After Concussion: 1 in 9 Kids Face Mental Health Challenges, Study Finds

• A systematic review of studies found that of the kids and teens who have prolonged symptoms after a concussion (about one in three), a third develop mental health issues.
• Among the most common symptoms were depression, anxiety, and difficulty concentrating.
• Based on the study’s findings, the researchers suggest encouraging children and teens to ease back into physical activity sooner rather than later.

Researchers found that many children and teenagers develop mental health issues after a concussion, especially those who experience lingering concussion symptoms.

The meta-analysis conducted by researchers at the Murdoch Children’s Research Institute (MCRI) in Melbourne, Australia, found that one-third of youth who experience a concussion go on to develop mental health problems. The research was published in the British Journal of Sports Medicine in late April.

“The mental health problems that we see, and that came up in our study, are primarily what psychologists call internalizing problems, like anxiety and depression,” study author Vicki Anderson, PhD, a pediatric neuropsychologist and director of psychology at The Royal Children’s Hospital in Melbourne, tells.

What Is a Concussion?

Concussions are fairly common. But children who experience concussions may have a hard time describing how they feel. A child needs to be closely monitored for the first 24 hours after they get a concussion. In the short term, a concussion can cause a headache, nausea, and/or blurry vision. Some people experience symptoms that last longer. A 2018 study found that 20% to 30% of people who get a concussion experience symptoms for an unusually long time. While the symptoms of a concussion are expected to go away in about a week, some people continue to have symptoms for months or even up to a year.

Mental Health Symptoms After Concussion

The study systematically reviewed 69 articles from nine countries that were published between 1980 to 2020. The studies included almost 90,000 children between the ages of 0 and 18 years who experienced a concussion. Falls accounted for the majority (42.3%) of the injuries, followed by sporting injuries (29.5%), and car accidents (15.5%).

The researchers noted that compared to healthy children or children who had other injuries (like a broken bone) kids with concussions experienced more internalizing and externalizing mental health issues.

Of the children and teens with lingering symptoms, 36.7% experienced significantly high levels of what psychologists call “internalizing problems,” which include withdrawing, anxiety, depression, and post-traumatic stress. Around 20% exhibited “externalizing problems,” like aggression, attention difficulties, and hyperactivity.

Anderson, who frequently treats young people with concussions, says that internalizing symptoms arise from the need to adjust to changes following a concussion and to the trauma of the event. A young person’s preexisting characteristics and environments—such as an anxious temperament—can also influence the gravity and duration of mental health symptoms following concussion.

Yes, there’s a physical injury, but the ongoing environmental and psychological impacts—if they’re not supportive—can be quite destructive.

— VICKI ANDERSON, PHD

Researchers found that prior mental health conditions or symptoms predicted the emergence of negative mental health consequences following a concussion. Anderson says that family dynamics—specifically anxious parents—also play an important role in concussion recovery in kids. A recent study shows that kids with anxious parents are four times more likely to experience delayed recovery from a concussion.

“Yes, there’s a physical injury,” Anderson says. “But the ongoing environmental and psychological impacts—if they’re not supportive—they can be quite destructive.”

The study also found that negative mental health symptoms usually subsided within three to six months post-injury. However, a minority of kids experienced lasting symptoms for years.

What Makes a Kid At-Risk?

There are several factors making some youth more prone not just to concussions, but to the subsequent mental health effects.

A child’s temperament and personality might play a role in mental health effects. In her pediatric clinic, Anderson sees a “classic constellation of characteristics” in her patients: they tend to be female (which could be because females can be more likely to verbally communicate about their mental health than males) and they are often high-achieving teenagers with pre-existing anxiety temperaments.

“It would be very common for it to be the captain of the football team, the A-grade student, the school captain,” Anderson says. “Very high achievers set high expectations for themselves, and then when they have a concussion, what they express is worry that that high achievement will be impacted.”

Anderson says that it’s also common to see “conversion,” in which stress from prior factors—like school and sports—expresses itself through stress over an injury. Additionally, while it does not apply to all patients, Anderson says that COVID-19 lockdowns in Melbourne exacerbated many of her patient’s symptoms.

Easing Back Into Physical—And Mental—Activity

A common prescription for concussion is rest, preferably in the dark. This means not looking at a phone, tablet, or any screens—or even reading a book. However, Anderson says that this treatment is old-fashioned and outdated. “If you imagine today’s teenager, who is constantly on a screen, on Snapchat, and not being able to do that, then what do they do?” Anderson says. “They sit there and they worry about what’s going to happen.”

In light of research challenging these old models, Anderson encourages kids to get back to exercising as soon as they can. Experts now recommend a maximum of 48 hours of rest post-concussion, with a little bit of screen or book time. After 48 hours, patients should see if they can walk around the block, and work on increasing the distance they go each day.

“The idea is you work very quickly towards a gradually increasing exercise in cognitive activities, so each day that child has a goal to reach, and they’re getting better all the time,” Anderson says. “Our message is that that early and gradual return to activity is absolutely critical to minimize the mental health problem.”

The update comes as a growing body of research shows that there is a thing as too much rest after a mild concussion—in fact, light physical and mental activity may help a patient’s symptoms resolve more quickly.

Anderson and her colleagues recommend that mental health assessment, prevention, and intervention be integrated into the standard procedures following concussion. The team is also working on an app called Headcheck that will give caregivers actionable concussion-related information and monitoring tools to help them support a child who is recovering.

“There’s a lot of misunderstanding of concussion in the community,” Anderson says. “But our focus is very much on, ‘What do we do so that we can get these kids better?'”