Psychiatric outcomes after pediatric sports-related concussion

Michael J. Ellis Departments of Surgery,
Pediatrics and Child Health,
Section of Neurosurgery, University of Manitoba;
Pan Am Concussion Program;
Childrens Hospital Research Institute of Manitoba; and
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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Lesley J. Ritchie Clinical Health Psychology, and
Pan Am Concussion Program;
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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Mark Koltek Psychiatry, and
Pan Am Concussion Program;
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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Shahid Hosain Psychiatry, and
Pan Am Concussion Program;
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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Dean Cordingley Pan Am Concussion Program;
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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Stephanie Chu Pediatrics and Child Health,
Childrens Hospital Research Institute of Manitoba; and
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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Erin Selci Pediatrics and Child Health,
Childrens Hospital Research Institute of Manitoba; and
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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Jeff Leiter Departments of Surgery,
Pan Am Concussion Program;
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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Kelly Russell Pediatrics and Child Health,
Childrens Hospital Research Institute of Manitoba; and
Canada North Concussion Network, Winnipeg, Manitoba, Canada

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OBJECT

The objectives of this study were twofold: 1) to examine the prevalence of emotional symptoms among children and adolescents with a sports-related concussion (SRC) who were referred to a multidisciplinary pediatric concussion program and 2) to examine the prevalence, clinical features, risk factors, and management of postinjury psychiatric outcomes among those in this clinical population.

METHODS

The authors conducted a retrospective chart review of all patients with SRC referred to a multidisciplinary pediatric concussion program between September 2013 and October 2014. Clinical assessments carried out by a single neurosurgeon included clinical history, physical examination, and Post-Concussion Symptom Scale (PCSS) scoring. Postinjury psychiatric outcomes were defined as a subjective worsening of symptoms of a preinjury psychiatric disorder or new and isolated suicidal ideation or diagnosis of a novel psychiatric disorder (NPD). An NPD was defined as a newly diagnosed psychiatric disorder that occurred in a patient with or without a lifetime preinjury psychiatric disorder after a concussion. Clinical resources, therapeutic interventions, and clinical and return-to-play outcomes are summarized.

RESULTS

One hundred seventy-four patients (mean age 14.2 years, 61.5% male) were included in the study. At least 1 emotional symptom was reported in 49.4% of the patients, and the median emotional PCSS subscore was 4 (interquartile range 1–8) among those who reported at least 1 emotional symptom. Overall, 20 (11.5%) of the patients met the study criteria for a postinjury psychiatric outcome, including 14 patients with an NPD, 2 patients with isolated suicidal ideation, and 4 patients with worsening symptoms of a preinjury psychiatric disorder. Female sex, a higher initial PCSS score, a higher emotional PCSS subscore, presence of a preinjury psychiatric history, and presence of a family history of psychiatric illness were significantly associated with postinjury psychiatric outcomes. Interventions for patients with postinjury psychiatric outcomes included pharmacological therapy alone in 2 patients (10%), cognitive behavioral therapy alone in 4 (20%), multimodal therapy in 9 (45%), and no treatment in 5 (25%). Overall, 5 (25%) of the patients with postinjury psychiatric disorders were medically cleared to return to full sports participation, whereas 5 (25%) were lost to follow-up and 9 (45%) remained in treatment by the multidisciplinary concussion program at the end of the study period. One patient who was asymptomatic at the time of initial consultation committed suicide.

CONCLUSIONS

Emotional symptoms were commonly reported among pediatric patients with SRC referred to a multidisciplinary pediatric concussion program. In some cases, these symptoms contributed to the development of an NPD, isolated suicidal ideation, and worsening symptoms of a preexisting psychiatric disorder. Future research is needed to clarify the prevalence, pathophysiology, risk factors, and evidence-based management of postinjury psychiatric outcomes after pediatric SRC. Successful management of these patients requires prompt recognition and multidisciplinary care by experts with clinical training and experience in concussion and psychiatry.

ABBREVIATIONS

ADHD = attention-deficit hyperactivity disorder; ICD-10 = International Classification of Diseases, 10th Revision; IQR = interquartile range; NOS = not otherwise specified; NPD = novel psychiatric disorder; OCD = obsessive-compulsive disorder; PCS = postconcussion syndrome; PCSS = Post-Concussion Symptom Scale; SRC = sports-related concussion; TBI = traumatic brain injury.
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  • 1

    Babcock L, , Byczkowski T, , Wade SL, , Ho M, , Mookerjee S, & Bazarian JJ: Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatr 167:156161, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Barlow KM, , Crawford S, , Stevenson A, , Sandhu SS, , Belanger F, & Dewey D: Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics 126:e374e381, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Boake C, , McCauley SR, , Levin HS, , Contant CF, , Song JX, & Brown SA, et al.: Limited agreement between criteria-based diagnoses of postconcussional syndrome. J Neuropsychiatry Clin Neurosci 16:493499, 2004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Brown G, , Chadwick O, , Shaffer D, , Rutter M, & Traub M: A prospective study of children with head injuries: III. Psychiatric sequelae Psychol Med 11:6378, 1981

  • 5

    Burton LJ, , Quinn B, , Pratt-Cheney JL, & Pourani M: Headache etiology in a pediatric emergency department. Pediatr Emerg Care 13:14, 1997

  • 6

    Corwin DJ, , Zonfrillo MR, , Master CL, , Arbogast KB, , Grady MF, & Robinson RL, et al.: Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population. J Pediatr 165:12071215, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Eisenberg MA, , Meehan WP III, & Mannix R: Duration and course of post-concussive symptoms. Pediatrics 133:9991006, 2014

  • 8

    Ellis MJ, , Cordingley D, , Vis S, , Reimer K, , Leiter J, & Russell K: Vestibuloocular dysfunction in pediatric sports-related concussion. J Neurosurg Pediatr 18, 2015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Fletcher JM: Adolescent depression: diagnosis, treatment, and educational attainment. Health Econ 17:12151235, 2008

  • 10

    Gibson S, , Nigrovic LE, , O’Brien M, & Meehan WP III: The effect of recommending cognitive rest on recovery from sport-related concussion. Brain Inj 27:839842, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Grubenhoff JA, , Deakyne SJ, , Brou L, , Bajaj L, , Comstock RD, & Kirkwood MW: Acute concussion symptom severity and delayed symptom resolution. Pediatrics 134:5462, 2014

  • 12

    Guskiewicz KM, , Marshall SW, , Bailes J, , McCrea M, , Harding HP Jr, & Matthews A, et al.: Recurrent concussion and risk of depression in retired professional football players. Med Sci Sports Exerc 39:903909, 2007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Harris EC, & Barraclough B: Suicide as an outcome for mental disorders. A meta-analysis Br J Psychiatry 170:205228, 1997

  • 14

    Hazrati LN, , Tartaglia MC, , Diamandis P, , Davis KD, , Green RE, & Wennberg R, et al.: Absence of chronic traumatic encephalopathy in retired football players with multiple concussions and neurological symptomatology. Front Hum Neurosci 7:222, 2013

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Iverson GL: Chronic traumatic encephalopathy and risk of suicide in former athletes. Br J Sports Med 48:162165, 2014

  • 16

    Kaufman J, , Birmaher B, , Brent D, , Rao U, , Flynn C, & Moreci P, et al.: Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36:980988, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Kerr ZY, , Marshall SW, , Harding HP Jr, & Guskiewicz KM: Nine-year risk of depression diagnosis increases with increasing self-reported concussions in retired professional football players. Am J Sports Med 40:22062212, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Lehman EJ, , Hein MJ, , Baron SL, & Gersic CM: Neurodegenerative causes of death among retired National Football League players. Neurology 79:19701974, 2012

  • 19

    Lewinsohn PM, , Rohde P, & Seeley JR: Psychosocial characteristics of adolescents with a history of suicide attempt. J Am Acad Child Adolesc Psychiatry 32:6068, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Luis CA, & Mittenberg W: Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study. J Clin Exp Neuropsychol 24:270279, 2002

  • 21

    Massagli TL, , Fann JR, , Burington BE, , Jaffe KM, , Katon WJ, & Thompson RS: Psychiatric illness after mild traumatic brain injury in children. Arch Phys Med Rehabil 85:14281434, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Max JE: Neuropsychiatry of pediatric traumatic brain injury. Psychiatr Clin North Am 37:125140, 2014

  • 23

    Max JE, , Castillo CS, , Robin DA, , Lindgren SD, , Smith WL Jr, & Sato Y, et al.: Posttraumatic stress symptomatology after childhood traumatic brain injury. J Nerv Ment Dis 186:589596, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Max JE, , Castillo CS, , Robin DA, , Lindgren SD, , Smith WL Jr, & Sato Y, et al.: Predictors of family functioning after traumatic brain injury in children and adolescents. J Am Acad Child Adolesc Psychiatry 37:8390, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Max JE, & Dunisch DL: Traumatic brain injury in a child psychiatry outpatient clinic: a controlled study. J Am Acad Child Adolesc Psychiatry 36:404411, 1997

  • 26

    Max JE, , Keatley E, , Wilde EA, , Bigler ED, , Levin HS, & Schachar RJ, et al.: Anxiety disorders in children and adolescents in the first six months after traumatic brain injury. J Neuropsychiatry Clin Neurosci 23:2939, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Max JE, , Keatley E, , Wilde EA, , Bigler ED, , Schachar RJ, & Saunders AE, et al.: Depression in children and adolescents in the first 6 months after traumatic brain injury. Int J Dev Neurosci 30:239245, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Max JE, , Koele SL, , Castillo CC, , Lindgren SD, , Arndt S, & Bokura H, et al.: Personality change disorder in children and adolescents following traumatic brain injury. J Int Neuropsychol Soc 6:279289, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Max JE, , Levin HS, , Landis J, , Schachar R, , Saunders A, & Ewing-Cobbs L, et al.: Predictors of personality change due to traumatic brain injury in children and adolescents in the first six months after injury. J Am Acad Child Adolesc Psychiatry 44:434442, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Max JE, , Levin HS, , Schachar RJ, , Landis J, , Saunders AE, & Ewing-Cobbs L, et al.: Predictors of personality change due to traumatic brain injury in children and adolescents six to twenty-four months after injury. J Neuropsychiatry Clin Neurosci 18:2132, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Max JE, , Lindgren SD, , Knutson C, , Pearson CS, , Ihrig D, & Welborn A: Child and adolescent traumatic brain injury: psychiatric findings from a paediatric outpatient specialty clinic. Brain Inj 11:699711, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Max JE, , Pardo D, , Hanten G, , Schachar RJ, , Saunders AE, & Ewing-Cobbs L, et al.: Psychiatric disorders in children and adolescents six-to-twelve months after mild traumatic brain injury. J Neuropsychiatry Clin Neurosci 25:272282, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Max JE, , Robin DA, , Lindgren SD, , Smith WL Jr, , Sato Y, & Mattheis PJ, et al.: Traumatic brain injury in children and adolescents: psychiatric disorders at one year. J Neuropsychiatry Clin Neurosci 10:290297, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Max JE, , Schachar RJ, , Landis J, , Bigler ED, , Wilde EA, & Saunders AE, et al.: Psychiatric disorders in children and adolescents in the first six months after mild traumatic brain injury. J Neuropsychiatry Clin Neurosci 25:187197, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Max JE, , Schachar RJ, , Levin HS, , Ewing-Cobbs L, , Chapman SB, & Dennis M, et al.: Predictors of attention-deficit/hyperactivity disorder within 6 months after pediatric traumatic brain injury. J Am Acad Child Adolesc Psychiatry 44:10321040, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Max JE, , Wilde EA, , Bigler ED, , MacLeod M, , Vasquez AC, & Schmidt AT, et al.: Psychiatric disorders after pediatric traumatic brain injury: a prospective, longitudinal, controlled study. J Neuropsychiatry Clin Neurosci 24:427436, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    McClincy MP, , Lovell MR, , Pardini J, , Collins MW, & Spore MK: Recovery from sports concussion in high school and collegiate athletes. Brain Inj 20:3339, 2006

  • 38

    McCrory P, , Meeuwisse WH, , Aubry M, , Cantu B, , Dvorák J, & Echemendia RJ, et al.: Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 47:250258, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    McKee AC, , Cantu RC, , Nowinski CJ, , Hedley-Whyte ET, , Gavett BE, & Budson AE, et al.: Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol 68:709735, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    McKee AC, , Stern RA, , Nowinski CJ, , Stein TD, , Alvarez VE, & Daneshvar DH, et al.: The spectrum of disease in chronic traumatic encephalopathy. Brain 136:4364, 2013

  • 41

    McKinlay A, , Dalrymple-Alford JC, , Horwood LJ, & Fergus-son DM: Long term psychosocial outcomes after mild head injury in early childhood. J Neurol Neurosurg Psychiatry 73:281288, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Meehan WP III, , d’Hemecourt P, & Comstock RD: High school concussions in the 2008–2009 academic year: mechanism, symptoms, and management. Am J Sports Med 38:24052409, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Meehan WP III, , Mannix R, , Monuteaux MC, , Stein CJ, & Bachur RG: Early symptom burden predicts recovery after sport-related concussion. Neurology 83:22042210, 2014

  • 44

    Meehan WP III, , Mannix RC, , Stracciolini A, , Elbin RJ, & Collins MW: Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. J Pediatr 163:721725, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Moore E, , Indig D, & Haysom L: Traumatic brain injury, mental health, substance use, and offending among incarcerated young people. J Head Trauma Rehabil 29:239247, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Omalu B: Chronic traumatic encephalopathy. Prog Neurol Surg 28:3849, 2014

  • 47

    Omalu BI, , Bailes J, , Hammers JL, & Fitzsimmons RP: Chronic traumatic encephalopathy, suicides and parasuicides in professional American athletes: the role of the forensic pathologist. Am J Forensic Med Pathol 31:130132, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48

    Prigatano GP, & Gray J: Parental perspectives on recovery and social reintegration after pediatric traumatic brain injury. J Head Trauma Rehabil 23:378387, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49

    Rune V: Acute head injuries in children. A retrospective epidemiologic, child psychiatric and electroencephalographic study on primary school children in Umea. Acta Paediatr Scand Suppl 209:Suppl 209 209312, 1970

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 50

    Solomon GS, & Zuckerman SL: Chronic traumatic encephalopathy in professional sports: Retrospective and prospective views. Brain Inj 29:164170, 2014

  • 51

    Stewart TC, , Gilliland J, & Fraser DD: An epidemiologic profile of pediatric concussions: identifying urban and rural differences. J Trauma Acute Care Surg 76:736742, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52

    Tator CH: Chronic traumatic encephalopathy: how serious a sports problem is it?. Br J Sports Med 48:8183, 2014

  • 53

    Teasdale TW, & Engberg AW: Suicide after traumatic brain injury: a population study. J Neurol Neurosurg Psychiatry 71:436440, 2001

  • 54

    Vasa RA, , Gerring JP, , Grados M, , Slomine B, , Christensen JR, & Rising W, et al.: Anxiety after severe pediatric closed head injury. J Am Acad Child Adolesc Psychiatry 41:148156, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Wade SL, , Taylor HG, , Drotar D, , Stancin T, & Yeates KO: Family burden and adaptation during the initial year after traumatic brain injury in children. Pediatrics 102:110116, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56

    Yeates KO, , Luria J, , Bartkowski H, , Rusin J, , Martin L, & Bigler ED: Postconcussive symptoms in children with mild closed head injuries. J Head Trauma Rehabil 14:337350, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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