An accumulating body of research suggests a link between early-life concussion and the subsequent risk for mental health disorders and dementia in later adulthood.1 Among the pediatric population, 30% will experience persistent postconcussion symptoms beyond 1 month of initial concussion, including physical, emotional, cognitive, and sleep issues.2 However, there is a dearth of well-designed research regarding the shorter-term mental health effects on youth who sustain a concussion, despite the high incidence of traumatic brain injury (TBI) among children and adolescents .
Between 2008 and 2013 in the United States and Canada, emergency department (ED) and physician visits for pediatric concussion have increased up to 4-fold, according to a March study published this year in JAMA Network Open.3 Researchers assessed mental health outcomes in children and youths aged 5-18 years who sustained a concussion compared with those who experienced an orthopedic injury. Participants with concussion demonstrated an increased risk for mental health disorders, such as anxiety and neurotic disorders, self-harm, and psychiatric hospitalization over the 10-year period postconcussion compared with the orthopedic injury group.
The findings of this recent study provide insights into the specific sequelae of concussion in youth, according to David Howell, PhD, assistant professor of orthopedics at the University of Colorado School of Medicine at Anschutz in Aurora. “The comparison of those with a concussion vs those with an orthopedic injury helps us to understand or disentangle whether it is the brain injury specifically, or any injury that is more strongly associated with development of mental health problems, as orthopedic injuries also result in pain or disruption of life,” said Dr Howell. The findings indicate a unique association between concussion and various mental health problems.
Mechanisms and Overlapping Risk Factors
Heather Sesma, PhD, LP, CBIS, a researcher and neuropsychologist at the Children’s Minnesota Concussion Clinic in St Paul, points to the inextricable connection between brain health and mental health. “In childhood and adolescence, brains are still developing and changing, and sustaining a concussion represents a major disruption to the brain’s neurometabolic functioning,” Dr Sesma explained. She added that “the necessary reduction in physical and cognitive activity while the brain recovers represents an additional major disruption to the child’s daily participation in the roles and activities that define his or her sense of self — whether at school, in sports, or with friends and families.”
While symptoms resolve within a few weeks in many of these patients, allowing the resumption of usual activities, others experience persistent symptoms that interfere with their participation in school, sports, and social events. Dr Sesma notes that it can be challenging to determine whether mental health symptoms detected following concussion are attributable to the injury or due in part to preexisting genetic or environmental risk factors such as poverty, family history of mental health disorders, or traumatic or stressful events. 4
“In some cases, risk factors for mental health conditions are also risk factors for concussion, such as when children live in an unsafe neighborhood or a home with an abusive or inattentive caregiver, and we know that risk is cumulative,” she said. “Children with multiple risk factors may be more vulnerable to developing mental health problems after a concussion because the experience of injury and related disruption to daily routines adds additional stress to the system.”
These issues may become compounded by prolonged symptoms that prevent a timely return to activities, resulting in social isolation and physical deconditioning that further increase mental health risk.
screening and treatment
Each postconcussion visit should include an evaluation of the patient’s mental health status. “The authors describe that collaborative care and mental health treatment has been found as a positive treatment for chronic symptoms after a concussion and, as such, should be included in each follow-up evaluation,” Dr Howell advised.
Recovery needs vary across patients. A mental health evaluation can be helpful in identifying specific issues and tailoring treatments for each individual patient.
“While some treatments such as aerobic exercise may assist with the reduction in symptoms for athletes, more customized referrals to appropriate health care providers with expertise in mental health evaluation and intervention may be appropriate for those who clinicians identify as having the potential to develop short- or long-term mental health problems,” Dr Howell said.
Dr Sesma adds that there is a substantial degree of overlap between depression and anxiety symptoms and postconcussive symptoms such as sadness, irritability, sleep impairment, fatigue, and difficulty concentrating. She advises that clinicians consider referral to mental health services for youth whose symptoms persist beyond 4-6 weeks after concussion. In addition, recovery times may be longer in patients with known pre-existing mental health conditions such as anxiety, depression, or attention deficit hyperactivity disorder.5,6 “Educating patients and families about this possibility early in their recovery process helps manage their expectations and reduce stress,” said Dr Sesma.
Reducing Concussion Risk and Supporting Recovery
Dr Sesma recommends the following measures and resources to help reduce concussion risk and support recovery among youth.
- Primary care providers can provide regular education and guidance to caregivers about the importance of safety practices such as regular use of helmets — not only for team contact sports such as football and hockey, but also for recreational activities like bicycling, skateboarding, and skiing. The Centers for Disease Control and Prevention Heads Up includes guidelines for choosing and maintaining helmets for different sports.7
- Heads Up also provides online concussion safety training for parents, coaches, and school personnel to improve awareness of signs and symptoms of concussion and help establish a culture of safety.7 In particular, coaches can avoid practice drills and game plays that involve repeated head impacts and support removing athletes from play when a head injury is suspected. Health care providers can familiarize themselves with the return-to-play laws in their states.
- It is critically important for health care providers, schools, and coaches to work together to support students during their recovery. Regular communication among health care providers, school personnel, and parents help students return to a modified school day within 2-3 days of injury and ensure consistent implementation of accommodations across teachers.
- School nurses and teachers can monitor students for worsening of symptoms and changes in behavior or academic performance that suggest a need for additional supports or accommodations. As students’ symptoms improve, schools can gradually lift these accommodations. Supporting students with appropriate accommodations early on is essential for reducing the risk of more long-term problems with school avoidance and mounting numbers of missing assignments.
Overall, findings from in JAMA Network Open study “will allow researchers to move forward with identifying specific types of patients who may be at risk for postconcussion mental health problems and develop treatments that can substantively help them with the overall concussion recovery across all facets of their life,” Dr Howell stated.
1. Izzy S, Tahir Z, Grashow R, et al. Concussion and risk of chronic medical and behavioral health comorbidities. J Neurotrauma. Published online June 10, 2021. doi:10.1089/neu.2020.7484
2. Davis GA, Anderson V, Babl FE, et al. What is the difference in concussion management in children compared with adults? A systematic review. Br J Sports Medicine. Published online April 28, 2017. doi:10.1136/bjsports-2016-097415
3. Ledoux AA, Webster RJ, Clarke AE, et al. Risk of mental health problems in children and youths following concussion. JAMA Netw Open. Published online March 7, 2022. doi:10.1001/jamanetworkopen.2022.1235
4. Babikian T. Contextual considerations for the increased risk of mental health problems following concussion in youth. JAMA Netw Open. Published online March 7, 2022. doi:10.1001/jamanetworkopen.2022.1242
5. Martin AK, Petersen AJ, Sesma HW, et al. Concussion symptomology and recovery in children and adolescents with preexisting anxiety. J Neurol Neurosurg Psychiatry. Published online August 11, 2020. doi:10.1136/jnnp-2020-323137
6. Martin AK, Petersen AJ, Sesma HW, et al. Learning and attention deficit/hyperactivity disorders as risk factors for prolonged concussion recovery in children and adolescents. J Int Neuropsychol Soc. Published online March 22, 2021. doi:10.1017/S1355617721000229
7. Centers for Disease Control and Prevention. heads up Updated February 22, 2022. Accessed August 4, 2022. https://www.cdc.gov/headsup/index.html