Mild TBI may increase risk of postconcussive symptoms in children

Children who experience mild traumatic brain injury may be more likely to show increases in symptoms over time that could impact quality of life, more so than children who experience an orthopedic injury. Injury severity could play a role.

Mild traumatic brain injuries (TBI), including concussions, are common in children and adolescents. Studies indicate that children with mild TBI display more postconcussive symptoms than healthy children or children with injuries not involving the head. Postconcussive symptoms include somatic complaints including headache or fatigue and cognitive complaints including inattention and forgetfulness.

"Group differences in postconcussive symptoms are most pronounced shortly after injury," said Keith O. Yeates, PhD, director of Behavioral Health Services at Nationwide Children's Hospital and one of the study authors. "Comparing group averages is informative, but does not indicate whether individual children show significant increases in postconcussive symptoms following mild TBI more commonly than after other injuries. Health providers need to be able to identify children with mild TBI who are at risk for persistent postconcussive symptoms so that they can target such children for appropriate management."

Estimates of reliable change have become a common approach to assess individual changes in neurobehavioral functioning. Analyses of reliable change determine whether an individual displays a statistically reliable change in neurobehavioral test scores or symptom ratings across two occasions.

Using data from a prospective, longitudinal project, Dr. Yeates and colleagues examined reliable change in postconcussive symptoms among children with mild TBI as compared to children with orthopedic injuries. This study, which appears in Archives of Pediatrics & Adolescent Medicine, is the first study to assess reliable change in this patient population.

Participants included children between 8 and 15 years of age who either came to the emergency department at Nationwide Children's Hospital or Rainbow Babies and Children's Hospital in Cleveland with either closed-head trauma or orthopedic injury. To determine reliable change, parents were asked to rate their children's pre-injury symptoms. These ratings were then compared to parent symptom ratings post-injury, during a 3-month assessment and a 12-month assessment.

The study found that children with mild TBI were more likely to exhibit reliable increases in both cognitive and somatic symptoms than children with orthopedic injury. These differences became less common over time for somatic symptoms, but persisted to 12 months post-injury for cognitive symptoms. Among children with mild TBI, symptom increases were more common among children with loss of consciousness or abnormalities on neuroimaging. "These results extend previous findings by showing that many individual children with mild TBI show substantial and persistent increases in postconcussive symptoms relative to their pre-injury functioning," said Dr. Yeates.

Reliable increases in cognitive and somatic symptoms were associated with declines in physical and psychosocial quality of life. Additionally, reliable increases in somatic symptoms at 3 months post-injury predicted an increased likelihood of educational intervention. "These results indicate that persistent postconcussive symptoms have functional consequences that are likely to reflect impairment in children's daily functioning," said Dr. Yeates.

Dr. Yeates warns that these findings do not encompass the entire population of children presenting to emergency departments for minor closed-head trauma, but represents those with clear evidence of a mild TBI.

"Research is needed to clarify which injury and non-injury related factors increase the likelihood of reliable increases in postconcussive symptoms," said Dr. Yeates. "The current research suggests that injury severity is one key factor. Advanced neuroimaging techniques may more clearly differentiate injury severity and its relationship to outcomes."