex or age.

STUDY SETTING AND PARTICIPANTS

A total of 3063 participants with acute concussion, presenting to 9 Canadian pediatric emergency departments, were enrolled from August 2013 to June 2015.

DESIGN

A planned secondary analysis of a prospective, multicenter cohort study (Predicting Persistent Post-concussive Problems in Pediatrics or 5P). Primary outcome was PPCS at 4 weeks, defined as 3 or more new or worsening individual symptoms compared with the preinjury score at 28 days on the PCSI. The association between preinjury scores and PPCS was analyzed with a multivariable logistic regression analysis that included preinjury, sex, age, sex × preinjury, and age × preinjury interactions as predictors. Missing baseline covariates were imputed.

RESULTS

A total of 2123 (n = 844 [39.8%] girls; median [IQR] age = 12.9 [10.7, 15.0] participants were included in the analysis. Preinjury physical symptom score was associated with PPCS at 4 weeks (χ2 = 13.87, df = 6, P = .031). The preinjury emotional score also contributed to the variability in PPCS (χ2 = 11.79, df = 6, P = .067). While girls reported higher preinjury physical, emotional, and cognitive scores than boys, neither sex nor age interacted with preinjury to predict PPCS at 4 weeks. Independent of age and sex, preinjury physical symptoms were associated with PPCS at 4 weeks (OR = 1.40; 95% CI, 1.15-1.70).

CONCLUSION

Preinjury physical symptoms are associated with the probability of having PPCS at 4 weeks postconcussion independent of age and sex. Providers should consider preinjury symptoms to inform prognosis and recovery management.

Mental health after paediatric concussion: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis sought to rigorously examine mental health outcomes following paediatric concussion. To date, heterogeneous findings and methodologies have limited clinicians' and researchers' ability to meaningfully synthesise existing literature. In this context, there is a need to clarify mental health outcomes in a homogeneous sample, controlling for key methodological differences and applying a consistent definition of concussion across studies.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched Medline, Embase, PsycINFO, CINAHL, SportDiscus, Scopus and PubMed.

ELIGIBILITY

Peer-reviewed studies published between 1980 and June 2020 that prospectively examined mental health outcomes after paediatric concussion, defined as per the Berlin Consensus Statement on Concussion in Sport.

RESULTS

Sixty-nine articles characterising 60 unique samples met inclusion criteria, representing 89 114 children with concussion. Forty articles (33 studies) contributed to a random effects meta-analysis of internalising (withdrawal, anxiety, depression, post-traumatic stress), externalising (conduct problems, aggression, attention, hyperactivity) and total mental health difficulties across three time points post-injury (acute, persisting and chronic). Overall, children with concussion (n=6819) experienced significantly higher levels of internalising (g=0.41-0.46), externalising (g=0.25-0.46) and overall mental health difficulties compared with controls (g=0.18-0.49; n=56 271), with effects decreasing over time.

SUMMARY/CONCLUSIONS

Our review highlights that mental health is central to concussion recovery. Assessment, prevention and intervention of mental health status should be integrated into standard follow-up procedures. Further research is needed to clarify the mechanisms underlying observed relationships between mental health, post-concussion symptoms and other psychosocial factors. Results suggest that concussion may both precipitate and exacerbate mental health difficulties, thus impacting delayed recovery and psychosocial outcomes.

Anxiety, depression, and symptom experience in concussed children and youth

PURPOSE

To describe and explore the relationship between baseline anxiety, depression and symptom experience in children and youth assessed at a concussion clinic.

DESIGN AND METHODS

A retrospective chart review of concussed children and youth referred to a pediatric teaching hospital concussion clinic over a 15-month period was completed. Kutcher Adolescent Depression Scale (KAD-6), General Anxiety Disorder Scale (GAD-7), and the Post-Concussion Symptom Inventory (PCSI) scores were extracted.

RESULTS

A total of 155 patients were included. The most common symptoms (PCSI) at baseline were headache, fatigue, and feelings of head pressure. Symptoms were rated as mild to moderate in intensity. Overall, mean depression and anxiety scores were low. The mean anxiety scores, as measured by the GAD-7 (n = 108), was 7.4 (range, 0-24). The mean depression score, as measured by the KAD-6 (n = 94), was 4.7 (range, 0-18). A statistically significant, moderate positive correlation between PCSI scores with KAD-6 scores for male (r = .64, p < .001) and female (r = .61, p < .001) participants was identified. Similarly, a statistically significant, moderate positive correlation between PCSI scores with GAD-7 scores for male (r = .68, p < .001) and female (r = .60, p < .001) participants was identified.

PRACTICE IMPLICATIONS

Concussed children may experience a wide array of symptoms, including emotional challenges such as anxiety and depression. Feelings of anxiety and depression may contribute to overall post concussive symptoms in concussed children. The electronic health record can be leveraged to provide important patient data. Clinicians should systematically assess symptoms at each visit in concussed children and youth so that appropriate interventions can be implemented and monitored.

Mental Health in the Young Athlete

PURPOSE OF REVIEW

The goal of the present paper is to provide a comprehensive overview of mental health concerns in young athletes, with a focus on common disorders, as well as population-specific risk factors.

RECENT FINDINGS

Athletes experience similar mental health concerns as non-athlete peers, such as anxiety, depression and suicidal ideation, ADHD, eating disorders, and substance abuse. However, they also experience unique stressors that put them at risk for the development or exacerbation of mental health disorders. Student athletes have to balance academics with rigorous training regimens while focusing on optimal performance and managing high expectations. Physical injuries, overtraining, concussion, sleep disorders, and social identity are some of the factors that also impact the mental health of student athletes. Existing literature highlights the need to develop proactive mental health and wellness education for young athletes, and to develop services that recognize the unique needs of this population.

Mood-related changes in children and adolescents with persistent concussion symptoms following a six-week active rehabilitation program

PRIMARY OBJECTIVE

The purpose of this study is to explore changes in mood in youth with persistent post-concussion symptoms following participation in a six-week active rehabilitation program.

RESEARCH DESIGN

A pre-post test design was used.

METHODS AND PROCEDURES

Participants (N = 40 children and adolescents with concussion symptoms >2 weeks post-injury) were recruited from the concussion services at an urban children's rehabilitation hospital and the community. The program consisted of individualized low-intensity aerobic exercise, sport-specific drills, relaxation exercises and comprehensive education and support. The 6 week program was completed by participants in their home or local community with weekly check-ins with the research team. Data were analyzed using descriptive statistics and linear regressions.

MAIN OUTCOMES AND RESULTS

Outcome measures included the Beck Youth Inventories (youth), and the Child Behavior Checklist (parents). Results indicated significant improvements in anger and anxiety post-intervention with anger reduction being more pronounced in girls.

CONCLUSIONS

Active rehabilitation interventions may have positive effects on mood in youth recovering from concussion. Clinicians may wish to consider addressing anxiety and anger management strategies as part of comprehensive concussion management in youth.

Detecting mental health problems after paediatric acquired brain injury: A pilot Rasch analysis of the strengths and difficulties questionnaire

The parent-reported Strengths and Difficulties Questionnaire (SDQ-P) is commonly used to assess for mental health problems, but its psychometric properties have not been studied in the paediatric Acquired Brain Injury (ABI) population. This study investigated the properties of the SDQ-P and its subscales in this population using Rasch analysis. One hundred and forty-three SDQ-Ps and 123 Impact Supplements were analyzed. Sixty-nine percent of SDQ-Ps were completed by female carers, 59% of young people were male, and 58% had Traumatic Brain Injury (TBI). In this population the SDQ-P Total Difficulties Scale and the Conduct Problems subscale showed questionable construct validity. The individual subscales and Impact Supplement did not meet the criteria for reliability. Two items had disordered thresholds. The individual subscales showed mistargeting and 13-24% person misfit. Two items were significantly underdiscriminating. There was differential item functioning with age and time post-injury, and local dependence between subscale items. The Total Difficulties scale was multidimensional. The most easily endorsed items were in keeping with common symptoms of brain injury. These findings suggest the SDQ-P in its current form may not be a reliable and valid assessment measure for mental health difficulties in the paediatric ABI population and requires further investigation.

A commentary for neuropsychologists on CDC's guideline on the diagnosis and management of mild traumatic brain injury among children

Objective: In 2018, the Centers for Disease Control Prevention (CDC) published an evidence-based guideline on the diagnosis and management of mild traumatic brain injury (mTBI) among children. This commentary summarizes the key recommendations in the CDC Pediatric mTBI Guideline most relevant for neuropsychologists and discusses research gaps and topics that should receive attention in future iterations of the Guideline.Method: We described the methods used to develop the Guideline, which included a comprehensive Systematic Review. We also distilled and presented key practice strategies reflected in Guideline.Results: To optimize care of pediatric patients with mTBI, neuropsychologists should: use validated, age-appropriate symptom scales, assess evidence-based risk factors for prolonged recovery, provide patients with instructions on return to activity customized to their symptoms, and counsel patients to return gradually to nonsports activities after a short period of rest. Future iterations of the Guideline should encompass a review and guidance on care of patients with psychiatric and psychological difficulties, as well as the potential use of imaging to assess patients with persistent symptoms. Expanded research on mTBI among girls, children age 8 and under, and effective treatments for pediatric mTBI will be beneficial to inform care practices.Conclusions: Recommendations in the CDC Pediatric mTBI Guideline highlight multiple opportunities for neuropsychologists to take action to improve the care of young patients with mTBI and to advance research in the field. Multiple resources and tools are available to support implementation of these recommendations into clinical practice.

Predictors for Psychological Distress 2 Months After Mild Traumatic Brain Injury

Objective: To predict psychological distress at 2 months for patients with mild traumatic brain injury.

Method: A prospective cohort study of 162 patients with mild traumatic brain injury (MTBI) admitted consecutively to an outpatient clinic at Haukeland University Hospital, Norway. Demographic data were obtained from Statistics Norway and injury characteristics were obtained from the hospital records. Sick leave data from the last year before the injury were obtained from The Norwegian Labor and Welfare Service. Self-report questionnaires were used to obtain history about earlier disease and symptom profiles. The Hospital Anxiety and Depression Scale (HAD) detecting states of depression and anxiety were used as the dependent variable in a stepwise linear regression. Pre-injury factors and injury-related factors were examined as potential predictors for HAD.

Results: In the first steps we observed a significant association between HAD at 2 months and education, whiplash associated disorder (WAD), and earlier sick listed with a psychiatric diagnosis. In the final step there was an association only between HAD and self-reported anxiety and WAD. There were no associations between HAD and injury-characteristics like severity at Glasgow Coma Scale or intracranial injury.

Conclusion: Patients with low education, earlier psychiatric diagnosis, self-reported earlier anxiety and WAD were more likely to develop a psychological distress after a MTBI. These findings should be taken into consideration when treating patients with MTBI.