











































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW  

 

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 

 
 

Childhood Mental Health Outcomes Following Mild Traumatic Brain 
Injury: An Evidence-to-Practice Review  
Leona J. Keller, MS, ATC*; Sooji M. Berthiaume, MS, ATC†; Karis J. Landry MS, ATC‡; Alyssa L. Bolno, MS, ATC§; Zachary K. 
Winkelmann, PhD, ATC? 
*Vanderbilt University, Nashville, TN; †West Creek High School, Clarksville, TN; ‡Landrum High School and Middle School, 
Campobello, SC; §The Walker School, Marietta, GA ;?University of South Carolina, Columbia, SC 
 

 
ABSTRACT 
Concussions can have lasting symptoms in children such as depression, anxiety, hyperactivity, or failure to control anger. If diminished 
mental health outcomes are not monitored and do not improve after concussion, children may need additional treatment as a result 
of sequela. The purpose of the guiding systematic review was to determine if there are increased mental health symptoms in pediatric 
patients who sustained a concussion as compared to pediatric patients who have not sustained a concussion. The guiding systematic 
review and meta-analysis authors used seven different databases for articles published from 1980 to 2020. Selected articles had 
mental health outcomes classified as internalizing, externalizing, or total mental health difficulties. Mental health was assessed by 
new psychiatric findings post-injury, as well as total problem subscales. Twenty-nine articles identified mental health complications 
following a pediatric concussion. Children with pre-injury mental health (50% to 60%) were more likely than children without pre-
injury mental health symptoms to have decreased mental health outcomes following concussion. In acute (less than 3 months post-
injury), persistent (between 3- and 12-months post-injury), and chronic (over 12 months post-injury) timelines, the concussion group 
demonstrated significant, moderate effects in mental health for internalizing and externalizing. This topic is clinically relevant for 
athletic trainers as they may work with adolescent populations with a previous medical history of concussion or who may experience 
a concussion in the future. Mental health training sessions, such as online continuing education courses, for athletic trainers will build 
the skills to treat patients who may be experiencing diminished mental health outcomes following concussion.  
Content Focus: Health Care Competency  
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Keller LJ, Berthiaume SM, Landry KJ, Bolno AL, Winkelmann ZK. Childhood mental health outcomes following mild traumatic 
brain injury: An evidence-to-practice review. Clin Pract Athl Train. 2023;6(1): 61-66. 
https://doi.org/10.31622/2023/0006.01.9.  
 

 
ORIGINAL REFERENCE 
Gornall A, Takagi M, Morawakage T, Liu X, Anderson V. Mental health after paediatric concussion: A 
systematic review and meta-analysis. Br J Sports Med. 2021;55: 1048-1058.  
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 
Sports related concussions are estimated to affect between 1.1-1.9 million children under the age of 18 per 
year.1 Concussion is a form of mild traumatic brain injury (mTBI) as defined by the International Concussion 
in Sports Group (CISG) as “a traumatic brain injury induced by direct or indirect biomechanical forces to the 
head, neck or body”.2  Concussions can have lasting difficulties such as cognitive, behavioral, physical, 
somatic, and emotional symptoms and often coincide with mental health symptoms.2 Specifically, in children 
aged 0-18 years, symptoms may present as internalizing which are focused inward or externalizing features 
which are focused outward. Internalizing features may be anxiety or depressive symptoms, and externalizing 
features may be aggression, hyperactivity, or disruptive conduct. This topic is clinically relevant because 
athletic trainers often work with adolescent populations who have or will experience a concussion, as well as 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2023/0006.01.9


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work with patients who have been diagnosed with a mental health condition by a psychiatrist. The lasting 
impact of concussions can be hard to determine which makes assessments and interventions critical. Poor 
Increased mental health symptoms typically decrease after concussion, but occasionally children have lasting 
mental health symptoms that require additional treatment. Utilizing mental health outcomes and mental health 
questionnaires could help concussion management regarding mental health difficulties faced post-
concussion.3 The purpose of the guiding systematic review was to determine if there are increased mental 
health symptoms in pediatric patients with concussions as compared to pediatric patients without concussion. 

Summary of Literature  

The guiding systematic review used Medline, Embase, PsycINFO, CINAHL, SportDiscus, Scopus and 
PubMed in their search for articles published from 1980 to June 2020. Article inclusion criteria was 1) peer-
reviewed articles reporting prospective mental health outcomes following concussion in pediatric populations 
(ages 0-18 years at time of injury), 2) quantitative studies included observational designs, prospective and 
retrospective cohort studies, case-control studies and analytical cross-sectional studies, 3) qualitative studies 
included phenomenology, grounded theory, ethnography and action research, 4) mixed-methods studies 
were considered if data from the quantitative or qualitative components could be extracted, 5) the 
concussion definition was consistent with the Berlin CISGCriteria, regardless of whether or not these criteria 
were explicitly cited, 6) presence of a control group, and 7) completion of mental health measures (SCAT5, 
VOMS, symptom evaluation, etc.). The classifications of mental health symptoms were internalizing (symptoms 
focused inwardly), externalizing (symptoms focused outwardly) and overall mental health difficulties 
measured by novel psychiatric diagnoses post-injury.4 Internalizing classifications were disorders such as 
anxiety, depressive, and somatic symptoms.4 Externalizing classifications were disorders such as prominent 
impulsive, disruptive conduct, aggression, and substance use symptoms.5 Mental health was assessed by new 
psychiatric findings post-injury as well as total problem subscales of confirmed behavioral and emotional 
inventories. The study included a broader range of time since injury to capture the context of recovery, the 
time points were defined as: 1) acute, 2) persisting, and 3) chronic. The Downs and Black Quality Appraisal 
Criteria (DBC) and the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence was used to 
assess the quality and strength of the eligible studies.6,7 The studies that were included were rated as 
excellent or good quality on the DBC. Forty-three studies recruited participants using consecutive admissions 
or inception cohort design, indicating low risk of selection bias. Risk of selection bias was suggested in 22 
studies in the meta-analysis because they recruited controls from the same setting as the concussion 
sample. The search of databases discovered 69 articles that met the eligibility criteria and 60 were 
included in the systematic review. Out of the 69 articles, 29 were excluded from the meta-analysis because 
of the absence of a control group, or because the meta-analysis did not complete the mental health measures, 
resulting in 40 articles. 

SUMMARY OF OUTCOMES  

The data was collected from the characteristics of 89,114 children (60.9% males) with concussions. The three 
main mechanisms of injury were from falls (42.3%), sporting injuries (29.5%), and motor vehicle accidents 
(15.5%).8 The mental health outcomes were defined by validated questionnaire measures (n=60), interviews 
of the children (n=2), a formal psychiatric diagnosis (n=3), or engagement with mental health services (n=3). 
The most commonly used outcome measures to detect mental health outcomes were the Child Behavior 
Checklist, The Behavior Assessment System for Children, and The Personality Inventory for Children. The Child 
Behavior Checklist (n=19, 27.5%) is a self-administered test given to a parent, teacher, and the child. This 



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test 
is 

part 
of 

the 

Achenbach System of Empirically Based Assessment to test for behavioral and emotional problems in 
children.9 The Behavior Assessment System for Children (n=7, 10.1%) was used to assess the behavioral and 
emotional functions from taking the results of a questionnaire given to the child, parent, and a teacher.9,10 
The Personality Inventory for Children (n=7, 10.1%) was also used to measure mental health outcomes. 
Internalizing features (n=43), overall mental health (n=32), and externalizing features (n=29) were assessed 
(Table 1). Twenty-eight of the studies assessed the premorbid mental health status. This included the pre-
injury behavior (n=19) or psychiatric diagnoses (n=9) using the International Classification of Disease 
Criteria-10 (ICD-10).  

FINDINGS AND CLINICAL IMPLICATIONS 

The present systematic review showed significant, moderate effect sizes of internalizing features with 
comparing the acute, persisting and chronic outcomes (Table 1). The acute outcome was measured over less 
than three months, the persisting difficulties was from 3 to 12 months and the chronic difficulties were any 
case over 12 months. There were significant, moderate effect sizes observed in the externalizing features 
comparing the acute persisting, and chronic outcomes. For total features, the results showed that mental 
health in children generally improves over a span of 12 months with the acute cases experiencing the most 
effects. Several of the articles addressed the frequency of decreased mental health after a pediatric 
concussion. These studies suggest a minority of the children experienced clinically significant levels of 
internalizing, externalizing, and total mental health difficulties following their concussions.11 The factors that 
predicted mental health challenges following pediatric concussion included pre-injury mental health, age 
from 2.5 to 18 years old (the younger kids from age 2.5 to11 showed more externalizing features), and 
sex (females have a greater risk of developing new mental health symptoms).8,12,13 Males with psychiatric 
history were at a greater risk for further complications. Overall, age and sex were inconsistent predictors of 
mental health difficulties but some studies showed females to be more vulnerable to internalizing mental 
health features post-concussion.11 Familial factors such as the family functioning, anxiety, characteristics (e.g., 

Figure 1. Systematic Review Flow Chart 



Childhood Mental Health Outcomes Following Mild Traumatic Brain Injury: An Evidence-to-Practice Review 

 

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parent education, family socioeconomic status, living arrangements of the child), as well as parent mental 
health, and distress played a role in the mental health of the children studied.14 Mental health and post-
concussion syndrome was examined in 11 studies. Internalizing symptoms significantly predicted the acute 
and post-acute post-concussion syndrome recovery.15 Mental health remains consistent  over time post-injury 
with the mental health issues developing within the first-year post-concussion.11 It took 3 to 6 months to see 
significant improvements post-concussion with infants and toddlers experiencing social and emotional 
behavior issues (oppositional defiance, attention-deficit/hyperactivity, substance use and mood disorder 
symptoms seen around ages 14 to 16).16 Additional studies are needed on the impact of age and sex due 
to the lack of age-specific and sex-specific data acquired.  

Table 1. Mental health difficulties following pediatric concussions as compared to controls 
 Acute Timeline Persistent Timeline Chronic Timeline 
 

Internalizing Externalizing Internalizing Externalizing Internalizing Externalizing 

Mean size difference 
Likelihood ratio 
95% CI 
p 

5.12  
0.45  
0.17-0.74 
0.01  

5.77  
0.37  
0.09-0.65  
0.03  

4.26  
0.42  
0.20-0.63  
0.001  

4.94  
0.46  
0.25-0.66 
<0.001  

2.88  
0.41  
0.10-0.72  
0.01  

3.46  
0.25  
0.09-0.41 
0.005  

 t=mean size difference between two groups; g=likelihood ratio that the test would be 
positive in the target population; 95% CI=confidence interval means that there is a 
95% chance the real value is in the interval; p=means that there is the p-value chance 
that the observed differences occurred by chance 
 

CLINICAL BOTTOM LINE 

Clinicians who work with patients who participate in sports are likely to have experiences with mild traumatic 
brain injuries (mTBI) and mental health conditions. It is especially important for pediatric patients that the 
sports medicine team remains aware of the patient’s mental health as a factor in their concussion recovery. 
Athletic trainers can greatly improve the concussion recovery by including a mental health screen with the 
baseline concussion test before the onset of the sport/activity. For mental health concerns to be detected 
early, a psychiatric screening should be conducted in accordance with a yearly concussion baseline test as 
part of PPE. These additions can be implemented into the established policies and procedures manuals. As 
the National Athletic Trainers’ Association position statement on concussion management does not adequately 
address mental health screenings, The Translating Research into Injury Prevention Practice (TRIPP) framework 
would be necessary to start those changes. The previous recommendation would be a part of stages 5 and 
6 of the TRIPP frameworks which would help explore how to implement changes and then if those changes 
would be effective. 

After typical concussion symptoms have decreased, it is recommended that the same psychiatric screening 
used prior to the injury is utilized again. This will allow providers to assess if there is a change in the patients 
baseline mental health and the mental health concerns they may still be facing. After sustaining a concussion, 
the patient’s “symptoms check” should include physical and cognitive symptoms, as well as mental health-
related items such as nervousness, anxiety, sadness, depression, and/or increased irritability.3 In children, 
externalizing features are prominent such as hyperactivity, failure to control anger, or disordered conduct.8 



Childhood Mental Health Outcomes Following Mild Traumatic Brain Injury: An Evidence-to-Practice Review 

 

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It is key to remember that children that have been diagnosed with a concussion will experience overall mental 
health problems what will express internally and externally. As athletic trainers, we must be able to 
recognize and refer based off these symptoms. Internalizing symptoms would include anxious/overwhelmed 
(e.g., restlessness, uneasiness, panic), somatic concerns (e.g., excessive thoughts or feelings related to body 
symptoms such as pain or aches), and withdrawal (e.g., social isolation, introverted personality). A patient 
presenting with aggressive behaviors, intrusive thoughts, and risky behaviors are experiencing more 
externalizing symptoms. Athletic trainers should consider using screening instruments, like the Brief Symptom 
Inventory 18 (BSI-18) in conjunction with a psychological care team, to measure psychological distress prior 
to and following a pediatric concussion. 

Individuals with an existing history of mental health challenges appear to be at a greater risk for persistent 
symptoms prior to their concussion diagnosis.17 Athletic trainers should be mindful of assessing persistent post-
concussion symptoms and recognize the possible overlap of mental health symptoms. Athletic trainers should 
work with other health care providers when there are persistent mental health concerns. An interprofessional 
team consisting of an athletic trainer, physician, counselor, or psychologist is recommended with prolonged 
mental health concerns.18 If the site does not have an athletic trainer, the physician who is responsible for 
clearing the athlete for participation after their concussion should screen the athlete for any mental health 
concerns and if found, there should be a follow-up appointment with that physician, or a referral made to a 
counselor or psychologist to. 

Previous management recommendations included prolonged rest, but studies have identified this to be 
associated with poor mental health outcomes.19 Participation in early physical activity is associated with 
shorter symptom recovery times and fewer overall symptoms such as dizziness, nausea, headache, or visual 
problems..20 Athletic trainers have an important duty to educate and increase awareness for the pediatric 
patients and their families regarding the effects of mental health-related symptoms associated with 
concussions. An educational pamphlet can be incorporated with the initial PPE form including information on 
post-concussion management as well as potential mental health consequences for the parents or guardians 
since they play a vital role in the patient’s care. The physical, cognitive, and mental health-related symptoms 
of concussion occur at different rates and last for various periods of time. This represents an important 
diagnostic criterion of post-concussion syndrome for both ICD-10 and Diagnostic and Statistical Manual of 
Mental Disorders (DSM-5).3  

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All rights reserved. ISSN Online 2577-8188                                                                              Volume 6 – Issue 1 – April 2023 
  

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https://doi.org/10.1089/neu.2018.6235
https://doi.org/10.1089/neu.2018.6235
https://doi.org/10.1002/mrdd.20071
https://doi.org/10.1017/s1092852916000316
https://doi.org/10.1016/j.apmr.2003.12.036
https://doi.org/10.1089/neu.2018.5792
https://doi.org/10.1089/neu.2017.5265
https://doi.org/10.1080/13548500500535654
https://doi.org/10.1089/neu.2019.6683
https://doi.org/10.1097/htr.0b013e3181a40590
https://doi.org/10.1136/bjsports-2017-097729
https://doi.org/10.1016/j.apmr.2019.10.179
https://doi.org/10.1177/0009922815589914

	ABSTRACT

