Relationships among post-concussive symptoms and symptoms of PTSD in children following mild traumatic brain injury

The journey back to normality: Support systems and posttrauma needs following exposure to single-incident trauma among children and adolescents

Social support has been linked to posttrauma adjustment in children and adolescents, but the components of good support remain poorly defined. We conducted qualitative interviews with 30 youths aged 7-16 years after being admitted to a hospital following a single-incident trauma, predominantly injury or illness. The aim was to identify youths' support needs and examine the support they received across different recovery stages. Thematic analysis revealed that although participants appreciated increased attention and warm support during their hospital stay, most wanted their lives to return to normal soon afterward and were frustrated by barriers to achieving this. Participants received support from different sources, but parents and peers were the most important providers of emotional support and the people with whom these individuals most frequently engaged in trauma-related conversations. Furthermore, although it was important that schools were sensitive to the youths' potential limitations regarding their ability to engage with lessons, emotional support from teachers was less valued. Overall, this study implies that ecological models incorporating multiple interacting layers capture the structure of youths' posttrauma support systems well. These findings may be used to tailor posttrauma interventions more closely to child and adolescent needs at different recovery stages and highlight the importance of having parents and, where possible, peers involved in posttrauma interventions or prevention programs.

ENIGMA brain injury: Framework, challenges, and opportunities

Traumatic brain injury (TBI) is a major cause of disability worldwide, but the heterogeneous nature of TBI with respect to injury severity and health comorbidities make patient outcome difficult to predict. Injury severity accounts for only some of this variance, and a wide range of preinjury, injury-related, and postinjury factors may influence outcome, such as sex, socioeconomic status, injury mechanism, and social support. Neuroimaging research in this area has generally been limited by insufficient sample sizes. Additionally, development of reliable biomarkers of mild TBI or repeated subconcussive impacts has been slow, likely due, in part, to subtle effects of injury and the aforementioned variability. The ENIGMA Consortium has established a framework for global collaboration that has resulted in the largest-ever neuroimaging studies of multiple psychiatric and neurological disorders. Here we describe the organization, recent progress, and future goals of the Brain Injury working group.

Structural connectome differences in pediatric mild traumatic brain and orthopedic injury

Sophisticated network‐based approaches such as structural connectomics may help to detect a biomarker of mild traumatic brain injury (mTBI) in children. This study compared the structural connectome of children with mTBI or mild orthopedic injury (OI) to that of typically developing (TD) children. Children aged 8–16.99 years with mTBI (n = 83) or OI (n = 37) were recruited from the emergency department and completed 3T diffusion MRI 2–20 days postinjury. TD children (n = 39) were recruited from the community and completed diffusion MRI. Graph theory metrics were calculated for the binarized average fractional anisotropy among 90 regions. Multivariable linear regression and linear mixed effects models were used to compare groups, with covariates age, hemisphere, and sex, correcting for multiple comparisons. The two injury groups did not differ on graph theory metrics, but both differed from TD children in global metrics (local network efficiency: TD > OI, mTBI, d = 0.49; clustering coefficient: TD < OI, mTBI, d = 0.49) and regional metrics for the fusiform gyrus (lower degree centrality and nodal efficiency: TD > OI, mTBI, d = 0.80 to 0.96; characteristic path length: TD < OI, mTBI, d = −0.75 to −0.90) and in the superior and middle orbital frontal gyrus, paracentral lobule, insula, and thalamus (clustering coefficient: TD > OI, mTBI, d = 0.66 to 0.68). Both mTBI and OI demonstrated reduced global and regional network efficiency and segregation as compared to TD children. Findings suggest a general effect of childhood injury that could reflect pre‐ and postinjury factors that can alter brain structure. An OI group provides a more conservative comparison group than TD children for structural neuroimaging research in pediatric mTBI.

Three-Month Psychiatric Outcome of Pediatric Mild Traumatic Brain Injury: A Controlled Study

The objective was to clarify occurrence, phenomenology, and risk factors for novel psychiatric disorder (NPD) in the first 3 months after mild traumatic brain injury (mTBI) and orthopedic injury (OI). Children aged 8-15 years with mTBI (n = 220) and with OI but no TBI (n = 110) from consecutive admissions to an emergency department were followed prospectively at baseline and 3 months post-injury with semi-structured psychiatric interviews to document the number of NPDs that developed in each participant. Pre-injury child variables (adaptive, cognitive, and academic function, and psychiatric disorder), pre-injury family variables (socioeconomic status, family psychiatric history, and family function), and injury severity were assessed and analyzed as potential confounders and predictors of NPD. NPD occurred at a significantly higher frequency in children with mTBI versus OI in analyses unadjusted (mean ratio [MR] 3.647, 95% confidence interval [CI₉₅] (1.264, 15.405), p = 0.014) and adjusted (MR = 3.724, CI₉₅ (1.264, 15.945), p = 0.015) for potential confounders. In multi-predictor analyses, the factors besides mTBI that were significantly associated with higher NPD frequency after adjustment for each other were pre-injury lifetime psychiatric disorder [MR = 2.284, CI₉₅ (1.026, 5.305), p = 0.043]; high versus low family psychiatric history [MR = 2.748, CI₉₅ (1.201, 6.839), p = 0.016], and worse socio-economic status [MR = 0.618 per additional unit, CI₉₅ (0.383, 0.973), p = 0.037]. These findings demonstrate that mild injury to the brain compared with an OI had a significantly greater deleterious effect on psychiatric outcome in the first 3 months post-injury. This effect was present even after accounting for specific child and family variables, which were themselves independently related to the adverse psychiatric outcome.

Post-Concussion and Post-Traumatic Stress Symptoms after Pediatric Traumatic Brain Injury: Shared Vulnerability Factors?

Following pediatric traumatic brain injury (TBI), post-concussion symptoms (PCS) and post-traumatic stress symptoms (PTSS) occur commonly; however, it is unknown to what degree they overlap. The study examined PCS and PTSS persisting 7 weeks after injury in children and adolescents ages 8-15 years with TBI (n = 89) or extracranial injury (EI; n = 40) after vehicle collisions. TBI was divided into mild, complicated-mild/moderate, and severe groups. Parents retrospectively rated children's pre-injury symptoms and behavior problems, and children completed self-report measures after injury. PCS and PTSS total scores were significantly correlated in TBI and EI groups, respectively, for child (rs = 0.75; rs = 0.44), and adolescent (rs = 0.61; rs = 0.67) cohorts. Generalized linear models examined whether injury type and severity, age, sex, and pre-injury symptom ratings predicted PCS and PTSS total scores and factor scores. Specific PCS and PTSS factor scores were elevated in different TBI severity groups, with most frequent problems following mild or severe TBI. PCS did not differ by age; however, girls had more emotional symptoms than boys. Only PTSS were predicted by pre-injury externalizing behavior. Significant age by sex interactions indicated that adolescent girls had more total, avoidance, and hyperarousal PTSS symptoms than younger girls or all boys. PCS and PTSS significantly overlapped in both TBI and EI groups, highlighting shared persistent symptoms after injury. Shared vulnerability factors included female sex, milder TBI, and poorer pre-injury adjustment. Older age was a unique vulnerability factor for PTSS. Psychological health interventions after injury should be customized to address comorbid symptoms.

Involvement in litigation in children with PTSD following motor vehicle accident: Associations with emotional distress and treatment outcomes

OBJECTIVES

Litigation is common in the context of Post-traumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI), adding contradicting motivations to individuals' engagement in psychotherapeutic interventions. This study's main goal was to explore the relationship between litigation status and emotional distress among children with PTSD following motor vehicle accidents (MVAs). We also present preliminary findings from a pilot study on treatment efficacy for children with PTSD, with and without litigation.

METHODS

Participants included 76 children with PTSD following MVA and their main caregiving parent. The associations between litigation status (litigation involvement, litigation phase, and litigation's emotional impact) and children's global distress, PTSD, persistent post-concussion symptoms (PPCS), and sub-optimal effort, and parents' PTSD symptoms were assessed before and after intervention for PTSD. Comorbid mTBI was explored as a possible moderating factor.

RESULTS

Involvement in litigation was not related to children's and parents' pre-intervention distress, nor to the presence of mTBI or to children's effort. However, higher emotional impact of litigation on parents was associated with children's higher PPCS pre-intervention. A pilot study on intervention outcomes found an improvement both in children with and without litigation involvement. A greater decrease in PPCS following intervention was found in children of parents with higher emotional impact of litigation.

CONCLUSIONS

The emotional impact of litigation on parents should be considered while addressing children in litigation context. However, this study's preliminary findings suggest that children with litigation involvement may benefit from treatment, thus litigation should not serve solely as an exclusion criterion for psychological intervention. A larger study should further explore this issue.

Challenges and opportunities for neuroimaging in young patients with traumatic brain injury: a coordinated effort towards advancing discovery from the ENIGMA pediatric moderate/severe TBI group

Traumatic brain injury (TBI) is a major cause of death and disability in children in both developed and developing nations. Children and adolescents suffer from TBI at a higher rate than the general population, and specific developmental issues require a unique context since findings from adult research do not necessarily directly translate to children. Findings in pediatric cohorts tend to lag behind those in adult samples. This may be due, in part, both to the smaller number of investigators engaged in research with this population and may also be related to changes in safety laws and clinical practice that have altered length of hospital stays, treatment, and access to this population. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Pediatric Moderate/Severe TBI (msTBI) group aims to advance research in this area through global collaborative meta-analysis of neuroimaging data. In this paper, we discuss important challenges in pediatric TBI research and opportunities that we believe the ENIGMA Pediatric msTBI group can provide to address them. With the paucity of research studies examining neuroimaging biomarkers in pediatric patients with TBI and the challenges of recruiting large numbers of participants, collaborating to improve statistical power and to address technical challenges like lesions will significantly advance the field. We conclude with recommendations for future research in this field of study.

Traumatic Brain Injury in Children: The Psychological Effects of Mild Traumatic Brain Injury

Concussion, or mild traumatic brain injury (mTBI), results from a force to the head and can cause acute physical, cognitive, and psychological symptoms. The majority of concussion symptoms will resolve within a month, but upward of a third of patients will have persistent, chronic symptoms. When these symptoms become chronic and persist beyond 1-3 months, this is termed post-concussion syndrome (PCS). Psychological changes associated with PCS may in part be due to a traumatic event and the injury itself and therefore post-traumatic stress reactions may contribute. In addition, alterations to daily life and alteration of lifestyle as a result of the injury can cause feelings of disconnection which in turn can feed anxiety and depression symptoms. A preinjury diagnosis or history of psychiatric or mood disorder, migraine, or family history of psychiatric illness is one the greatest risk factors for the development of PCS. It is recommended that evaluation of concussion and those with PCS take a multidisciplinary approach including evaluation by psychology, psychiatry, and/or neuropsychology. While most concussions do not require treatment, those with PCS will not likely see the resolution of their physical and psychological symptoms without intervention. Treatment is limited, but cognitive behavioral treatment has shown promise in the management of PCS symptoms. It is important to recognize the role psychology plays in the development and persistence of PCS and to recognize and seek collaborative care when treating these patients.

[Formula: see text] The role of family burden on informant discrepancies between parents and youths with protracted recovery from mild traumatic brain injury

Previous literature shows that family burden can lead to symptom-report discrepancies between parents and children. The present study sought to extend this research by investigating the influence of family burden factors, including socioeconomic status (SES) and family stress on informant discrepancies between parents and youths with mild traumatic brain injury (mTBI). Participants were clinically referred youths with mTBI ages 8-17, consecutively seen in a hospital-based neuropsychology concussion clinic (N = 81; females = 54.3%). Parents and children completed the Behavioral Assessment for Children System (BASC) and the Postconcussive Symptom Scale (PCSS). Parents rated changes in family stress related to the mTBI (categorized as "no change," "minor change," or "major change") and provided information to calculate SES. Results revealed that family stress but not SES influenced parent-child report discrepancies for the BASC Internalizing Symptoms Index (F = 8.72(2, 79), p <.000), and that the discrepancies were independent of postconcussive symptom severity. Clinical implications of these findings are discussed.

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.

Acute cognitive postconcussive symptoms follow longer recovery trajectories than somatic postconcussive symptoms in young children

Objective: To investigate somatic and cognitive postconcussive symptoms (PCS) using the symptom evaluation subtest (cSCAT3-SE) of the Child Sports Concussion Assessment Tool 3 (Child SCAT) in tracking PCS up to 2 weeks postinjury.Methods: A total of 96 participants aged 5 to 12 years (M_age = 9.55, SD = 2.20) completed three assessment time points: 48 h postinjury (T0), 2 to 4 days postinjury (T1), and 2 weeks postinjury (T2). The Wilcoxon signed-rank test was used to analyze differences between cognitive and somatic symptoms over time, while the Friedman test was used to analyze differences within symptom type over time.Results: Cognitive PCS were found to be significantly higher than somatic PCS at all assessment time points and were also found to significantly decline from 4 days onwards postinjury; in contrast, somatic PCS significantly declined as early as 48 hpostinjury.Discussion: Differences between cognitive and somatic PCS emerge as early as a few days postinjury, with cognitive PCS being more persistent than somatic PCS across 2 weeks. Research in symptom-specific interventions may be of benefit in helping young children manage severe PCS as early as 2 weeks postinjury.

Longitudinal Neuroimaging in Pediatric Traumatic Brain Injury: Current State and Consideration of Factors That Influence Recovery

Traumatic brain injury (TBI) is a leading cause of death and disability for children and adolescents in the U.S. and other developed and developing countries. Injury to the immature brain varies greatly from that of the mature, adult brain due to numerous developmental, pre-injury, and injury-related factors that work together to influence the trajectory of recovery during the course of typical brain development. Substantial damage to brain structure often underlies subsequent functional limitations that persist for years following pediatric TBI. Advances in neuroimaging have established an important role in the acute management of pediatric TBI, and magnetic resonance imaging (MRI) techniques have a particular relevance for the sequential assessment of long-term consequences from injuries sustained to the developing brain. The present paper will discuss the various factors that influence recovery and review the findings from the present neuroimaging literature to assess altered development and long-term outcome following pediatric TBI. Four MR-based neuroimaging modalities have been used to examine recovery from pediatric TBI longitudinally: (1) T1-weighted structural MRI is sensitive to morphological changes in gray matter volume and cortical thickness, (2) diffusion-weighted MRI is sensitive to changes in the microstructural integrity of white matter, (3) MR spectroscopy provides a sensitive assessment of metabolic and neurochemical alterations in the brain, and (4) functional MRI provides insight into the functional changes that occur as a result of structural damage and typical developmental processes. As reviewed in this paper, 13 cohorts have contributed to only 20 studies published to date using neuroimaging to examine longitudinal changes after TBI in pediatric patients. The results of these studies demonstrate considerable heterogeneity in post-injury outcome; however, the existing literature consistently shows that alterations in brain structure, function, and metabolism can persist for an extended period of time post-injury. With larger sample sizes and multi-site cooperation, future studies will be able to further examine potential moderators of outcome, such as the developmental, pre-injury, and injury-related factors discussed in the present review.

Lifelong consequences of brain injuries during development: From risk to resilience

Traumatic brain injuries in children represent a major public health issue and even relatively mild injuries can have lifelong consequences. However, the outcomes from these injuries are highly heterogeneous, with most individuals recovering fully, but a substantial subset experiencing prolonged or permanent disabilities across a number of domains. Moreover, brain injuries predispose individuals to other kinds of neuropsychiatric and somatic illnesses. Critically, the severity of the injury only partially predicts subsequent outcomes, thus other factors must be involved. In this review, we discuss the psychological, social, neuroendocrine, and autonomic processes that are disrupted following traumatic brain injury during development, and consider the mechanisms the mediate risk or resilience after traumatic brain injury in this vulnerable population.

Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial

Background

Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition.

Methods/design

This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11–18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline.

Discussion

The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated.

Trial registration

ClinicalTrials.gov, NCT03034720. Registered on January 27, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3662-3) contains supplementary material, which is available to authorized users.

Investigating the Connection Between Traumatic Brain Injury and Posttraumatic Stress Symptoms in Adolescents

OBJECTIVE

To identify potentially modifiable individual and social-environmental correlates of posttraumatic stress symptoms (PTSS) among adolescents hospitalized for traumatic brain injury (TBI).

SETTING

Four pediatric hospitals and 1 general hospital in the United States.

PARTICIPANTS

Children ages 11 to 18 years, hospitalized for moderate-severe TBI within the past 18 months.

DESIGN

Retrospective cross-sectional analysis.

MAIN MEASURES

The University of California at Los Angeles (UCLA) Post-traumatic Stress Disorder (PTSD) Reaction Index and the Youth Self-Report (YSR) PTSD subscale.

RESULTS

Of 147 adolescents enrolled, 65 (44%) had severe TBI, with an average time since injury of 5.8 ± 4 months. Of the 104 who completed the UCLA-PTSD Reaction Index, 22 (21%) reported PTSS and 9 (8%) met clinical criteria for PTSD. Of the 143 who completed the YSR-PTSD subscale, 23 (16%) reported PTSS and 6 (4%) met clinical criteria for PTSD. In multivariable analyses, having a negative approach to problem solving and depressive symptoms were both associated (P < .001) with higher levels of PTSS based on the UCLA-PTSD Reaction Index (β = 0.41 and β = 0.33, respectively) and the YSR-PTSD subscale (β = 0.33 and β = 0.40, respectively).

CONCLUSION

Targeting negative aspects of problem solving in youths after brain injury may mitigate PTSS.

A Multidimensional Approach to Post-concussion Symptoms in Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) presents a substantial burden to patients, families, and health care systems. Whereas, recovery can be expected in the majority of patients, a subset continues to report persisting somatic, cognitive, emotional, and/or behavioral problems, generally referred to as post-concussion syndrome (PCS). However, this term has been the subject of debate since the mechanisms underlying post-concussion symptoms and the role of pre- and post-injury-related factors are still poorly understood. We review current evidence and controversies concerning the use of the terms post-concussion symptoms vs. syndrome, its diagnosis, etiology, prevalence, assessment, and treatment in both adults and children. Prevalence rates of post-concussion symptoms vary between 11 and 82%, depending on diagnostic criteria, population and timing of assessment. Post-concussion symptoms are dependent on complex interactions between somatic, psychological, and social factors. Progress in understanding has been hampered by inconsistent classification and variable assessment procedures. There are substantial limitations in research to date, resulting in gaps in our understanding, leading to uncertainty regarding epidemiology, etiology, prognosis, and treatment. Future directions including the identification of potential mechanisms, new imaging techniques, comprehensive, multidisciplinary assessment and treatment options are discussed. Treatment of post-concussion symptoms is highly variable, and primarily directed at symptom relief, rather than at modifying the underlying pathology. Longitudinal studies applying standardized assessment strategies, diagnoses, and evidence-based interventions are required in adult and pediatric mTBI populations to optimize recovery and reduce the substantial socio-economic burden of post-concussion symptoms.

Orthopedic Injured versus Uninjured Comparison Groups for Neuroimaging Research in Mild Traumatic Brain Injury

To address controversy surrounding the most appropriate comparison group for mild traumatic brain injury (mTBI) research, mTBI patients 12-30 years of age were compared with an extracranial orthopedic injury (OI) patient group and an uninjured, typically developing (TD) participant group with comparable demographic backgrounds. Injured participants underwent subacute (within 96 h) and late (3 months) diffusion tensor imaging (DTI); TD controls underwent DTI once. Group differences in fractional anisotropy (FA) and mean diffusivity (MD) of commonly studied white matter tracts were assessed. For FA, subacute group differences occurred in the bilateral inferior frontal occipital fasciculus (IFOF) and right inferior longitudinal fasciculus (ILF), and for MD, differences were found in the total corpus callosum, right uncinate fasciculus, IFOF, ILF, and bilateral cingulum bundle (CB). In these analyses, differences (lower FA and higher MD) were generally observed between the mTBI and TD groups but not between the mTBI and OI groups. After a 3 month interval, groups significantly differed in left IFOF FA and in right IFOF and CB MD; the TD group had significantly higher FA and lower MD than both injury groups, which did not differ. There was one exception to this pattern, in which the OI group demonstrated significantly lower FA in the left ILF than the TD group, although neither group differed from the mTBI group. The mTBI and OI groups had generally similar longitudinal results. Findings suggest that different conclusions about group-level DTI analyses could be drawn, depending on the selected comparison group, highlighting the need for additional research in this area. Where possible, mTBI studies may benefit from the inclusion of both OI and TD controls.

Traumatic Brain Injury, Sleep Disorders, and Psychiatric Disorders: An Underrecognized Relationship

Traumatic brain injury (TBI) is commonplace among pediatric patients and has a complex, but intimate relationship with psychiatric disease and disordered sleep. Understanding the factors that influence the risk for the development of TBI in pediatrics is a critical component of beginning to address the consequences of TBI. Features that may increase risk for experiencing TBI sometimes overlap with factors that influence the development of post-concussive syndrome (PCS) and recovery course. Post-concussive syndrome includes physical, psychological, cognitive and sleep-wake dysfunction. The comorbid presence of sleep-wake dysfunction and psychiatric symptoms can lead to a more protracted recovery and deleterious outcomes. Therefore, a multidisciplinary evaluation following TBI is necessary. Treatment is generally symptom specific and mainly based on adult studies. Further research is necessary to enhance diagnostic and therapeutic approaches, as well as improve the understanding of contributing pathophysiology for the shared development of psychiatric disease and sleep-wake dysfunction following TBI.

Investigating the Variability in Mild Traumatic Brain Injury Definitions: A Prospective Cohort Study

OBJECTIVE

To prospectively compare the proportion of traumatic brain injuries (TBIs) that would be classified as mild by applying different published definitions of mild TBI to a large prospectively collected dataset, and to examine the variability in the proportions included by various definitions.

DESIGN

Prospective observational study.

SETTING

Hospital emergency departments.

PARTICIPANTS

Children (N=11,907) aged 3 to 16 years (mean age, 8.2±3.9y). Of the participants, 3868 (32.5%) were girls, and 7374 (61.9%) of the TBIs were the result of a fall. Median Glasgow Coma Scale score was 15.

MAIN OUTCOME MEASURES

We applied 17 different definitions of mild TBI, identified through a published systematic review, to children aged 3 to 16 years. Adjustments and clarifications were made to some definitions. The number and percentage identified for each definition is presented.

RESULTS

Adjustments had to be made to the 17 definitions to apply to the dataset: none in 7, minor to substantial in 10. The percentage classified as mild TBI across definitions varied from 7.1% (n=841) to 98.7% (n=11,756) and varied by age group.

CONCLUSIONS

When applying the 17 definitions of mild TBI to a large prospective multicenter dataset of TBI, there was wide variability in the number of cases classified. Clinicians and researchers need to be aware of this variability when examining literature concerning children with mild TBI.

Understanding the resistance to creating safer ice hockey: essential points for injury prevention

Introduction

Despite the known negative health outcomes of concussions in minor level boys’ hockey, there has been significant resistance to creating a safer game with less body checking.

Methods

To better understand cultural barriers that prevent making the sport safer for youth and adolescents, semistructured interviews, with 20 ice hockey stakeholders, were conducted and analysed using thematic analysis.

Results

Through this analysis, two primary concepts arose from respondents. The first concept is that body checking, despite the harm it can cause, should be done in a respectful sportsmanlike fashion. The second concept is the contradiction that the game of ice hockey is both dynamic and unchangeable.

Discussion

Using structural functionalist theory, we propose an argument that the unfortunate perpetuation of violence and body checking in youth ice hockey serves to maintain the social order of the game and its culture. Any strategies aimed at modifying and promoting healthy behaviour in the game should take these concepts into account.

Psychiatric Sequelae of Concussions

PURPOSE OF REVIEW

The purpose of this study was to review the frequency, risk factors, phenomenology, and course of prolonged recovery from concussion and of psychiatric sequelae in pediatric populations.

RECENT FINDINGS

Youth with prolonged recovery from concussions have higher initial symptoms, a history of multiple and/or recent concussions, and a tendency to somatization. Depression, post-traumatic stress disorder, behavioral disorders, and perhaps, suicidal behavior disorder are more common as both short- and longer-term sequelae of concussions. The weight of evidence supports a graduated return to function as compared to prolonged rest, which may actually impede recovery. For those with prolonged recovery, cognitive behavior therapy aimed at education about concussions, improving coping, problem-solving, sleep hygiene, and dealing with anxiety and depression provided in a collaborative care model is superior to usual care. Concussed youth have an increased risk of psychiatric symptoms and sleep disturbance that can be prevented or treated with proper management.

Trajectories and Risk Factors for Post-Traumatic Stress Symptoms following Pediatric Concussion

A substantial minority of children experience post-traumatic stress symptoms (PTSS) following injury. Research indicates variation in the trajectory of PTSS following pediatric injury, but investigation of PTSS following concussion has assumed homogeneity. This study aimed to identify differential trajectories of PTSS following pediatric concussion and to investigate risk factors, including acute post-concussive symptoms (PCS), associated with these trajectories. A total of 120 children ages 8-18 years reported PTSS for 3 months following concussion diagnosis using the Child PTSD Symptom Scale, with a score of 16 or above indicating probable post-traumatic stress disorder diagnosis. Age, gender, injury mechanism, loss of consciousness, previous concussions, prior hospitalization, prior diagnosis of depression or anxiety, and acute PCS were assessed as risk factors. Data were analyzed using group-based trajectory modeling. Results revealed 16% of children had clinically significant PTSS 2 weeks post-concussion, declining to 10% at 1 month and 6% at 3 months post-injury. Group-based trajectory modeling identified three trajectories of PTSS post-concussion: "resilient" (70%); "recovering" (25%), in which children experienced elevated acute symptoms that declined over time; and "chronic symptomatology" (5%). Due to small size, the chronic group should be interpreted with caution. Higher acute PCS and prior diagnosis of depression or anxiety both significantly increased predicted probability of recovering trajectory group membership. These findings establish that most children are resilient to PTSS following concussion, but that PTSS do occur acutely in a substantial minority of children. The study indicates mental health factors, particularly PTSS, depression, and anxiety, should be considered integral to models of concussion management and treatment.

Evaluation of a follow-up program for mild traumatic brain injury in schoolchildren

INTRODUCTION

Mild traumatic brain injury is a common condition in childhood. Although classified as mild, post-concussive symptoms may persist and interfere with daily activities. Because no established guidelines exist with respect to follow-up medical care for these children, there may be a delay in receiving appropriate care. We developed a follow up program to screen for persistent symptoms and if necessary, refer patients for further medical assistance.

METHODS

From July 2010 until December 2013, eligible children aged 4-18 years who presented after sustaining a mild traumatic brain injury were included. All patients received a phone call after 6 weeks. After a period of 3 months, both their schoolteacher and parents were asked to complete in a questionnaire. The results were discussed monthly by a multidisciplinary team.

RESULTS

A total of 305 children were enrolled in our follow-up program. Headache was the most common acute symptom upon presentation (63%). Overall, 19% of all patients had problems, either at 6 weeks or 3 months. 14% of these patients were referred for special care. Most common persistent post-concussive symptoms were headache (32%), cognitive problems (23%) and behavioural problems (16%). After a period of two years, a review of patient charts revealed that all of the problems were resolved.

CONCLUSION

One fifth of the children exhibit post-concussive symptoms after mild traumatic brain injury. Education of patients and caregivers and a follow up visit if needed applied appropriate care at an early stage to minimise physical and mental problems.

Collaborative Care for Adolescents With Persistent Postconcussive Symptoms: A Randomized Trial

BACKGROUND AND OBJECTIVES

Postconcussive and co-occurring psychological symptoms are not uncommon after sports-related concussion and are associated with functional impairment and societal costs. There is no evidence-based treatment targeting postconcussive symptoms in children and adolescents. The goal of this study was to test a collaborative care intervention model with embedded cognitive-behavioral therapy, care management, and psychopharmacological consultation. We hypothesized that patients in collaborative care would demonstrate greater reductions in postconcussive, depressive, and anxiety symptoms and improvement in functioning over the course of 6 months, compared with usual care control.

METHODS

Patients aged 11 to 17 years with persistent symptoms ≥1 month after sports-related concussion were randomly assigned to receive collaborative care (n = 25) or care as usual (n = 24). Patients were assessed before randomization and after 1, 3, and 6 months. Groups were compared over time via linear mixed effects regression models.

RESULTS

Adolescents assigned to collaborative care experienced clinically and statistically significant improvements in postconcussive symptoms in addition to functional gains at 6 months compared with controls. Six months after the baseline assessment, 13.0% of intervention patients and 41.7% of control patients reported high levels of postconcussive symptoms (P = .03), and 78% of intervention patients and 45.8% of control patients reported ≥50% reduction in depression symptoms (P = .02). No changes between groups were demonstrated in anxiety symptoms.

CONCLUSIONS

Orchestrated efforts to systematically implement collaborative care treatment approaches for slow-to-recover adolescents may be useful given the reductions in postconcussive and co-occurring psychological symptoms in addition to improved quality of life.

Research Review: Changes in the prevalence and symptom severity of child post-traumatic stress disorder in the year following trauma - a meta-analytic study

BACKGROUND

Understanding the natural course of child and adolescent posttraumatic stress disorder (PTSD) has significant implications for the identification of, and intervention for, at-risk youth. We used a meta-analytic approach to examine longitudinal changes in youth PTSD prevalence and symptoms over the first 12 months posttrauma.

METHODS

We conducted a systematic review to identify longitudinal studies of PTSD in young people (5-18 years old), excluding treatment trials. The search yielded 27 peer-reviewed studies and one unpublished dataset for analysis of pooled prevalence estimates, relative prevalence reduction and standardised mean symptom change. Key moderators were also explored, including age, proportion of boys in the sample, initial prevalence of PTSD and PTSD measurement type.

RESULTS

Analyses demonstrated moderate declines in PTSD prevalence and symptom severity over the first 3-6 months posttrauma. From 1 to 6 months posttrauma, the prevalence of PTSD reduced by approximately 50%. Symptoms also showed moderate decline, particularly across the first 3 months posttrauma. There was little evidence of further change in prevalence or symptom severity after 6 months, suggesting that it is unlikely a child would lose a PTSD diagnosis without intervention beyond this point.

CONCLUSIONS

The current findings provide key information about the likelihood of posttrauma recovery in the absence of intervention and have important implications for our understanding of child and adolescent PTSD. Results are discussed with reference to the timing of PTSD screening and the potential role of early interventions. Findings particularly highlight the importance of future research to develop our understanding of what factors prevent the action of normal recovery from the 'acute' posttrauma period.

Effect of Mild Traumatic Brain Injury and Demographic Factors on Psychological Outcome

Background

It is well-known that severe brain injury can make people susceptible to psychological symptoms. However, mild traumatic brain injury (MTBI) is still open for discussion.

Objectives

This study aimed to compare psychological symptoms of MTBI patients with those without MTBI considering demographic auxiliary variables.

Patients and Methods

This prospective cohort study was conducted on 50 MTBI patients and 50 healthy subjects aged 15 - 65 years. Psychological assessment was carried out six months post-injury using a series of self-report measures including the brief symptom inventory (BSI) scale. Other information of the individuals in the two groups was recorded prospectively. Data were analyzed using the chi-square test, t-test, and multiple linear regression tests.

Results

There was a significant difference between the MTBI patients and healthy subjects in all subscales and total score of BSI. Our findings showed that obsession-compulsion and anxiety subscales were significantly more common in the MTBI patients than in the healthy subjects. Also, multivariate regression analysis six months post- injury showed that head trauma and substance abuse can have an effect on psychological symptoms.

Conclusions

Mild traumatic brain injuries despite of the normal CT scan and history of substance abuse are closely related to psychological symptoms. Therefore, it is recommended that patients with brain trauma 6 months post-injury and subjects with a history of substance abuse be evaluated for psychological distress to support better rehabilitation.

A Systematic Review of Psychiatric, Psychological, and Behavioural Outcomes following Mild Traumatic Brain Injury in Children and Adolescents

BACKGROUND

Evidence regarding longer-term psychiatric, psychological, and behavioural outcomes (for example, anxiety, mood disorders, depression, and attention disorders) following mild traumatic brain injury (mTBI) in children and adolescents has not been previously synthesized.

OBJECTIVE

To conduct a systematic review of the available evidence examining psychiatric, psychological, and behavioural outcomes following mTBI in children and adolescents.

MATERIALS AND METHODS

Nine electronic databases were systematically searched from 1980 to August 2014. Studies selected met the following criteria: original data; study design was a randomized controlled trial, quasi-experimental design, cohort or historical cohort study, case-control study, or cross-sectional study; exposure included mTBI (including concussion); population included children and adolescents (<19 years) at the time of mTBI, as well as a comparison group (for example, healthy children, children with orthopaedic injuries); and included psychiatric, psychological, or behavioural outcomes (for example, anxiety, mood disorders, depression, attention disorders). Two authors independently assessed the quality and level of evidence with the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine (OCEBM) model, respectively, for each manuscript.

RESULTS

Of 9472 studies identified in the initial search, 30 were included and scored. Heterogeneity in methodology and injury definition precluded meta-analyses. The median methodological quality for all 30 studies, based on the DB criteria, was 15/33 (range 6 to 19). The highest level of evidence demonstrated by all reviewed studies was level 2b based on OCEBM criteria, with the majority (28/30 studies) classified at this level. Based on the literature included in this systematic review, psychological and psychiatric problems in children with a history of mTBI were found to be more prevalent when mTBI is associated with hospitalization, when assessment occurs earlier in the recovery period (that is, resolves over time), when there are multiple previous mTBIs, in individuals with preexisting psychiatric illness, when outcomes are based on retrospective recall, and when the comparison group is noninjured healthy children (as opposed to children with injuries not involving the head).

CONCLUSIONS

Overall, few rigorous prospective studies have examined psychological, behavioural, and psychiatric outcomes following mTBI. In the absence of true reports of preinjury problems and when ideally comparing mild TBI to non-TBI injured controls, there is little evidence to suggest that psychological, behavioural, and/or psychiatric problems persist beyond the acute and subacute period following an mTBI in children and adolescents.

Mental Health Implications of Traumatic Brain Injury (TBI) in Children and Youth

OBJECTIVE

Traumatic brain injury (TBI) is the most common cause of death and disability in children and adolescents. Psychopathology is an established risk factor for, and a frequent consequence of, TBI. This paper reviews the literature relating psychopathology and TBI.

METHOD

Selective literature review.

RESULTS

The risk of sustaining a TBI is increased by pre-existing psychopathology (particularly ADHD and aggression) and psychosocial adversity. Even among individuals with no psychopathology prior to the injury, TBI is frequently followed by mental illness especially ADHD, personality change, conduct disorder and, less frequently, by post-traumatic stress and anxiety disorders. The outcome of TBI can be partially predicted by pre-injury adjustment and injury severity, but less well by age at injury. Few individuals receive treatment for mental illness following TBI.

CONCLUSION

TBI has substantial relevance to mental health professionals and their clinical practice. Available evidence, while limited, indicates that the risk for TBI in children and adolescents is increased in the presence of several, potentially treatable mental health conditions and that the outcome of TBI involves a range of mental health problems, many of which are treatable. Prevention and management efforts targeting psychiatric risks and outcomes are an urgent priority. Child and adolescent mental health professionals can play a critical role in the prevention and treatment of TBI through advocacy, education, policy development and clinical practice.

Applying a traumatic stress approach to understanding PCS following pediatric mild TBI

Pediatric traumatic brain injury is a significant public health concern affecting hundreds of thousands of children each year. The majority of children who sustain traumatic brain injuries are classified as having a mild traumatic brain injury, and a subset of these children go on to experience persistent physical, cognitive, and emotional symptoms. These symptoms, known as postconcussive symptoms, can endure for months and even years after injury. The outcomes of mild traumatic brain injury are variable and not well understood for a small percentage of children who experience persistent symptoms. The current article explores the potential influence of children's posttraumatic stress symptoms on persistent postconcussive symptoms. Despite the high incidence of posttraumatic stress symptoms after pediatric accidental injury, they have not yet been identified as an important factor for consideration in the understanding of pediatric postconcussive outcomes. The article will review the literature on posttraumatic stress and postconcussive symptoms after pediatric injury and consider neurobiological and cognitive factors to propose a model explaining a pathway through which posttraumatic stress reactions may serve as the mechanism for the expression and maintenance of postconcussive symptoms after mild traumatic brain injury. The clinical implications for the proposed relationship between posttraumatic stress symptoms and postconcussive symptoms are considered prior to the conclusion of the article, which acknowledges limitations in the current literature and provides suggestions for future research.

Psychiatric disorders in children and adolescents six-to-twelve months after mild traumatic brain injury

The objective of this study was to understand how novel psychiatric disorders (NPD) in children with mild traumatic brain injury (MTBI) are related to pre-injury variables, injury-related variables, and concurrent neurocognitive outcome. A group of 79 children, ages 5 to 14 years, who had experienced MTBI, were studied from consecutive hospital admissions with semistructured psychiatric interviews soon after injury (baseline); 60 children were reassessed 12 months post-injury. Standardized instruments were used to assess injury severity; lesion characteristics; pre-injury variables, including psychiatric disorder, family psychiatric history, family functioning, socioeconomic status, psychosocial adversity, adaptive functioning, and post-injury neurocognitive and adaptive functioning. NPD occurred in 17 of 60 participants (28%) in the 6-12-month interval after injury, with disorders that were significantly associated with socioeconomic status, psychosocial adversity, estimated pre-injury academic functioning, and concurrent deficits in adaptive functioning, academic performance, processing speed, memory, and expressive language. NPD was not significantly associated with pre-injury adaptive functioning, injury severity, family psychiatric history, pre-injury psychiatric disorder, lesion location, gender, or age at injury. These findings suggest that the short-term psychiatric morbidity associated with MTBI in children occurs more commonly than previously reported and is related to both pre-injury social factors and concurrent neurocognitive functioning.

Mean diffusivity in the amygdala correlates with anxiety in pediatric TBI

Traumatic brain injury (TBI) and orthopedic injury (OI) patients are prone to anxiety and mood disorders. In the present study, we integrated anatomical and diffusion tensor neuroimaging to investigate structural properties of the amygdala and hippocampus, gray matter regions implicated in anxiety and mood disorders. Children and adolescents were evaluated during the late sub-acute phase of recovery following trauma resulting from either moderate to severe TBI or OI. Mean diffusivity (MD) of the amygdala and hippocampus was elevated following TBI. An interaction of hemisphere, structure, and group revealed that MD of the right amygdala was elevated in females with TBI. Self-reported anxiety scores were not related to either volume or microstructure of the hippocampus, or to volume or fractional anisotropy of the amygdala. Left amygdala MD in the TBI group accounted for 17.5% of variance in anxiety scores. Anxiety symptoms may be mediated by different mechanisms in patients with TBI or OI.

Association between posttraumatic stress, depression, and functional impairments in adolescents 24 months after traumatic brain injury

The degree to which postinjury posttraumatic stress disorder (PTSD) and/or depressive symptoms in adolescents are associated with cognitive and functional impairments at 12 and 24 months after traumatic brain injury (TBI) is not yet known. The current study used a prospective cohort design, with baseline assessment and 3-, 12-, and 24-month followup, and recruited a cohort of 228 adolescents ages 14-17 years who sustained either a TBI (n = 189) or an isolated arm injury (n = 39). Linear mixed-effects regression was used to assess differences in depressive and PTSD symptoms between TBI and arm-injured patients and to assess the association between 3-month PTSD and depressive symptoms and cognitive and functional outcomes. Results indicated that patients who sustained a mild TBI without intracranial hemorrhage reported significantly worse PTSD (Hedges g = 0.49, p = .01; Model R(2) = .38) symptoms across time as compared to the arm injured control group. Greater levels of PTSD symptoms were associated with poorer school (η(2) = .07, p = .03; Model R(2) = .36) and physical (η(2) = .11, p = .01; Model R(2) = .23) functioning, whereas greater depressive symptoms were associated with poorer school (η(2) = .06, p = .05; Model R(2) = .39) functioning.

Mild traumatic brain injury and postconcussive symptoms in children and adolescents

The vast majority of traumatic brain injuries (TBI) in children are of mild severity. Even if only a small proportion of children with mild TBI suffer negative outcomes, then mild TBI is a serious public health problem. This review summarizes the literature regarding the neurobehavioral outcomes associated with mild TBI in children and adolescents, focusing on the longstanding debate regarding postconcussive symptoms and attendant conceptual and methodological issues. The review also discusses future research directions, the long-term goal of which is to develop a comprehensive and integrated biopsychosocial model of outcomes that helps guide clinical management.