The topic of concussions has generally been in reference to professional sport athletes, although we now know that children and adolescents are also common victims of this injury, which can occur during any type of activity. A concussion is defined as a type of brain injury caused by a bump, blow, or jolt to the head that causes the brain to move rapidly back and forth like Jell-O, often hitting the front and back of the skull. It is not a “bruise” to the brain, but rather a trauma that is associated with a diverse constellation of temporary cognitive, physical and/or emotional symptoms.
Although each recovery is different, most symptoms from a single concussion resolve within a few hours to a few months. However, a proportion of youngsters continue to experience persisting symptoms that extend well beyond the expected recovery period, and a number of factors have been postulated to influence recovery. While an in-depth examination of all of these factors is beyond the scope of this discussion, this article will focus on the psychological and emotional elements that can impact recovery and contribute to a child’s persisting symptoms.
For both student athletes and non-student athletes, the restriction of physical and social activities following a concussive injury can result in a sense of loss in skills, normalcy, and social isolation, resulting in secondary symptoms of depression and anxiety. Physical, cognitive, and emotional symptoms related to the injury also interfere with learning, and the injured student may feel overwhelmed and frustrated. Missed school days can further compound feelings of anxiety due to the increased workload and having to “catch up.”
The potential impact on the family should be considered. Parents generally know the drill when it comes to ankle sprains and broken bones, although parents report a lack of clarity about how to help their child with ongoing difficulties, thus creating increased family stress and hindering recovery. Furthermore, extensive media coverage exposing people to inaccurate information related to traumatic brain injuries has created a culture of fear and parents and youngsters may inadvertently (mis)attribute lingering symptoms to the concussion when emotional factors secondary to the injury are really at play.
The experience of secondary depression, anxiety, and/or mood disturbance can manifest in physiological symptoms that masquerade as post-concussion symptoms and further slow recovery. Thus careful consideration of emotional conditions is particularly important when youngsters present with persisting symptoms and/or do not report a reduction in symptoms over time. Children and adolescents with pre-existing mood challenges are also at risk for delayed recovery. Moreover, there are also no biomarkers of concussion or telltale signs such as drawn blood or neuroimaging so untangling the neurological factors related to the injury from secondary psychological factors becomes particularly complex.
Successful recovery from a concussion is best obtained through a multi-disciplinary approach involving multiple providers, although a consultation with a neuropsychologist is a good first step to help determine the factors contributing to a child’s protracted recovery. A neuropsychological evaluation generally entails an assessment of cognitive skills (e.g., aspects of memory, attention, processing speed) and mood that will help determine if psychological factors are at work. A neuropsychologist can also ensure relevant cognitive and psychological symptoms are managed appropriately. In certain cases, a referral to a clinical psychologist may be appropriate for more long-term therapy.
From an intervention perspective, the overarching goal is to reduce distress and promote psychological and cognitive strategies that help reduce symptoms and improve the youngster’s overall functioning. Therapies related to emotional challenges associated with concussion generally involve the following interventions:
Psychoeducation teaches patients and families about common concussion symptoms and normal recovery patterns. These methods also help empower the family with a greater sense of control over the recovery process.
Psychotherapy gives the patient and family a safe space to talk about problems and feelings and helps untangle the sources of emotional distress related to the injury. Interventions may include problem-solving, mindfulness-based techniques, and cognitive behavioral therapy with the latter being particularly useful for correcting thinking errors, modifying unhelpful behaviors, and increasing coping skills. A neuropsychologist, collaborating with sports-medicine and/or rehabilitation specialists, can further determine when an athlete can safely to return to sports activities.
School-based accommodations involve developing a temporary academic support plan for students experiencing various school-related difficulties. Accommodations may include a gradual re-introduction of schoolwork, modified homework, test-taking accommodations, and supports to address specific symptoms. Given the invisible nature of the injury, ongoing communication with teachers and other school staff about the plan and expectations for recovery is also key.
In summary, recovery from a concussion can go awry if psychological and emotional factors are not taken into consideration. The unique contribution of psychological factors is an important consideration when children and adolescents present with persisting symptoms and delayed recovery patterns. Thus, understanding, assessing and treating the psychological factors associated with a concussion can be an effective means of preventing or shortening the length of post-concussion syndrome and reducing the likelihood of complications.
If you have questions or concerns about head injuries or concussions, you can find more information and resources at the CDC Heads-Up Concussion website. Pediatric neuropsychologists, sports psychologists, and sports medicine physicians are also great resources to help families navigate the mental and emotional consequences of the injury and give appropriate referrals.