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

Contemporary diagnosis and management of mild TBI (concussions): What you need to know

ABSTRACT

Concussion is a common injury in children and adolescents and is a form of mild traumatic brain injury that surgeons will see in their acute care practice. With a rapidly changing evidence base for diagnosis and management, we will focus on the importance of timely identification and diagnosis, as well as the early initiation of active management of pediatric concussion immediately after injury through recovery. This approach involves the application of targeted therapies for specific deficits identified after concussion, addressing the individual pattern of symptoms experienced by patients following concussion. We will review what is known about the underlying pathophysiology that drives the clinical manifestations of concussion, the targeted clinical assessments that can both aid in the diagnosis of concussion, as well as drive the active rehabilitation of deficits seen after concussion. The standardized approach to the return to activities will also be described, including return to learning and sports.

Impact of Sex and Pubertal Development on Anxiety in Adolescents After Concussion

Concussion often results in psychological symptoms, including anxiety. Post-concussion anxiety has been well documented, although much of this research has focused on collegiate athletes. The purpose of this study was to compare (1) anxiety symptoms in concussed and healthy controls over time and (2) to explore sex differences in post-concussion anxiety within the context of pubertal development. Participants (N = 126, mean age = 15.1 years old), including concussed (n = 86) and healthy adolescents (n = 40), completed the Pubertal Development Scale (PDS) and the Screen for Child Anxiety and Related Disorders (SCARED-C). The concussed groups completed SCARED-C at three visits (<10 days, 4 weeks, 3 months). Results of an analysis of covariance (ANCOVA) and multi-variate analysis of covariance (MANCOVA) found concussed adolescents reported higher SCARED-C total, generalized, and panic anxiety scores than healthy controls, after controlling for sex, age, and PDS score (PDSS). A three-way mixed ANCOVA examined the effects of sex, PDSS, time, and their interaction on SCARED-C total score in concussed adolescents while controlling for age. There was a significant three-way interaction between sex, age, and PDSS on SCARED-C total score while controlling for age. Overall, we observed increased anxiety in concussed adolescents, compared with controls, as well as greater post-concussion anxiety reported by females compared with males, including within PDSS groups. Concussion providers should be prepared to receive training to administer well-validated measures of psychopathology and should consider that female adolescents, compared with males, regardless of pubertal development, may be at greater risk for post-concussion anxiety.

Relations between concussion symptoms and depression among patients with mild traumatic brain injury: A moderated mediation model

INTRODUCTION

Concussion symptoms following a traumatic accident are both common and known to adversely affect mental health and recovery in patients with traumatic brain injury. Depression, highly prevalent among patients with traumatic brain injury, is also associated with the important factors of sleep quality and resilience. However, the mediator and moderator roles of depression following concussion in patients with traumatic brain injury have been underexplored. The aims of this study were to investigate the mediating role of sleep quality in the relation between concussion symptoms and depression and to examine the moderating effect of resilience on this mediated model.

DESIGN

Cross-sectional pretest data analysis of a randomized controlled trial.

METHODS

A total of 249 adult patients with mild traumatic brain injury (Glasgow Coma Scale 13-15) at admission following brain injury were surveyed at a medical center in Taipei, Taiwan. The outcome variables were concussion symptoms (Rivermead Post-Concussion Symptom Questionnaire), sleep quality (Pittsburgh Sleep Quality Index), resilience (Resilience Scale for Adults), and depression (Beck Depression Inventory II). These data were analyzed using moderated mediation regressions with the SPSS PROCESS macro.

RESULTS

In patients with mild traumatic brain injury, there was a significant positive relation between concussion symptoms and depression, of which sleep quality was a significant mediator. Additionally, resilience had a negative moderating effect on the relations between sleep quality and depression. Patients with less resilience showed a stronger negative effect of sleep quality on depression.

CONCLUSION

Our findings suggest that ameliorating both concussion symptoms and sleep disturbance is important for reducing the risk of depression in patients with mild traumatic brain injury, especially in those patients with less resilience.

CLINICAL RELEVANCE

It is essential for clinical nurses to develop interventions for patients with mild traumatic brain injury that will improve their sleep quality, while strengthening their resilience, to alleviate depression.

Health-Related Quality of Life after Pediatric Traumatic Brain Injury: A Qualitative Comparison of Perspectives of Children and Adolescents after TBI and a Comparison Group without a History of TBI

BACKGROUND

The assessment of the impact of pediatric traumatic brain injury (TBI) on the health-related quality of life (HRQoL) of the children and adolescents affected can be ameliorated by a disease-specific instrument. Such an instrument does not yet exist. This qualitative study investigates how children and adolescents after TBI subjectively perceive their HRQoL and whether and how this differs from the perspective of individuals without a history of TBI.

METHODS

Eight problem-centered interviews were conducted with 11 children and adolescents around four years after mild TBI and with eight children and adolescents around three years after moderate to severe TBI. Nine problem-centered interviews were conducted with 25 participants without a history of TBI. The interviews were recorded and transcribed verbatim. The statements were assigned to inductively and deductively derived categories relevant to the HRQoL of children and adolescents after TBI and compared with those of individuals without a history of TBI.

RESULTS

The HRQoL of children and adolescents after TBI tended to display both structural and content-related differences, independently of TBI severity, on several HRQoL dimensions, in contrast to the comparison group. For example, participants after TBI reported a broader range of negative emotions (such as worry, sadness, shame, and guilt), permanent physical impairments, felt that they were treated differently from others, and perceived cognitive limitations.

CONCLUSIONS

The results of this qualitative study identified HRQoL dimensions that are relevant to children and adolescents after TBI and underlined the need for the development of a disease-specific instrument.

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.

The Emerging Role of Telehealth for Concussion Clinical Care During the Coronavirus (COVID-19) Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has substantially altered the delivery of healthcare for providers and their patients. Patients have been reticent to seek care for many diseases and injuries including concussion due to fears of potential exposure to COVID-19. Moreover, because of social distancing recommendations and stay-at-home orders, patient screening, evaluation, and delivery of care have become less efficient or impossible to perform via in-person clinic visits. Consequently, there was a sudden need to shift healthcare delivery from primarily in-person visits to telehealth. This sudden shift in healthcare delivery brings with it both challenges and opportunities for clinical concussion care. This article is designed to discuss these challenges and opportunities and provide an experiential-based framework for providing concussion care via telehealth. We first provide an overview of a clinical concussion model utilized at concussion specialty clinics from 3 geographically disparate healthcare systems for in-person service delivery prior to COVID-19. We then discuss the creation of new clinical workflows to facilitate the continued provision of concussion specialty care using telehealth. Finally, we examine lessons learned during this healthcare delivery shift including limitations and potential barriers for telehealth for concussion care, as well as opportunities for expansion of concussion care in rural and underserved areas. We also discuss the need to empirically evaluate the comparative efficacy of telehealth and in-person concussion care moving forward.