A third of youngsters develop a mental health problem after concussion, review finds

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Identifying young people at risk of ongoing difficulties after concussion remains a major challenge for doctors, according to researchers.
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A third of children and adolescents develop a mental health problem after a concussion, which could persist for several years following the injury, a just-published review has found.

The Australian research, led by the Murdoch Children’s Research Institute in Melbourne, found mental health should be evaluated as part of standard pediatric concussion assessment and management.

Monash University doctoral candidate Alice Gornall, a researcher with the institute, said that despite many post-concussion and mental health symptoms overlapping, the relationship between delayed recovery and mental health had remained poorly understood until the review.

The review, published in the British Journal of Sports Medicine, examined 69 scientific papers published between 1980 to June 2020, involving almost 90,000 children aged up to 18 from nine countries, including Australia, the US, Canada and New Zealand, who had a concussion.

Falls (42.3 per cent) and sporting injuries (29.5 per cent) were the most common cause of injury, followed by car accidents (15.5 per cent).

It found up to 36.7 per cent experienced significantly high levels of internalising problems such as withdrawing, anxiety, depression and post-traumatic stress and 20 per cent externalising problems such as aggression, attention problems and hyperactivity after concussion compared with healthy children or children who sustained other injuries such as an arm fracture.

Pre-existing mental health problems were a strong predictor of post-concussion mental health issues. The review found that 29 percent of children with a pre-injury mental health diagnosis received a new mental health diagnosis post-concussion. Up to 26 percent without prior mental health problems went on to develop symptoms.

Gornall said while significant improvements in mental health emerged between three and six months after the injury, a minority of children experienced persisting symptoms for several years.

The findings come after a recent study, led by the institute and published in The Journal of Head Trauma Rehabilitation, found having a traumatic brain injury in early childhood was associated with lower IQ scores that persist up to seven years post-injury.

Gornall said concussion was a growing public health concern with a third of children experiencing a head injury before 13 years of age.

“Despite the high incidence of concussion among children and adolescents, identifying those at risk of ongoing difficulties after concussion remains a prominent challenge for clinicians,” she said.

“On top of this, children take twice as long to recover from concussion than adults, with one in four children experiencing symptoms beyond one month post-injury.”

Melbourne resident Emma, 17, has been seeking mental health support after suffering two concussions, a year apart.

In 2019, while playing netball, she knocked her head on a goal post and last March she was hit with a ball in the back of the head.

Emma said after the second concussion she developed anxiety, headaches, a sense of hopelessness and had trouble concentrating.

“After my last concussion, I found it very hard to be motivated for school and everyday life. Doing the simplest of tasks such as a walk was difficult for me, not being able to complete these tasks got me quite disheartened which impacted on my mental health,” she said.

Emma’s dad, Bruce Henry, said he welcomed the push for mental health to be part of paediatric concussion assessment and management as many cases would be going untreated.

“When a child has a concussion they might look fine but you can’t see the underlying impact,” he said. It’s so important for mental health to form part of concussion management, which has been essential to Emma’s recovery process.”

Researchers with the institute are also trialling an intervention, Concussion Essentials, to prevent children from suffering long term post-concussion symptoms.

The eight-session intervention combines physiotherapy and psychology treatments that target presenting symptoms with education around common concerns such as headache, fatigue and return to exercise, school and sports. Early data shows that the intervention is effective in accelerating recovery.

Professor Vicki Anderson, who is with the institute said the assessment, prevention and intervention of mental health difficulties after concussion should be integrated into standard concussion management.

“Mental health is central to concussion recovery. Concussion may both precipitate and exacerbate mental health difficulties, impacting delayed recovery and psychosocial outcomes,” she said.

“Incorporating mental health risk into post-injury management represents an opportunity to engage children and adolescents with mental health services to either prevent unnecessary problems emerging or to treat already existing issues.”

The HeadCheck app, developed by concussion experts at the institute and The Royal Children’s Hospital and in collaboration with the Australian Football League, also helps parents, coaches and first aiders to recognise the signs of concussion and manage the child’s safe return to school, play and organised sport.

Researchers from Monash University, the University of Melbourne and The Royal Children’s Hospital also contributed to the study.

Alice Gornall, Michael Takagi, Thilanka Morawakage, Xiaomin Liu and Vicki Anderson. ‘Mental Health After Pediatric Concussion: A Systematic Review & Meta-Analysis,’ British Journal of Sports Medicine. DOI: 10.1136/bjsports-2020-103548

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