Psychiatric Disorders After Pediatric Traumatic Brain Injury: A Prospective, Longitudinal, Controlled Study

Abstract

The objective was to examine the effects of traumatic brain injury (TBI), as compared with orthopedic injury (OI), relative to the risk for psychiatric disorder. There has only been one previous prospective study of this nature. Participants were age 7-17 years at the time of hospitalization for either TBI (complicated mild-to-severe) or OI. The study used a prospective, longitudinal, controlled design, with standardized psychiatric assessments conducted at baseline (reflecting pre-injury functioning) and 3 months post-injury. Assessments of pre-injury psychiatric, adaptive functioning, family adversity, and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales. The outcome measure was the presence of a psychiatric disorder not present before the injury ("novel"), during the first 3 months after TBI. Enrolled participants (N=141) included children with TBI (N=75) and with OI (N=66). The analyses focused on 118 children (84%) (TBI: N=65; OI: N=53) who returned for follow-up assessment at 3 months. Novel psychiatric disorder (NPD) occurred significantly more frequently in the TBI (32/65; 49%) than the OI (7/53; 13%) group. This difference was not accounted for by pre-injury lifetime psychiatric status; pre-injury adaptive functioning; pre-injury family adversity, family psychiatric history, socioeconomic status, injury severity, or age at injury. Furthermore, none of these variables significantly discriminated between children with TBI who developed, versus those who did not develop, NPD. These findings suggest that children with complicated mild-to-severe TBI are at significantly higher risk than OI-controls for the development of NPD in the first 3 months after injury.

Psychiatric outcomes after pediatric sports-related concussion

“…32 Novel psychiatric disorders diagnosed among patients with TBI in these studies were heterogeneous and included depressive disorders, anxiety disorders such as generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and OCD, somatoform disorder, ADHD, and behavioral disorders such as oppositional-defiant disorder and conduct disorder. 4,[21][22][23][26][27][28]30,[34][35][36]49 Among the most common NPDs observed among prospective studies has been personality change resulting from a generalized medical condition, which has been diagnosed in up to 40% of pediatric patients after TBI but was not formally assessed in the present study. 22,36 Clinical variables associated with the development of NPDs after pediatric TBI include history of preinjury psychiatric disorder, family history of psychiatric illness, severity of injury, low socioeconomic status, and preinjury adaptive and intellectual functioning.…”

“…4,[21][22][23][26][27][28]30,[34][35][36]49 Among the most common NPDs observed among prospective studies has been personality change resulting from a generalized medical condition, which has been diagnosed in up to 40% of pediatric patients after TBI but was not formally assessed in the present study. 22,36 Clinical variables associated with the development of NPDs after pediatric TBI include history of preinjury psychiatric disorder, family history of psychiatric illness, severity of injury, low socioeconomic status, and preinjury adaptive and intellectual functioning. 20,22,25,31,34,54 In addition, psychosocial stress and family functioning have also been identified as important factors that affect the risk of developing NPDs after pediatric TBI.…”

“…Of the 20 patients who developed postinjury psychiatric outcomes in this study, 75% had a history of 1 or 2 lifetime concussions, whereas 25% had a history of 3 or more lifetime concussions. Although injury severity has been identified as a key predictor of NPD development in the TBI literature, 20,22,36 the severity of concussion is difficult to assess clinically among children and adolescents. The mean or median PCSS score has been used in previous pediatric SRC studies as a measure of concussion severity, 8,10,43,44 whereas the use of the emotional PCSS subscore as a measure of psychological health has not been well studied.…”

“…First, we did not use a standardized psychiatric interview to provide comprehensive assessment of both preinjury and postinjury emotional symptoms and psychiatric disorders in all patients referred to the multidisciplinary concussion program. Among the patients referred to adolescent psychiatry, they all underwent formal assessments that included assessing preinjury and postinjury symptoms and psychiatric disorders; however, the incorporation of standardized instruments such as the Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime Version (K-SADS-PL), which has been used in previous studies, 16,36 may have led to a more comprehensive assessment of preinjury and postinjury psychiatric disorders. Second, as mentioned, we did not use standardized instruments that assessed for personality change among those referred to adolescent psychiatry.…”

“…Previous studies have observed novel psychiatric disorders (NPDs) occurring in 10%-100% of children and adolescents with TBI of various severities, including personality changes, attention-deficit hyperactivity disorder (ADHD), behavioral disorders, depression, and anxiety disorders. 4,21,22,[26][27][28]30,31,[33][34][35][36]49 Children and adolescents with psychiatric disorders are at risk for additional long-term comorbidities such as impaired school performance, 9 social isolation, 48 family dysfunction, 55 substance abuse, 45 and suicidal behavior. 19 Successful management of isolated pediatric mood disorders requires a multidisciplinary approach that includes behavioral and pharmacological treatment options.…”