Concussions Linked to Mental Health Issues in Kids

Concussion in kids was associated with an increased risk of mental health problems compared with orthopedic injury, a 10-year retrospective cohort study from Canada found.

Among over 400,000 youths ages 5 to 18, those who had a concussion were at greater risk for mental health problems (adjusted HR [aHR] 1.39, 95% CI 1.37-1.40), as well as self-harm (aHR 1.49, 95% CI 1.42-1.56) and psychiatric hospitalization (aHR 1.47, 95% CI 1.41-1.53), reported Andrée-Anne Ledoux, PhD, of the Children’s Hospital of Eastern Ontario Research Institute, and colleagues.

The incidence rate of any mental health problem was 11,141 per 100,000 person-years in the concussion group versus 7,960 per 100,000 person-years in the orthopedic injury group, they noted in JAMA Network Open.

“Our findings suggest that during concussion follow-up visits, physicians should assess patients’ mental health,” Ledoux and colleagues wrote. “It has been found that collaborative care and mental health treatment improve outcomes in pediatric concussion with chronic symptoms.”

While one in five Canadian children has a mental health disorder, this proportion was higher among the kids in both study groups. “This may be due to differences in the time period and method of identifying and/or defining mental health problems,” the authors suggested. “It may also reflect the mutual experience of trauma, as it has been reported that individuals with orthopedic injury may have long-lasting behavioral changes after injury.”

“Such a large-scale study highlights associations between concussion and mental health but also raises important unanswered questions,” wrote Talin Babikian, PhD, of the University of California Los Angeles, in an invited commentary. Despite the increased public health concern about the long-term effects of concussions, “the mechanism of this increased risk remains largely elusive.”

Babikian warned of a “dichotomy trap” when discussing the role of concussions in increased mental health problems in youth, with “artificial division of mental vs physical, psychological vs neurological, and organic vs environmental.”

“These divisions are largely remnants of the historical conditioning of our training paradigms,” she explained. “In reality, all of these frames of reference characterize the same system: our intricate nervous system.”

“Youth arrive at a concussion not as a blank slate, but rather as a tapestry of risks and resiliencies — personal, familial, and environmental,” Babikian noted. Therefore, when managing a concussion, it is important to maintain a “sense of safety and agency” and a “sense of connection and belonging.”

The study matched 152,321 children (median age 13, 56.7% boys) who had a concussion with 296,482 who had an orthopedic injury (median age 13, 57.9% boys) from April 2010 through March 2020 in Ontario, Canada.

“Orthopedic injuries have been shown to be a good comparison group, as they share injury-related experiences (e.g., emergency department visit, pain, injury-related stress) and premorbid characteristics,” Ledoux and team noted.

If a patient had more than one concussion or orthopedic injury, the first diagnosed incident was included for the study. Children were excluded from the study if they did not have continuous Ontario Health Insurance Plan coverage in the 5 years before the injury index event, or if they had a mental health diagnosis in the year before the event or a mental health diagnosis code during their index visit.

The study authors acknowledged that their retrospective observational design was an “inherent weakness” to the study. They also noted that their study relied on diagnoses codes and administrative databases, which may introduce misclassification errors and do not account for all mental health services provided.