title: Psychiatric outcomes after pediatric sports-related concussion.
abstract: OBJECTIVE
  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.
authors.affiliation: Departments of 1 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.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Ellis
authors.affiliation: Clinical Health Psychology, and.|Pan Am Concussion Program;|Canada North Concussion Network, Winnipeg, Manitoba, Canada.
authors.forename: Lesley J
authors.initials: LJ
authors.lastname: Ritchie
authors.affiliation: Psychiatry, and.|Pan Am Concussion Program;|Canada North Concussion Network, Winnipeg, Manitoba, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Koltek
authors.affiliation: Psychiatry, and.|Pan Am Concussion Program;|Canada North Concussion Network, Winnipeg, Manitoba, Canada.
authors.forename: Shahid
authors.initials: S
authors.lastname: Hosain
authors.affiliation: Pan Am Concussion Program;|Canada North Concussion Network, Winnipeg, Manitoba, Canada.
authors.forename: Dean
authors.initials: D
authors.lastname: Cordingley
authors.affiliation: Pediatrics and Child Health.|Childrens Hospital Research Institute of Manitoba; and.|Canada North Concussion Network, Winnipeg, Manitoba, Canada.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Chu
authors.affiliation: Pediatrics and Child Health.|Childrens Hospital Research Institute of Manitoba; and.|Canada North Concussion Network, Winnipeg, Manitoba, Canada.
authors.forename: Erin
authors.initials: E
authors.lastname: Selci
authors.affiliation: Departments of 1 Surgery.|Pan Am Concussion Program;|Canada North Concussion Network, Winnipeg, Manitoba, Canada.
authors.forename: Jeff
authors.initials: J
authors.lastname: Leiter
authors.affiliation: Pediatrics and Child Health.|Childrens Hospital Research Institute of Manitoba; and.|Canada North Concussion Network, Winnipeg, Manitoba, Canada.
authors.forename: Kelly
authors.initials: K
authors.lastname: Russell
mesh_terms: D000293:Adolescent; D001265:Athletic Injuries / Q000150:complications* / Q000453:epidemiology; D001924:Brain Concussion / Q000453:epidemiology* / Q000209:etiology / Q000523:psychology*; D002648:Child; D004644:Emotions; D005260:Female; D006801:Humans; D008297:Male; D008350:Manitoba / Q000453:epidemiology; D008499:Medical Records; D009483:Neuropsychological Tests; D010348:Patient Care Team; D038223:Post-Concussion Syndrome / Q000453:epidemiology* / Q000209:etiology / Q000523:psychology*; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D013177:Sports
keywords: 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; anxiety; depression; pediatric; postconcussion syndrome; psychiatric disorder; sports-related concussion; suicide; trauma