Psychological & Social Impacts of Sports Concussion in Youth

It is well-known that sports-related concussion (SRC) can produce a variety of physical, cognitive, and emotional symptoms (1-3). In comparison to neurocognitive outcomes of concussion, however, far less is known about the psychological and social consequences of SRC in youth athletes.

The Particular Importance of Understanding This Area for Youth

This is an incredibly important area to explore as youth typically have longer lasting symptoms – 14-20% of youth experience symptoms beyond 3 months and 12% beyond 12 months – which has a direct impact on multiple aspects of daily life including academic and social areas (4-7).

The Current State of Literature is Underwhelming

A review of the current state of literature on the social and psychological impacts of SRC in youth found 6 main domains that youth’s issues and struggles fall under: emotional and social dysfunction, behavioural problems, academic difficulties, sleep disturbance, headache, and quality of life (QoL). Unfortunately, as explored below, the amount of information specific to SRC is underwhelming. Oftentimes, the authors of this study had to extrapolate conclusions based on studies about general mild Traumatic Brain Injury (mTBI) (i.e. not sport-specific mTBI), but even that research leave questions unanswered.

The Six Domains Impacted by SRC

Emotional and Social Dysfunction: Changes in mood are well associated with SRC and it is hypothesized that the biochemical changes that occur after SRC may directly impact mood (8). Yet, there are other factors that also can compound or produce emotional or social disturbances, such as symptoms of SRC (concentration, headaches, sleep disturbance, etc.) and potential frustration or stress-inducing restrictions in sport (9).

Highlighting the prevalence of emotional and social impacts of SRC, one study found that 50% of children with SRC experience emotional symptoms (10). In the same study, poorer psychiatric outcomes was associated with symptom burden at the time of injury as well as post-concussive syndrome (PCS), highlighting the importance of properly managing symptoms right from the start (10). A concerning statistic in this study is that a new or worsening psychiatric disorder occurred in 10% of the group with 25% of those children being left untreated (10). Another interesting find is that in comparison to other injuries, youth with SRC had more pronounced maladaptive coping (11).

Depression: In regards to depression, no SRC-specific studies have examined depression in youth. In saying that, depressive symptoms appear in youth with mTBI but often are at the subclinical level meaning that the child would not be diagnosed with depression. In one study, criteria for major depressive disorder were met by 4-6% of patients with uncomplicated mTBI (12). In another study, youth were 9x more likely to have a new mood diagnosis at 6 months (13). A third study found that youth with mTBI experience greater mood swings and withdrawal – but not necessarily clinical depression – 2 years after concussion (14). These statistics may highlight the fact that healthcare professionals managing concussion cases should be aware of the possibility that depression and other mood disorders may arise – potentially at the subclinical level – and regardless, should be addressed. One reason youth may experience depressive symptoms is that other symptoms and academic or QoL outcomes may produce or exacerbate low mood, suggesting that addressing these areas may help manage or resolve depressive symptoms (15).

Anxiety: Similarly, anxiety-related symptoms have not been explored in pediatric SRC. One study in pediatric mTBI literature suggests that around 10% of youth with mTBI develop “a new anxiety disorder within a year” and another study found that concussed children were “4x more likely to have a new anxiety diagnosis within 6 months” (16, 17). Fortunately in the latter study, in comparison with orthopaedic controls, the anxiety symptoms in mTBI youth were comparable 1 and 2 years later (18,19).

Social Functioning: There is a void of information in this area regarding pediatric SRC. The authors of this literature review suggest “it could be” that an extended disruption in a concussed child’s integration back into school and sports may “temporarily interfere with social relationships at a critical time in personal development.” One study examined uninjured, moderate/severe TBI, and mTBI children, finding that the mTBI group had the poorest social competence (20). These difficulties emerged after 2 years and are likely representative of the fact that children with mTBI receive less support because mTBI is an invisible, and not as severe, head injury in comparison to other traumatic brain injuries (19,21). Social support after traumatic brain injury aids in improving physical health and overall QoL and any negative impacts on social functioning due to concussion should be adequately addressed, but more information is required (22).

Behavioural Problems: Following the trend, there is very little research investigating behavioural disorders following pediatric concussion, sport-related or otherwise. In a New Zealand study, children with a history of mTBI during preschool years were at a greater risk of “attention-deficit/hyperactivity, conduct, or oppositional defiant disorder during adolescence” (23). Once again, this may be as a result of a disruption in the child acquiring behaviour skills during a “critical development period” (23, 24). In saying that, in one study, behavioural problems were either an issue or not present depending on who was asked about child conduct (parent vs. teacher) (25). Regardless, more research on this topic specific to SRC and mTBI generally is necessary.

Academic Difficulties: It is well-known that the symptoms of concussion can have negative impacts in the school environment, such as challenges with learning new material or difficulties concentrating, especially if one returns to school too soon which exacerbates symptoms (26). One study found that 45% of concussed students returned to school too early and suffered from worse symptoms (27, 28). Cognitive rest and slowly returning to school via a step-by-step program is important. Yet, it is important to find a balance between mental rest and activity as cognitive stimulation is important in recovery and there is a concern that the student may suffer from social isolation if withdrawn from school for too long (29).

Sleep Disturbance: Much like cognitive stimulation, it is important to find a balance between too much and too little sleep. Sleeping patterns often change immediately after a concussion — 33% of concussed youth claimed they slept too much or had troubles sleeping (30, 31). Excessive sleep – identified in one study as longer than 9 hours – was associated with “reduced visual memory, visual motor speed, and reaction time” and prolonged symptoms (32,33). On the other end of the spectrum, sleep difficulties are associated with poorer functional, social, and emotional outcomes ( but these difficulties are not necessarily associated to concussion) (34,35). Sleep is an important restorative measure for the brain after concussive injury and these side-effects should be acknowledged and addressed for the most effective recovery (31, 32, 36, 37).

Headache: Chronic headaches are a common symptom after concussion, reported in more than 90% of high school concussions (31). The prevalence of chronic headache in youth 3 months after injury range from 8%-31% depending on the study (38, 39). Headaches, and pain in general, can have a negative impact on daily activities, mental health, sleep, and personal relationships (40). Interestingly, in one study that looked at post-injury headache in mTBI compared to arm fractures, more concussed females suffered from headache, highlighting that there are differences in concussion symptomatology and severity between males and females (41). More research is required in this area, particularly to understand the prevalence and duration of chronic headache in youth suffering from SRC as well as to understand the transition of acute post-concussion headache to chronic headache pain.

Quality of Life (QoL): The impact concussion has on overall QoL is up for debate. Some studies have found that athletes with greater post concussive symptoms or longer recovery had reduced QoL (42, 43) One study even found that QoL remained “significantly below normative levels even after symptom resolution” in 11% of children at 3 months and 13% at 12 months (44-47). This may be an important finding because it reinforces the idea that just because concussion symptoms are resolved does not mean all of concussion’s effects are resolved. This fact ultimately should have an impact on return to play (RTP) and treatment decisions. On the other hand, there are studies that also have mixed findings (48). Ultimately, QoL impairments seem to be minimal, with symptom burden likely being the cause of a lower QoL (46).

Final Conclusions

Ultimately, more information is required on these topics to fully understand what psychological and social components youth with SRC suffer from as well as to understand how to address these side-effects to most effectively manage concussion and promote recovery. Regardless, for the time being, it could be suggested that medical professionals managing concussion cases consider these 6 areas as potential areas that may be impacting the youth’s recovery.

The original review can be found here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383087/

Bibliography

1. Ayr LK, Yeates KO, Taylor HG, Browne M. Dimensions of postconcussive symptoms in children with mild traumatic brain injuries. J Int Neuropsychol Soc. 2009;15:19–30.
2. Heyer GL, Schaffer CE, Rose SC, Young JA, McNally KA, Fischer AN. Specific factors influence postconcussion symptom duration among youth referred to a sports concussion clinic. J Pediatr. 2016;174:33–38.e2.
3. Teel EF, Marshall SW, Shankar V, McCrea M, Guskiewicz KM. Predicting recovery patterns after sport-related concussion. J Athl Train. 2017;52:288–298
4. Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010;126:e374–e381.
5. Ponsford J, Willmott C, Rothwell A, et al. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001;108:1297–1303.
6. Taylor HG, Dietrich A, Nuss K, et al. Post-concussive symptoms in children with mild traumatic brain injury. Neuropsychology. 2010;24:148–159.
7. Taylor HG, Orchinik LJ, Minich N, et al. Symptoms of persistent behavior problems in children with mild traumatic brain injury. J Head Trauma Rehabil. 2015;30:302–310.
8. Mainwaring LM, Hutchison M, Bisschop SM, Comper P, Richards DW. Emotional response to sport concussion compared to ACL injury. Brain Inj. 2010;24:589–597.
9. Meehan WP., III Medical therapies for concussion. Clin Sports Med. 2011;30:115–124, ix.
10. Ellis MJ, Ritchie LJ, Koltek M, et al. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr. 2015;16:709–718.
11. Covassin T, Elbin RJ, Beidler E, Lafevor M, Kontos AP. A review of psychological issues that may be associated with a sport-related concussion in youth and collegiate athletes. Sport Exerc Perform. 2017;6:220–229.
12. O’Connor SS, Zatzick DF, Wang J, et al. Association between posttraumatic stress, depression, and functional impairments in adolescents 24 months after traumatic brain injury. Journal of Traumatic Stress. 2012;25:264–271.
13. Luis CA, Mittenberg W. Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study. J Clin Exp Neuropsychol. 2002;24:270–279.
14. Hawley CA, Ward AB, Magnay AR, Long J. Outcomes following childhood head injury: a population study. J Neurol Neurosurg Psychiatry. 2004;75:737–742.
15. Lau BC, Collins MW, Lovell MR. Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med. 2011;39:1209–1216.
16. Max JE, Lopez A, Wilde EA, et al. Anxiety disorders in children and adolescents in the second six months after traumatic brain injury. J Pediatr Rehabil Med. 2015;8:345–355.
17. Luis CA, Mittenberg W. Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study. J Clin Exp Neuropsychol. 2002;24:270–279.
18. Hawley CA, Ward AB, Magnay AR, Long J. Outcomes following childhood head injury: a population study. J Neurol Neurosurg Psychiatry. 2004;75:737–742.
19. Anderson V, Beauchamp MH, Yeates KO, et al. Social competence at two years after childhood traumatic brain injury. J Neurotrauma. 2017;34:2261–2271
20. Anderson V, Beauchamp MH, Yeates KO, Crossley L, Hearps SJ, Catroppa C. Social competence at 6 months following childhood traumatic brain injury. J Int Neuropsychol Soc. 2013;19:539–550.
21. Kennedy JE, Cullen MA, Amador RR, Huey JC, Leal FO. Symptoms in military service members after blast mTBI with and without associated injuries. Neurorehabilitation. 2010;26:191–197.
22. Lumba-Brown A, Yeates KO, Gioia G, et al. Report from the pediatric mild traumatic brain injury guideline workgroup: systematic review and clinical recommendations for healthcare providers on the diagnosis and management of mild traumatic brain injury among children.
23. McKinlay A, Grace R, Horwood J, Fergusson D, MacFarlane M. Adolescent psychiatric symptoms following preschool childhood mild traumatic brain injury: evidence from a birth cohort. J Head Trauma Rehabil. 2009;24:221–227.
24. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics. 2006;117:1359–1371.
25. Taylor HG, Orchinik LJ, Minich N, et al. Symptoms of persistent behavior problems in children with mild traumatic brain injury. J Head Trauma Rehabil. 2015;30:302–310
26. Halstead ME, McAvoy K, Devore CD, et al. Returning to learning following a concussion. Pediatrics. 2013;132:948–957.
27. Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sport-related concussion: physician’s chart review. Can Fam Physician. 2014;60:e310, e312–e315.
28. Makki AY, Leddy J, Hinds A, et al. School attendance and symptoms in adolescents after sport-related concussion. Glob Pediatr Health. 2016;3:2333794X16630493.
29. Majerske CW, Mihalik JP, Ren D, et al. Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train. 2008;43:265–274.
30. Eisenberg MA, Meehan WP, III, Mannix R. Duration and course of post-concussive symptoms.Pediatrics. 2014;133:999–1006.
31. Meehan WP, d’Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management. Am J Sports Med. 2010;38:2405–2409.
32. Kostyun R, Milewski MD, Hafeez I. Sleep disturbance and neurocognitive function during the recovery from a sport-related concussion in adolescents. Am J Sports Med. 2015;43:633–640.
33. Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017;51:930–934.
34. Albicini MS, Lee J, McKinlay A. Ongoing daytime behavioural problems in university students following childhood mild traumatic brain injury. Int J Rehabil Res. 2016;39:77–83.
35. Chan LG, Feinstein A. Persistent sleep disturbances independently predict poorer functional and social outcomes 1 year after mild traumatic brain injury. J Head Trauma Rehabil. 2015;30:E67–E75
36. Khoury S, Chouchou F, Amzica F, et al. Rapid EEG activity during sleep dominates in mild traumatic brain injury patients with acute pain. J Neurotrauma. 2013;30:633–641
37. Kostyun R. Sleep disturbances in concussed athletes: a review of the literature. Conn Med. 2015;79:161–165.
38. 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. 2013;167:156–161.
39. Kuczynski A, Crawford S, Bodell L, Dewey D, Barlow KM. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort. Dev Med Child Neurol. 2013;55:636–641.
40. McCarberg BH, Nicholson BD, Todd KH, Palmer T, Penles L. The impact of pain on quality of life and the unmet needs of pain management: results from pain sufferers and physicians participating in an Internet survey. Am J Ther. 2008;15:312–320. [PubMed] [Google Scholar]
41. Blume HK, Vavilala MS, Jaffe KM, et al. Headache after pediatric traumatic brain injury: a cohort study. Pediatrics. 2012;129:e31–e39.
42. Houston MN, Bay RC, Valovich McLeod TC. The relationship between post-injury measures of cognition, balance, symptom reports and health-related quality-of-life in adolescent athletes with concussion. Brain Inj. 2016;30:891–898.
43. Russell K, Selci E, Chu S, Fineblit S, Ritchie L, Ellis MJ. Longitudinal assessment of health-related quality of life following adolescent sports-related concussion. J Neurotrauma. 2017;34:2147–2153.
44. Zonfrillo MR, Durbin DR, Koepsell TD, et al. Prevalence of and risk factors for poor functioning after isolated mild traumatic brain injury in children. J Neurotrauma. 2014;31:722–727.
45. Moran LM, Taylor HG, Rusin J, et al. Quality of life in pediatric mild traumatic brain injury and its relationship to postconcussive symptoms. J Pediatr Psychol. 2012;37:736–744.
46. Yeates KO, Kaizar E, Rusin J, et al. Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med. 2012;166:615–622.
47. Rivara FP, Koepsell TD, Wang J, et al. Disability 3, 12, and 24 months after traumatic brain injury among children and adolescents. Pediatrics. 2011;128:e1129–e1138.
48. Fineblit S, Selci E, Loewen H, Ellis M, Russell K. Health-related quality of life after pediatric mild traumatic brain injury/concussion: a systematic review. J Neurotrauma. 2016;33:1561–1568.