Canadian

Psychiatric Association

Association des psychiatres

du Canada

In Review Series

A Systematic Review of Psychiatric,

Psychological, and Behavioural Outcomes
following Mild Traumatic Brain Injury
in Children and Adolescents

The Canadian Journal of Psychiatry /

La Revue Canadienne de Psychiatrie
2016, Vol. 61(5) 259-269
The Author(s) 2016
Reprints and permission:
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DOI: 10.1177/0706743716643741
TheCJP.ca | LaRCP.ca

Une revue systematique des resultats psychiatriques,

psychologiques et comportementaux par suite dun traumatisme
cranio-cerebral benin chez les enfants et les adolescents

Carolyn A. Emery, PT, PhD1,2, Karen M. Barlow, MRCP, MRCPCH1,

Brian L. Brooks, RPsych, PhD1, Jeffrey E. Max, MBBCh3,4,
Angela Villavicencio-Requis, BSc1, Vithya Gnanakumar, MD1,
Helen Lee Robertson, MLIS5, Kathryn Schneider, PT, PhD1,2,
and Keith Owen Yeates, PhD1,2

Abstract
Background: Evidence regarding longer-term psychiatric, psychological, and behavioural outcomes (for example, anxiety,
mood disorders, depression, and attention disorders) following mild traumatic brain injury (mTBI) in children and adolescents
has not been previously synthesized.
Objective: To conduct a systematic review of the available evidence examining psychiatric, psychological, and behavioural
outcomes following mTBI in children and adolescents.
Materials and Methods: Nine electronic databases were systematically searched from 1980 to August 2014. Studies
selected met the following criteria: original data; study design was a randomized controlled trial, quasi-experimental design,
cohort or historical cohort study, case-control study, or cross-sectional study; exposure included mTBI (including concussion); population included children and adolescents (<19 years) at the time of mTBI, as well as a comparison group (for
example, healthy children, children with orthopaedic injuries); and included psychiatric, psychological, or behavioural outcomes (for example, anxiety, mood disorders, depression, attention disorders). Two authors independently assessed the
quality and level of evidence with the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine
(OCEBM) model, respectively, for each manuscript.
Results: Of 9472 studies identified in the initial search, 30 were included and scored. Heterogeneity in methodology and
injury definition precluded meta-analyses. The median methodological quality for all 30 studies, based on the DB criteria, was
15/33 (range 6 to 19). The highest level of evidence demonstrated by all reviewed studies was level 2b based on OCEBM
criteria, with the majority (28/30 studies) classified at this level. Based on the literature included in this systematic review,
psychological and psychiatric problems in children with a history of mTBI were found to be more prevalent when mTBI is

1
2
3
4
5

Alberta Childrens Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
Rady Childrens Hospital, San Diego, California, USA
Neuropsychiatric Research, Department of Psychiatry, University of California, San Diego, California, USA
Health Sciences Library, University of Calgary, Calgary, Alberta, Canada

Corresponding Author:
Carolyn A. Emery, PT, PhD University of Calgary, 2500 University Dr NW, Calgary, Alberta, T2N1N4, Canada.
Email: caemery@ucalgary.ca

260

The Canadian Journal of Psychiatry 61(5)

associated with hospitalization, when assessment occurs earlier in the recovery period (that is, resolves over time), when
there are multiple previous mTBIs, in individuals with preexisting psychiatric illness, when outcomes are based on retrospective recall, and when the comparison group is noninjured healthy children (as opposed to children with injuries not
involving the head).
Conclusions: Overall, few rigorous prospective studies have examined psychological, behavioural, and psychiatric outcomes
following mTBI. In the absence of true reports of preinjury problems and when ideally comparing mild TBI to non-TBI injured
controls, there is little evidence to suggest that psychological, behavioural, and/or psychiatric problems persist beyond the
acute and subacute period following an mTBI in children and adolescents.
Abrege
Contexte : Les donnees probantes concernant les resultats psychiatriques, psychologiques et comportementaux a` long
terme (p. ex., lanxiete, les troubles de lhumeur, la depression, et les troubles de lattention) par suite dun traumatisme
cranio-cerebral benin (TCCb) chez les enfants et les adolescents nont pas ete synthetisees anterieurement.
Objectif : Mener une revue systematique des donnees probantes disponibles qui examinent les resultats psychiatriques,
psychologiques et comportementaux dun TCCb chez les enfants et les adolescents.
Materiel et methodes : Neuf bases de donnees electroniques ont ete systematiquement recherchees de 1980 au mois
daout 2014. Les etudes retenues satisfaisaient aux crite`res suivants: des donnees originales; la methode de letude etait un
essai randomise controle, une methode quasi-experimentale, une etude de cohorte ou de cohorte historique, une etude castemoin ou transversale; lexposition incluse dans le TCCb (y compris la commotion); la population comprenait des enfants et
adolescents (< 19 ans) au moment du TCCb, ainsi quun groupe de comparaison (p. ex., des enfants en sante; des enfants ayant
des blessures orthopediques); et comprenait des resultats psychiatriques, psychologiques ou comportementaux (p. ex.,
lanxiete, les troubles de lhumeur, la depression, et les troubles de lattention). Deux auteurs ont evalue independamment la
qualite et le niveau des donnees probantes a` laide des crite`res de Downs et Black (DB) et du mode`le Oxford Centre of
Evidence-Based Medicine (OCEBM), respectivement, pour chaque manuscrit.
Resultats : Sur les 9 472 etudes reperees dans la recherche initiale, 30 ont ete incluses et notees. Lheterogeneite de la
methodologie et la definition du traumatisme excluaient les meta-analyses. La qualite methodologique moyenne pour les 30
etudes, selon les crite`res DB, etait de 15/33 (ecart 6-19). Le niveau le plus eleve des donnees probantes demontre par toutes les
etudes examinees etait le niveau 2b, selon les crite`res de lOCEBM, la majorite des etudes (28/30) etant classees a` ce niveau.
Dapre`s la litterature incluse dans cette revue systematique, les proble`mes psychiatriques et psychologiques des enfants ayant des
antecedents de TCCb se sont reveles plus prevalents quand le TCCb est associe a` une hospitalisation, quand levaluation a lieu
plus tot dans la periode de retablissement (c.-a`-d., qui se resout avec le temps), quand il y a de multiples TCCb passes, chez des
personnes souffrant dune maladie psychiatrique preexistante, quand les resultats sont bases sur la memoire retrospective, et
quand le groupe de comparaison est forme denfants en sante non blesses (par opposition aux enfants blesses mais non a` la tete).
Conclusions : En general, peu detudes prospectives rigoureuses ont examine les resultats psychologiques, comportementaux et psychiatriques dun TCCb. En labsence de rapports fiables de proble`mes pre-traumatisme et en comparant
idealement des sujets ayant subi un TCCb avec des temoins nayant pas subi de TCC, il y a peu de donnees probantes qui
sugge`rent que les proble`mes psychologiques, comportementaux et/ou psychiatriques persistent au-dela` de la periode aigue et
subaigue suivant un TCCb chez les enfants et les adolescents.
Keywords
mild traumatic brain injury, concussion, psychological outcomes, psychiatric outcomes, behaviour outcomes

Background
Mild traumatic brain injuries (mTBI), including concussions, are very common in children and adolescents and
therefore pose a significant public health burden. Annually,
at least 700 000 youth ages 0 to 19 years seek hospital-based
medical care for TBI in the United States, and 80% to 90% of
these injuries are mild in severity.1 No comparable figures
are available for mTBI in Canada, but data from 8 Canadian
pediatric emergency departments indicate that 1 out of every
70 to 220 visits is for concussion.2,3 Moreover, more than
500,000 youth are registered hockey players in Canada, and

10% to 20% of hockey players aged 9 to 17 years report at

least 1 head injury annually.4-6 Thus, mTBI likely affects
thousands of Canadian children each year.
It can be difficult to detect and diagnose mTBI. They are
typically defined as injuries to the brain resulting from external physical forces and identified clinically by Glasgow
Coma Scale scores of 13 to 15, disorientation or other mental
status changes, loss of consciousness for no longer than 30
minutes, and/or posttraumatic amnesia lasting no longer than
24 hours.7 They may be associated with visible lesions on
neuroimaging but most commonly are not. 8 Common

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The Canadian Journal of Psychiatry 61(5)

associated with hospitalization, when assessment occurs earlier in the recovery period (that is, resolves over time), when
there are multiple previous mTBIs, in individuals with preexisting psychiatric illness, when outcomes are based on retrospective recall, and when the comparison group is noninjured healthy children (as opposed to children with injuries not
involving the head).
Conclusions: Overall, few rigorous prospective studies have examined psychological, behavioural, and psychiatric outcomes
following mTBI. In the absence of true reports of preinjury problems and when ideally comparing mild TBI to non-TBI injured
controls, there is little evidence to suggest that psychological, behavioural, and/or psychiatric problems persist beyond the
acute and subacute period following an mTBI in children and adolescents.
Abrege
Contexte : Les donnees probantes concernant les resultats psychiatriques, psychologiques et comportementaux a` long
terme (p. ex., lanxiete, les troubles de lhumeur, la depression, et les troubles de lattention) par suite dun traumatisme
cranio-cerebral benin (TCCb) chez les enfants et les adolescents nont pas ete synthetisees anterieurement.
Objectif : Mener une revue systematique des donnees probantes disponibles qui examinent les resultats psychiatriques,
psychologiques et comportementaux dun TCCb chez les enfants et les adolescents.
Materiel et methodes : Neuf bases de donnees electroniques ont ete systematiquement recherchees de 1980 au mois
daout 2014. Les etudes retenues satisfaisaient aux crite`res suivants: des donnees originales; la methode de letude etait un
essai randomise controle, une methode quasi-experimentale, une etude de cohorte ou de cohorte historique, une etude castemoin ou transversale; lexposition incluse dans le TCCb (y compris la commotion); la population comprenait des enfants et
adolescents (< 19 ans) au moment du TCCb, ainsi quun groupe de comparaison (p. ex., des enfants en sante; des enfants ayant
des blessures orthopediques); et comprenait des resultats psychiatriques, psychologiques ou comportementaux (p. ex.,
lanxiete, les troubles de lhumeur, la depression, et les troubles de lattention). Deux auteurs ont evalue independamment la
qualite et le niveau des donnees probantes a` laide des crite`res de Downs et Black (DB) et du mode`le Oxford Centre of
Evidence-Based Medicine (OCEBM), respectivement, pour chaque manuscrit.
Resultats : Sur les 9 472 etudes reperees dans la recherche initiale, 30 ont ete incluses et notees. Lheterogeneite de la
methodologie et la definition du traumatisme excluaient les meta-analyses. La qualite methodologique moyenne pour les 30
etudes, selon les crite`res DB, etait de 15/33 (ecart 6-19). Le niveau le plus eleve des donnees probantes demontre par toutes les
etudes examinees etait le niveau 2b, selon les crite`res de lOCEBM, la majorite des etudes (28/30) etant classees a` ce niveau.
Dapre`s la litterature incluse dans cette revue systematique, les proble`mes psychiatriques et psychologiques des enfants ayant des
antecedents de TCCb se sont reveles plus prevalents quand le TCCb est associe a` une hospitalisation, quand levaluation a lieu
plus tot dans la periode de retablissement (c.-a`-d., qui se resout avec le temps), quand il y a de multiples TCCb passes, chez des
personnes souffrant dune maladie psychiatrique preexistante, quand les resultats sont bases sur la memoire retrospective, et
quand le groupe de comparaison est forme denfants en sante non blesses (par opposition aux enfants blesses mais non a` la tete).
Conclusions : En general, peu detudes prospectives rigoureuses ont examine les resultats psychologiques, comportementaux et psychiatriques dun TCCb. En labsence de rapports fiables de proble`mes pre-traumatisme et en comparant
idealement des sujets ayant subi un TCCb avec des temoins nayant pas subi de TCC, il y a peu de donnees probantes qui
sugge`rent que les proble`mes psychologiques, comportementaux et/ou psychiatriques persistent au-dela` de la periode aigue et
subaigue suivant un TCCb chez les enfants et les adolescents.
Keywords
mild traumatic brain injury, concussion, psychological outcomes, psychiatric outcomes, behaviour outcomes

Background
Mild traumatic brain injuries (mTBI), including concussions, are very common in children and adolescents and
therefore pose a significant public health burden. Annually,
at least 700 000 youth ages 0 to 19 years seek hospital-based
medical care for TBI in the United States, and 80% to 90% of
these injuries are mild in severity.1 No comparable figures
are available for mTBI in Canada, but data from 8 Canadian
pediatric emergency departments indicate that 1 out of every
70 to 220 visits is for concussion.2,3 Moreover, more than
500,000 youth are registered hockey players in Canada, and

10% to 20% of hockey players aged 9 to 17 years report at

least 1 head injury annually.4-6 Thus, mTBI likely affects
thousands of Canadian children each year.
It can be difficult to detect and diagnose mTBI. They are
typically defined as injuries to the brain resulting from external physical forces and identified clinically by Glasgow
Coma Scale scores of 13 to 15, disorientation or other mental
status changes, loss of consciousness for no longer than 30
minutes, and/or posttraumatic amnesia lasting no longer than
24 hours.7 They may be associated with visible lesions on
neuroimaging but most commonly are not. 8 Common

La Revue Canadienne de Psychiatrie 61(5)

mechanisms of mTBI in children and adolescents include

sport and recreationrelated injury (typically referred to as
sport-related concussion), falls, and motor vehicle
collision.9
The outcomes of mTBI in children and adolescents have
historically been controversial.10,11 Research on outcomes is
imperative given the decreasing rate of hospitalization
among children with mTBI.12 This trend places a substantial
burden on health care providers in emergency medicine and
outpatient care settings to make evidence-based decisions
regarding the management of mTBI in children and adolescents.13 Accurate information about outcomes is of paramount importance for this purpose.
Although long-term deficits on standardized cognitive
testing are rare following mTBI,14,15 several prospective
cohort studies have shown that children with mTBI display
persistent postconcussive symptoms (PCS) as compared
with children with other types of injuries. PCS involve a
variety of cognitive, somatic, behavioural, and emotional
complaints, the most common of which include headaches,
dizziness, poor concentration or memory, and moodiness.
Although in most cases symptoms resolve during the first
few weeks following injury, they can persist for months and
sometimes years in some children. In 2 large prospective
cohort studies in Alberta, 12% to 14% of children sustaining
mTBI still displayed symptoms 3 months following
injury.16,17
In contrast, the extent to which mTBI results in psychopathology more generally, and specifically in new-onset psychiatric disorders, remains uncertain. In previous studies, the
rate of psychiatric disorders in children with mTBI has varied widely (between 10% and 100%) depending on study
design.18-34 The range of new-onset disorders reported in the
subset of studies that consecutively recruited children with
mTBI is narrower.18-29 However, many previous studies
have not included control groups. Thus, the relative risk for
new-onset psychiatric disorder among children with mTBI
as compared to children with injuries not involving the head
or to healthy controls is not clear.
Most previous studies have also not assessed psychiatric
outcomes in depth. Assessment using semistructured interviews with parent and child, supplemented by input from
collateral sources such as school teachers, provides a best
estimate diagnosis that is considered the gold standard for
psychiatric evaluation.35 Few studies of pediatric mTBI have
followed this procedure. Instead, the measurement of psychiatric and behavioural outcomes after mTBI has often
been limited to questionnaires and rating scales, typically
completed only by parents. Comprehensive reviews of
psychiatric, psychological, and behavioural outcomes
must necessarily encompass such studies despite their
limitations.
Previous systematic reviews have examined psychosocial
outcomes after paediatric TBI,36,37 but they have encompassed the entire spectrum of TBI injury severity including
adult populations. We are aware of only 1 previous

261

systematic review in the literature regarding psychiatric,

psychological, and behavioural outcomes specifically in
children with mTBI.38 That review was limited to 6 papers
published from 2001 to 2012 that met specific eligibility
criteria and were judged to be scientifically acceptable based
on judgments of likelihood of bias. The authors conceded the
limited evidence base in their review but concluded that
most children with mTBI demonstrate a good prognosis,
despite acknowledging that 3 studies concerned with psychiatric outcomes found a positive association between
childhood mTBI and subsequent psychiatric diagnoses.
The objective of the current systematic review was to
synthesize the available evidence regarding psychiatric, psychological, and behavioural outcomes following mTBI in
children and adolescents. We intended to build on Keightleys (2014)38 previous review by searching for all relevant
studies published from 1980 to August 2014 that met a priori
criteria and including all identified studies without restrictions based on judgments of risk of bias. Instead, we incorporated all studies meeting our inclusion criteria but assessed
the quality and level of evidence for each. The current
review adds to the literature by reporting on a broader range
of studies than summarized by Keightley and her colleagues,38 thereby providing a more comprehensive picture
of the extant evidence base.

Methods
The review was conducted according to the PRISMA
guidelines.39

Data Sources and Search

Relevant studies were identified by searching OVID MEDLINE, EMBASE, Cochrane Database of Systematic
Reviews, PsycINFO, PubMed, SPORTDiscus, CINAHL,
ERIC, and Web of Science. All searches were conducted
on August 15, 2014, using a combination of subject headings
and text words (Table 1), with results limited to publication
dates between 1990 and 2014 and to English language.
To be included in this systematic review, the published
manuscript needed to contain all necessary data, as
authors were not contacted for additional data or
clarification.

Study Selection
We used the following inclusion criteria: 1) The study design
included randomized controlled trial, quasi-experimental
design, cohort or historical cohort study, case-control study,
or cross-sectional study. Systematic reviews or meta-analyses
were used to identify additional relevant studies. 2) Children/
adolescents were <19 years of age at the time they sustained
the mTBI. 3) Brain injury severity studied was restricted to
mTBI (although varying definitions were accepted, including
traditional definitions such as a postresuscitation Glasgow

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The Canadian Journal of Psychiatry 61(5)

Table 1. Evaluation of Psychiatric, Psychological, and Behavioural Outcomes Following Mild Traumatic Brain Injury (mTBI) in Children and
Adolescents: Search Results of a Systematic Review.
MEDLINE EMBASE Cochrane PsycINFO PubMed

CINAHL

ERIC

SPORTDiscus

WoS

mTBI
Psychiatric, etc.
Pediatric
mTBI and psychiatric and
pediatric
Limit to humans
Limit to English
Limit to 1990
Limit to not MEDLINE

157 829 358 560

953 102 1 410 394
2 798 187 2 693 621
3472
6723

Total citations
After duplicates removed
After screening
After eligibility
Articles included

14 134
9472
105
58
30

3404
2 862
2314

6488
5 468
4919

240
3081
4492
63

37 042
769 053
690
690 492

3878

67 063
450 572
691 292
5250

5758
121 386
92 904
364

6868
63 442
137 093
110

101 431
1 173 453
1 506 614
1 827

63

1912
1695
1205

2787

5187 (1990)
5177 (English)
2778 (humans)
640 (not
MEDLINE)

341

108
107

1 777
1 758

Coma Scale score of 13 to 15, posttraumatic amnesia period

of less than 24 hours, duration of loss of consciousness of less
than 30 minutes). 4) Any mechanism of traumatic brain
injury, including assault, with the exception of infantile nonaccidental trauma. 5) Each study must include a control or
comparison population. This must be a comparable healthy
population, or comparable populations with other medical
conditions not involving brain injury (for example, orthopaedic injuries). 5) The study outcome must be a psychiatric,
psychological, or behavioural outcome.
We used the following exclusion criteria: 1) The control
population is selected for a specific psychiatric disorder or
any other neurological disorder. 2) Infantile nonaccidental
trauma. 3) Nontraumatic mechanisms of injury, such as
inflammation, infection, or autoimmunity.
Independently and in duplicate, 2 investigators (A.V.-R.
and V.G.) reviewed all potentially relevant titles after
removing duplicates to determine which abstracts to review.
Then, 6 investigators (B.L.B., K.M.B., C.A.E., V.G., K.S.,
K.O.Y.) reviewed the abstracts to select final full manuscripts for review. The abstract review was performed in
pairs, with arbitration performed by a second pair.

Data Extraction and Study Rating Process

A data extraction form was used to summarize the following
features of each study: study design, study location, population, exposure variable definitions (for example, mTBI and
control group), psychiatric/psychological/behavioural outcome (definition), effect estimates (for example, odds ratio
[OR], risk ratio, d), or other relevant statistics if no effect
estimate reported. The extracted data were then reviewed for
completeness and utility by 2 authors and categorized by
psychiatric or behavioural outcome for use in the systematic
review. Two authors (2/6 total) independently assessed the
quality and level of evidence of each study. The quality of
evidence was evaluated based on criteria for internal validity

(study design, quality of reporting, presence of selection and

misclassification bias, potential confounding) and external
validity (generalizability) using the Downs and Black (DB)
quality assessment tool, which assigns an individual score
calculated out of 33 total points for each study (Supplemental online Table S1). The level of evidence represented by
each study was categorized based on the Oxford Centre of
Evidence Based Medicine (OCEBM) model.40 As per study
exclusion criteria, levels 1a, 2a, 3a (systematic reviews),
4 (case series), and 5 (opinion-based papers) were not
included. Discrepancies in DB scoring or OCEBM categorization were resolved first by consensus between the
2 reviewers who rated the study and, if required, by a second
pair of reviewers.

Data Synthesis
Extracted data and quality and level of evidence were summarized for each study.

Results
Identification of Studies
An overview of the study identification process is provided
in Figure 1. A detailed breakdown of the search process is
summarized in Table 1. The initial search yielded 14 134
manuscripts; 4663 duplicates were removed, leaving 9472
potentially relevant articles. Following title and abstract
review by 2 authors (A.V.-R, V.G.) to identify potential
relevant records, 105 abstracts were selected and reviewed
by 1 additional pair of authors (2/6 authors) for relevance
and inclusion, resulting in a total of 58 full manuscripts.
These 58 manuscripts were divided among 3 pairs of
reviewers (6 reviewers) and further narrowed to 30 full
manuscripts that were included in the systematic review
based on inclusion/exclusion criteria.24,27,31,32,41-66

La Revue Canadienne de Psychiatrie 61(5)

263

PRISMA 2009 Flow Diagram

Idencaon

mTBI SR
search performed 2014.08.15

Records idened through

database searching
(n = 14134*)

MEDLINE 2314
EMBASE 4919
Cochrane 63
PsycINFO 1205
PubMed 2787
CINAHL 640
ERIC 341
SPORTDiscus 107
Web of Science 1758
TOTAL - 14134

Addional records idened

through other sources
(n = 0)

Eligibility

Screening

Records aer duplicates removed

(n = 9472)

Records screened
(n = 105)

Records excluded
(n = 9367)

Full-text arcles assessed

for eligibility
(n = 58)

Full-text arcles excluded

(n = 47)

Inc luded

Studies included in
qualitave synthesis
(n = 30)

Studies included in
quantave synthesis
(meta-analysis)
(n = n/a)

Figure 1. Study Identification Process.

Study Characteristics

Quality and Level of Evidence

Characteristics of the 30 studies are summarized in Table S1.

They consisted of 2 quasi-experimental, 26 cohort, and 2 casecontrol studies, drawn from 6 different countries. The median
number of participants per study was 226 (range 48 to 3182).

The median methodological quality score for all 30 studies,

based on the DB criteria, was 15/33 (range 6 to 19). Because
the included studies were primarily observational in nature,
7 items (4, 8, 14, 19, 23, 24, and 27; totalling 11 points) on
the DB checklist were not applicable for 28/30 studies.
Therefore, most studies could not achieve a full score. Several limitations were characteristic of most of the included
studies: incomplete description of how the sample was

Effect Estimates
Descriptions of effect estimates are presented in Table S1.

264

representative of the population of interest (for example,

recruitment strategy unclear), limited description of the characteristics of those lost to follow-up, use of unreliable or
invalid measures (or failure to report on reliability and/or
validity), insufficient reporting of how participants lost to
follow-up and differing length of follow-up were accounted
for in statistical analyses, inadequate sample size, and lack of
adjustment for potential modification and confounding by
factors such as exposure and previous injury. Further, several
of the studies that report a matched design did not account
for matching in their analyses.
The highest level of evidence demonstrated by all
reviewed studies was level 2b (defined as an individual
cohort study by the OCEBM Levels of Evidence Working
Group, 2011),40 with the majority (28/30) of studies classified at this level.

Synthesis of Results
The most commonly investigated behavioural/psychological/psychiatric outcomes that were included in multiple
studies were attention problems, depression and mood
disorders, anxiety, oppositional defiant disorder (ODD)/
disruptive behaviours, and posttraumatic stress disorder
(PTSD). In addition, autism/pervasive developmental disorder, schizophrenia, and substance abuse were evaluated
in 1 study each.
Attention Problems and Hyperactivity. Attention problems and
hyperactivity are the most commonly studied psychological/
psychiatric/behavioural outcomes of mTBI in youth. The
findings are fairly consistent, with higher rates of inattentive/hyperactive symptoms reported 1) in those who are hospitalized versus not hospitalized for mTBI and 2) when
comparing youth with mTBI to healthy (noninjured)
controls.
Several studies reported that children and adolescents
who are hospitalized for mTBI display more symptoms of
inattention and hyperactivity than those who are not hospitalized or healthy controls.44,46-48 Hawley et al44 reported a
relative risk of 6.34 for attention problems in youth who
were hospitalized for a mTBI, but the comparison group was
composed of healthy controls, and problems were reported
based on parents retrospective recall more than 2 years after
the injury.
The comparison group used for examining psychological/
behavioural symptoms in children with mTBI is key for
many studies, especially those focused on attention/hyperactivity. When youth with mTBI are compared with healthy
noninjured controls, secondary attention-deficit hyperactivity disorder (ADHD) is found in a higher proportion of the
children with mTBI (for example, Schachar et al50 reported
that 36% of mTBI and 12% of noninjured controls have
secondary ADHD). Youth who sustain any type of injury
are more likely to display attention problems; thus, using a
noninjured comparison group is likely to overestimate group

The Canadian Journal of Psychiatry 61(5)

differences in secondary ADHD by failing to adequately

account for preinjury status. Basson et al54 found that youth
who sustain multiple trauma, with or without mTBI, are
more likely to have attention problems (plus other psychological issues) than youth who present to the emergency
department for nontrauma medical care. Max et al45 reported
that the prevalence of primary ADHD was not significantly
different in a sample of youth with mTBI (5/24) and a sample of youth with an orthopaedic injury (4/24). When considering the prevalence of secondary ADHD in their sample,
Max et al45 reported no significant differences between the
mTBI group (3/19) and the orthopaedic injury control group
(1/20), w2(1) 1.00, P 0.317.
Depression/Withdrawal/Mood Problems. Both mood disorder
diagnoses and elevated mood symptoms as rated on questionnaires are reported in youth with mTBI. Luis and Mittenberg27 reported that children (mean 10.5 years, SD 3.3) who
were 6 months post-mTBI were 9.3 times more likely to
have a diagnosis of depression, w2(1) 2.83, P 0.016,
compared with the orthopaedic injury control group. Hawley
et al suggested that a higher relative risk (RR) for mood
swings (RR 8.16, 95% CI 1.16 to 57.30),44 but not necessarily depression (RR 0.42, 95% CI 0.01 to 20.04), was found
more than 2 years after mTBI.43 Young children between 4
and 6 years of age who sustain an mTBI when they are
younger than 3 years are more likely to be withdrawn (OR
or RR not available), although not necessarily depressed.58
Interestingly, mean symptom scores (and their standard
deviations) were solidly within the broadly normal range for
those with an mTBI, suggesting that significantly more
symptoms in young children do not necessarily translate to
clinically meaningful elevations. Trauma itself may be associated with elevations in mood symptoms,54 as is a history of
multiple mTBIs.63 Despite multiple studies suggesting significantly higher symptoms of depression, mood problems,
and withdrawal in children with mTBI, OConnor et al49
reported equivocal differences between mTBI and control
and Barker-Collo53 reported that children with mTBI actually had lower mood symptom ratings than the control group.
Anxiety. The evidence suggests that youth who sustain a single mTBI may be more likely to have elevated anxiety soon
after their injury but not necessarily as a long-term outcome.
At 6 months postinjury, Luis and Mittenberg27 reported that
children with mTBI were 4.3 times more likely (95% CI 1.1
to 17.6) to have a new-onset anxiety disorder diagnosis compared with orthopaedically injured controls, w2(1) 6.06,
P 0.014. However, when considering long-term anxiety
symptoms after an injury, children with mTBI are unlikely to
have elevated levels compared with controls at 1 year53
(mTBI had fewer symptoms than controls) or 2 years43,44
(95% CIs for RR crosses 1.0) post-mTBI. Children with
multiple mTBIs are 2.24 (95% CI 1.13 to 4.46) times more
likely to have significantly higher levels of anxiety symptoms,63 but the sample in this study was limited to young

La Revue Canadienne de Psychiatrie 61(5)

children who were injured when very young. Similar to

studies on depression/mood, the mean ratings of anxiety in
Liu and Li63 were well within the broadly normal range for
all groups, suggesting that significantly higher symptoms in
young children do not necessarily translate to clinically
meaningful elevations.
ODD/Conduct Disorder/Disruptive Behaviours. Several studies
have examined disruptive behaviours in youth with mTBI,
but specific diagnoses of behaviour disorders are relatively
understudied. Regarding ODD and conduct disorder (CD),
hospitalization for mTBI appears to be a common factor
associated with these diagnoses. McKinlay and colleagues48
reported that adolescents who were previously hospitalized
after mTBI were more likely than noninjured controls to
have an ODD diagnosis (OR 4.9, 95% CI 1.8 to 13.4). Adolescents who were injured early in life (<5 years of age) and
hospitalized for their mTBI also had significantly more problems associated with ODD/CD than those not hospitalized
for their mTBI or noninjured controls, although this finding
was based on symptom reporting rather than structured diagnostic interviews. Max and colleagues31 reported that adolescents with mTBI were more likely than controls to have
disruptive behaviours, including 1 or more of ADHD, undifferentiated attention deficit disorder, ODD, and/or CD (OR
2.2, 95% CI 1.0 to 5.0).
Most research on disruptive behaviours in children with
mTBI has considered a broad range of problems, such as
elevated ratings on scales measuring broad externalizing
behaviours or concerns with rage, emotional reactivity, or
aggression. The existing research is mixed, however, with
the presence of preinjury behavioural concerns,56,62 trauma
with or without mTBI,54 multiple mTBIs,63 and hospitalization for the injury47,48 appearing to be factors associated with
disruptive behaviours in children and adolescents who have
sustained an mTBI.
PTSD. The limited available literature presents mixed findings regarding the presence of PTSD or its symptoms in
children who sustain mTBI. Hajek et al42 reported that the
likelihood of children and adolescents having elevated PTSD
symptoms (parent rated) at 1 to 2 weeks, 3 months, and 12
months post-mTBI was not different from an orthopaedically
injured control group, suggesting that injury in general (and
not specifically mTBI) may be related to PTSD symptoms.
In contrast, OConnor et al49 reported that youth with mTBI
self-reported significantly more PTSD symptoms than orthopaedically injured youth, with higher PTSD symptoms early
after an injury being related to poorer school functioning at
1 and 2 years postinjury.
Autism/Pervasive Developmental Disorder. The possibility of a
relationship between mTBI in youth and subsequent autism/
pervasive developmental disorders has been the focus of
very little research. In one study, Max and colleagues32
reported that youth who sustain mTBI are significantly less

265

likely to have a Diagnostic and Statistical Manual of Mental

Disorders, Third Edition, Revised, diagnosis of autism or a
pervasive developmental disorder. In children with mTBI,
3 of 64 were identified historically based on unstructured
diagnostic interviewing as falling on this spectrum as
compared with 10 of 64 controls, w2(1) 4.20, P 0.04
(OR 3.8, 95% CI 0.9 to 18.3).
Schizophrenia. One study to date suggests that mTBI may be
associated with a diagnosis of schizophrenia.41 The association seems to be present if there is a familial predisposition
for the disorder. The authors also suggested that the risk of
schizophrenia after mTBI is a function of age at injury, with
the odds of having schizophrenia being greater if the injury
occurs before 11 years of age (OR 2.35, 95% CI 1.03 to
5.36).41
Substance Abuse. Very little research has considered whether
youth who sustain mTBI are more likely to have a substance
abuse problem. In a cohort study that involved adolescents
who had previously sustained an mTBI between 0 and 5
years of age, McKinlay et al48 reported that those who were
hospitalized for the mTBI had a 3-fold increase (95% CI 1.1
to 8.5) in the likelihood of a substance abuse diagnosis using
a semistructured interview (Diagnostic Interview Schedule
for Children) compared with uninjured controls. However,
children who were not hospitalized for their mTBI did not
differ in substance abuse diagnoses.

Discussion
MTBI affects a large number of children and adolescents
each year in Canada, through both sport-related and non
sport-related mechanisms. Although the vast majority of
children with mTBI recover relatively quickly and with few
sequelae,16,17 a small proportion displays persistent problems, often leading to a delayed return to school, a need for
academic accommodations, a delayed return to sport, and an
increased level of health care services. Although somatic
symptoms (for example, headaches, dizziness) are often the
focus following mTBI and a key marker of recovery,17,67
psychological/psychiatric recovery is also an important
aspect of postinjury outcome and recovery for children and
adolescents. Based on our systematic review, the evidence
for increased psychological, behavioural, and psychiatric
problems following a mTBI is mixed, most often based on
symptom ratings (not actual diagnosis) and founded on a
small number of studies characterized by multiple methodological limitations. Overall, some evidence supports an
increased prevalence of psychological, behavioural, and psychiatric problems (that is, symptoms) when 1) mTBI is associated with hospitalization,48 2) the injury occurs early in life
(<6 years old),48,58,63 3) outcomes are assessed earlier after
injury (that is, suggesting resolution over time),27 4) there
are multiple previous mTBIs,63 5) individuals have preexisting psychiatric illness, 56,62 6) outcomes are based on

266

retrospective recall,44 and 7) the comparison group is noninjured healthy children rather than children with nonhead
injuries.50
A recent systematic review of psychosocial outcomes in
children and adolescents with mTBI reached similar conclusions. Keightley et al38 reported an increased likelihood of
psychological or psychiatric problems in the short term following a mTBI in youth (that is, specifically increased risk
of mood disturbance and hyperactivity; no increased risk of
PTSD) but did not find evidence for long-term psychological
or psychiatric problems. Keightley et als systematic review
contained some of the same publications as this one but was
more limited in scope, including only 6 studies.38 The current systematic review was based on a wider time frame for
literature searching and a broader perspective on outcome
but yielded similar conclusions about early psychosocial
problems that resolve with time. Previous reviews of psychosocial outcomes have suggested more long-term difficulties after pediatric TBI but have based their conclusions on
studies that include children with more severe TBI, rather
than limiting their review to studies specifically of
mTBI.36,37
In many studies of psychological, behavioural, and psychiatric outcomes, comparison groups were composed of
healthy noninjured youth. Like all research on mTBI, the
comparison group is key to properly interpreting results.
Studies that compare children with mTBI to healthy controls
are more likely to find significantly elevated rates of psychological and psychiatric problems than studies that compare children with mTBI to children with orthopaedic
injuries. The use of a healthy control group fails to control
for the nonspecific effects of sustaining an injury or the risk
of sustaining an injury based on preexisting risk factors. In
fact, comparisons that are significant when based on a
healthy control group50 may disappear when comparisons
are made to controls with orthopaedic injuries (for example,
Max et al45). The use of children with nonhead injuries as a
comparison group represents a more appropriate and rigorous methodology for understanding outcomes following
pediatric mTBI.
Another key methodological distinction should be drawn
between significantly higher symptom ratings after mTBI
versus significantly higher rates of psychological/psychiatric
diagnoses. The former has much more support at present
than the latter. The current systematic review highlighted
the use of both methods for studying psychological/behavioural/psychiatric outcomes. Both are worthy methods for
studying outcome, but results can differ across the 2
approaches, and the interpretation of findings varies accordingly. Significantly higher symptom ratings do not necessarily translate into clinically elevated levels of problems or
formal diagnosis. For example, significantly higher levels of
symptoms of withdrawal were reported for children who
sustained mTBI early in life58; however, the mean scores
were still well within the normal range. Similar findings
were reported for anxiety symptoms in young children with

The Canadian Journal of Psychiatry 61(5)

multiple prior mTBIs,63 where significantly higher group

means were still well within the normal range. Moreover,
even when elevated, symptoms are not necessarily diagnostic, and considerable overlap exists between many psychological symptoms and the most common postconcussive
symptoms. The only study comparing semistructured psychiatric interview diagnoses with questionnaire-based symptom ratings when both were administered to the same
children with TBI (mild to severe) found a higher sensitivity
of the former method in detecting significant psychopathology.68 These findings may be useful in guiding interpretation
of clinically significant findings when questionnaire methods rather than psychiatric interviews are used to assess
psychological, behavioural, and psychiatric problems.
The literature to date is insufficient for proving a causal
link between mTBI and psychological/behavioural/psychiatric problems. Asking youth or their parents to provide retrospective recall of preinjury functioning, particularly at times
far removed from the injury, is not a methodologically sound
approach to controlling for preinjury status, as recall can be
heavily influenced by retrospective biases. 69,70 More
research is needed to determine if psychological/behavioural/psychiatric problems are the result of an mTBI, are
altered by an mTBI, are risk factors for sustaining an mTBI,
or are preinjury predictors of outcome.

Limitations
Meta-analyses were not possible because of inconsistent
methodology and heterogeneity of outcome measures and
research design methodologies. The inclusion of Englishonly studies may also have led to selection bias. Inadequate
reporting and control for potential confounders (for example,
multiple concussion history, age, sex) may have led to bias in
study results presented. In some studies, the inability to consider potential confounding was related to smaller sample
sizes. Recruitment of study participants was not random in
most studies, and selection bias may be associated with differences in participants selected for the study and those not
selected (for example, presenting to a large emergency
department vs. a primary care setting). Significant losses to
follow-up also increased the likelihood of selection bias in
many studies. Reliance on self-report measures and questionable validity of other measures also introduced measurement bias in many studies. Given significant concerns with
internal validity, generalizability is also questionable in this
body of literature.

Recommendations
More research is needed to tease out the complex interplay of
preexisting and new-onset psychological/behavioural/psychiatric problems and mTBI. These studies should employ
suitable control groups including children with non-TBI
injuries. Further, distinctions should be made between

La Revue Canadienne de Psychiatrie 61(5)

elevated symptoms of psychological illness and psychiatric

illness.

Conclusions
Although psychological, behavioural, and psychiatric problems can occur early in the recovery phase following mTBI,
these resolve in most cases. Children at risk for longer-term
problems are those with multiple previous mTBI or preexisting psychiatric illness.

What Are the New Findings?

 Early psychological problems may occur following
mTBI but appear to resolve with time.
 The level of evidence of studies investigating psychological and behavioural and psychiatric outcome of
pediatric mTBI is primarily level 2 evidence, largely
involving historical cohort studies.
 Future research should focus on high-quality prospective longitudinal cohort studies to evaluate change
over time in psychological, behavioural, and psychiatric outcomes following pediatric concussion.
Authors Note
Brian L. Brooks, RPsych, PhD, is a principal investigator, coinvestigator, or collaborator on several grants relating to the study
of mild TBI/concussion in youth. He receives royalties for the sales
of a pediatric forensic textbook and pediatric neuropsychological
tests. Jeffrey E. Max, MBBCh, has received funding from the
National Institutes of Health to study mTBI and provides expert
testimony in cases of TBI, including mTBI, on an ad hoc basis for
plaintiffs and defendants on a more or less equal ratio. This activity
constitutes approximately 5% of his professional activities.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
Carolyn A. Emery, PT, PhD, holds a Chair in Pediatric Rehabilitation supported by the Alberta Childrens Hospital Foundation.
Keith Owen Yeates, PhD, holds a Chair in Paediatric Brain Injury
supported by the Alberta Childrens Hospital Foundation. These
sponsors had no involvement with respect to design, collection or
data analyses, interpretation, writing or submission.

Supplemental Material
The supplemental table cited in this article is available online at
http://cpa.sagepub.com/supplemental.

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