Abstract - McMaster University



THE EMOTIONAL IMPACT OF CONCUSSION: EXPLORING THE RISKS AND EXPERIENCES OF DEPRESSION IN YOUTH RECOVERING FROM CONCUSSIONTHE EMOTIONAL IMPACT OF CONCUSSION: EXPLORING THE RISKS AND EXPERIENCES OF DEPRESSION IN YOUTH RECOVERING FROM CONCUSSIONByKATHRYN H STAZYK, BHSc., OT Reg (Ont.) A ThesisSubmitted to the School of Graduate StudiesIn Partial Fulfillment of the Requirements For the Degree Master of ScienceMcMaster University Copyright ? Kathryn Stazyk, June, 2015McMaster University MASTER OF SCIENCE (2015) Hamilton, Ontario (Rehabilitation Science)TITLE: The Emotional Impact of Concussion: Exploring the Risks and Experiences of Depression in Youth Recovering from Concussion. AUTHOR: Kathryn H. Stazyk, OT, BHSc. (McMaster University) SUPERVISOR: Dr. Cheryl Missiuna. NUMBER OF PAGES: ix, 115AbstractChildren and youth who suffer a mild traumatic brain injury or concussion are at risk for a number of negative outcomes. The symptoms of concussion and the management of these symptoms can be disruptive to the child’s everyday activities, especially if they are prolonged. Depression can result and may complicate the course of recovery.Depression has overlapping symptoms with concussion and is thought to lengthen the recovery period. There has been much research done in populations of mixed severities of brain injury but very little addresses children with concussion. Knowledge in this area is crucial due to depression’s impact on all aspects of functioning as well as the potential alteration of the child’s developmental trajectory.The purpose of this research was to examine the risks and predictors of depression following concussion in youth and to explore the experiences of a subsample of youth and their families with prolonged recovery from concussion, complicated by depression.Chapter One provides a review of the current literature setting the context for the research within what is known about concussion in youth, what is known about depression in youth and because of the early stages of this type of research, what is known about depression as an outcome of concussion in all age groups. Chapter Two presents a study highlighting the tangible risk for depression in a sample of children being followed in a tertiary care clinic (N=92). Significant predictors of depressive symptomatology were found to be the need for hospital admission and high symptom scores in the first few days and weeks after injury, which may be valuable information for prevention, early identification and treatment of youth at risk for depression after concussion.Chapter Three provides an in-depth exploration of the experiences of youth and families who have gone through prolonged recovery from concussion with significant depressive symptomatology. A phenomenological approach was used with six participants and their families who were interviewed and their responses analyzed. A trajectory of recovery was identified; common themes within each of four key stages of the trajectory were discussed and illustrated using direct quotes from the participants.Chapter Four outlines the important implications of these two studies for health care professionals; particularly in raising awareness of the mental health outcomes of concussion. Knowledge of the impact of debilitating symptoms, activity restrictions and depression can inform discussions early after a concussion to prepare and possibly prevent some of the losses experienced by youth that can lead to depression.Acknowledgements I have so enjoyed the opportunity of doing research here in Rehabilitation Science; a very supportive and generous faculty. I would like to express my sincere gratitude for the time, help and support given by a network of faculty, friends and family.First to my supervisor, Dr. Cheryl Missiuna who never said no to my ideas but asked those questions that challenged my thinking, encouraged me to keep going and was patient and ever so gentle in her guidance. Her time was very generously provided to help with both big and small issues alike.I was also very fortunate in my committee members who contributed greatly to my work; Carol DeMatteo, teacher, mentor and friend, inspired me with the passion for this work by providing me with opportunities to hear these children’s stories and to become immersed in this area of research. Her knowledge and insight were invaluable. Dr. Sandra Moll introduced me to the possibilities in qualitative research and made me aware of the privilege of going on this journey with these families. She was a fearless and persistent editor that made my work better.I would further like to acknowledge Dr. Steve Hanna who gave generously of his time and so patiently asked “Were you expecting me to give you the answer?” as he explained my statistical options for analysis in a way with which I could connect!Of course I owe much gratitude to friends and family who supported me emotionally and practically through this journey. I am privileged to have them all in my life but a special thanks to my understanding spouse, Mark Matson and our daughters, Jessica and Grace whose own endeavors inspire me to stay young in my outlook and to keep learning! Table of Contents TOC \o "1-3" \h \z \u AbstractivAcknowledgementsviChapter One: Introduction PAGEREF _Toc297792765 \h 1Concussion PAGEREF _Toc297792766 \h 2Recovery from Concussion PAGEREF _Toc297792767 \h 3Incidence of Concussion in Children PAGEREF _Toc297792768 \h 4Outcomes of Concussion PAGEREF _Toc297792769 \h 5Depression in Children PAGEREF _Toc297792770 \h 8Epidemiology PAGEREF _Toc297792771 \h 8Symptoms PAGEREF _Toc297792772 \h 10Causes of Depression PAGEREF _Toc297792773 \h 10Diagnosis of Depression PAGEREF _Toc297792774 \h 12Depression and Brain Injury PAGEREF _Toc297792775 \h 14Contributions from Adult Studies PAGEREF _Toc297792776 \h 14Contributions from Pediatric Studies PAGEREF _Toc297792777 \h 15The Relationship Between Post-Concussion Syndrome and Depression PAGEREF _Toc297792778 \h 17Research Objectives PAGEREF _Toc297792779 \h 18References PAGEREF _Toc297792780 \h 20Chapter Two PAGEREF _Toc297792781 \h 36Title of Paper: Depression in Children Recovering from Concussion: Correlates and Predictors PAGEREF _Toc297792782 \h 36Abstract PAGEREF _Toc297792783 \h 36Methods PAGEREF _Toc297792784 \h 41Sample PAGEREF _Toc297792785 \h 41Procedures PAGEREF _Toc297792786 \h 42Measures PAGEREF _Toc297792787 \h 42Data Analysis PAGEREF _Toc297792788 \h 44Results PAGEREF _Toc297792789 \h 45Non-Injury Related Factors PAGEREF _Toc297792790 \h 45Injury Related Factors PAGEREF _Toc297792791 \h 46Discussion PAGEREF _Toc297792792 \h 48Limitations PAGEREF _Toc297792793 \h 51Conclusion PAGEREF _Toc297792794 \h 52References PAGEREF _Toc297792795 \h 53Chapter Three PAGEREF _Toc297792796 \h 62Title of Paper: Exploring prolonged recovery and depression in youth after concussion: PAGEREF _Toc297792797 \h 62A trajectory of recovery PAGEREF _Toc297792798 \h 62Abstract PAGEREF _Toc297792799 \h 62Methods PAGEREF _Toc297792800 \h 66Design PAGEREF _Toc297792801 \h 66Sampling PAGEREF _Toc297792802 \h 66Procedures PAGEREF _Toc297792803 \h 67Screening tool PAGEREF _Toc297792804 \h 68Data Analysis PAGEREF _Toc297792805 \h 69Findings PAGEREF _Toc297792806 \h 70The Impact PAGEREF _Toc297792807 \h 70The Fallout PAGEREF _Toc297792808 \h 72Piecing it Back Together PAGEREF _Toc297792809 \h 75New or Renewed Path PAGEREF _Toc297792810 \h 77Experiences of Health Care PAGEREF _Toc297792811 \h 79Discussion PAGEREF _Toc297792812 \h 81Limitations PAGEREF _Toc297792813 \h 84Conclusion PAGEREF _Toc297792814 \h 85References PAGEREF _Toc297792815 \h 86Chapter Four: Discussion PAGEREF _Toc297792816 \h 93Integrating the Studies PAGEREF _Toc297792817 \h 97Implications for Clinical Practice PAGEREF _Toc297792818 \h 98Conclusion PAGEREF _Toc297792819 \h 102References PAGEREF _Toc297792820 \h 103List of FiguresChapter 3 Figure 1: Trajectory of prolonged recovery from concussion ………………………... 91Figure 2: Emotional and social implications along the trajectory of recovery from concussion ………………………………………………………………… 92Chapter 4Figure 1: Model explaining childhood concussion outcomes based on the differential susceptibility framework ............................................................99List of TablesChapter 2Table 1: Time from injury to depression screen …………………………………….. 58 Table 2: Characteristics of sample by CDI-2 scores (n=92) ………………………… 59Table 3: Correlation matrix of the relationships among non-injury and injury- related concussion variables ……………………………………………….. 60Table 4: Logistic regression predicting likelihood of depression in concussion recovery ……………………………………………………………………. 61Chapter 3Table 1: Participant characteristics ………………………………………………….. 90List of AppendicesAppendix A- Ethics Approval Letter ………………………………………………. 108Appendix B- Parent Consent Form ………………………………………………… 110Appendix C- Youth Assent Form ………………………………………………….. 112Appendix D- Interview Guide ………………………………………………………………………. 114Appendix E- Post-Concussive Symptom Inventory ……………………………………….. 115Chapter One: IntroductionConcussion or mild traumatic brain injury (mTBI) in children is a mounting public health concern. The increasing incidence, due in part to the widespread participation in competitive sports at younger ages, has contributed to a growing urgency in research to understand the short and long term effects of this injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1080/13854046.2011.556669", "ISSN" : "1744-4144", "PMID" : "21391151", "abstract" : "This article reviews current issues in the following areas of pediatric sports-related concussion: incidence of concussion, potential long-term effects, return to play, and the emergence of legislation regarding concussion education and management programs. Incidence of concussion is presented in context of emergency room visits, as well as under-reporting of concussions. The literature on history of concussion is reviewed, for high school, collegiate, and professional athletes, with respect to potential long-term effects of cerebral concussion. Specific discussions of effects include: decreased cognition and increased symptom reporting following multiple concussions, and recent diagnoses of chronic traumatic encephalopathy in non-professional and youth athletes. Recent legislative and advocacy efforts are reviewed, including mandated programs in specific states.", "author" : [ { "dropping-particle" : "", "family" : "Schatz", "given" : "Philip", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Moser", "given" : "Rosemarie Scolaro", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Clinical neuropsychologist", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2011", "8" ] ] }, "page" : "1042-57", "title" : "Current issues in pediatric sports concussion.", "type" : "article-journal", "volume" : "25" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Schatz & Moser, 2011)", "plainTextFormattedCitation" : "(Schatz & Moser, 2011)", "previouslyFormattedCitation" : "(Schatz & Moser, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Schatz & Moser, 2011). Depression is one of the secondary sequelae following traumatic brain injury of all severities and has multiple causes ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/HTR.0b013e3181e4622a", "ISSN" : "1550-509X", "PMID" : "20631632", "abstract" : "OBJECTIVE: To examine the influence of depression on postconcussion symptom reporting in patients following mild traumatic brain injury (MTBI).\n\nPARTICIPANTS: Sixty patients referred to a specialty clinic following MTBI, 58 outpatients with Structured Clinical Interview for DSM-diagnosed depression, and 72 healthy community control participants.\n\nPROCEDURE: Participants with MTBI were divided into 2 subgroups on the basis of self-reported symptoms of depression (23 MTBI-depressed, 37 MTBI-not depressed). All participants completed a postconcussion symptom questionnaire.\n\nMAIN OUTCOME MEASURE: British Columbia Post-concussion Symptom Inventory.\n\nRESULTS: There were significant differences in total reported postconcussion symptoms among all 4 groups (all P < .002; Cohen's d = 0.68-3.24, large to very large effect sizes; MTBI-depressed > depressed outpatients > MTBI-no depression > healthy controls). There were significant differences in the number of symptoms endorsed (P < .05), with the highest number of symptoms endorsed by the MTBI-depressed group, followed by depressed outpatients, MTBI-no depression, and healthy controls.\n\nCONCLUSIONS: Patients who experience MTBIs and who have a postinjury recovery course complicated by significant depression report more postconcussion symptoms, and more severe symptoms, than (a) outpatients with depression, and (b) patients with MTBIs who do not have significant symptoms of depression.", "author" : [ { "dropping-particle" : "", "family" : "Lange", "given" : "Rael T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Alice", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of head trauma rehabilitation", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "127-37", "title" : "Depression strongly influences postconcussion symptom reporting following mild traumatic brain injury.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Lange, Iverson, & Rose, 2011)", "plainTextFormattedCitation" : "(Lange, Iverson, & Rose, 2011)", "previouslyFormattedCitation" : "(Lange, Iverson, & Rose, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Lange, Iverson, & Rose, 2011). The complexity of the interaction between the physiological aspects of the head injury, the psychological aspects of the trauma and the subsequent loss of normal activities and routines all may play a role in the onset of depression. Understanding more about depression following concussion is important due to the potentially poor psychosocial outcomes that include behavioral, psychological and psychiatric consequences and a resultant impact on individual and family functioning ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.apmr.2013.12.018", "ISSN" : "1532-821X", "PMID" : "24581905", "abstract" : "OBJECTIVE: To synthesize the best available evidence regarding psychosocial consequences of mild traumatic brain injury (MTBI) in children.\n\nDATA SOURCES: MEDLINE, Embase, CINAHL, PsycINFO, and SPORTDiscus were searched (2001-2012). Inclusion criteria included published peer-reviewed reports in English, French, Norwegian, Spanish, Swedish, and Danish. References were also identified from relevant reviews and meta-analyses, and the bibliographies of eligible articles.\n\nSTUDY SELECTION: This article presents an update of a previous review with a much larger scope, of which this topic is a small subset of the questions addressed by that review. Controlled trials and cohort and case-control studies were selected according to predefined criteria. Two independent reviewers used modified Scottish Intercollegiate Guidelines Network criteria to critically appraise eligible studies. A total of 77,914 records were screened; 101 of these articles were deemed scientifically admissible, of which 6 investigated the psychosocial consequences of MTBI in children.\n\nDATA EXTRACTION: Two reviewers independently extracted data from accepted studies into evidence tables.\n\nDATA SYNTHESIS: We conducted a best-evidence synthesis by linking our conclusions to the evidence tables. Most accepted studies were exploratory rather than confirmatory. Preliminary evidence suggests that most children recover within 3 months post-MTBI. After 1 year, the prevalence of postconcussion symptoms and syndrome is similar between children with MTBI and children with orthopedic injuries. The functional status of children with MTBI improves over a 30-month follow-up period, but further research is needed to investigate the possibility that children with MTBI experience greater rates of psychiatric illness during the 3 years after their injury.\n\nCONCLUSIONS: The prognosis of MTBI is favorable in children. Most appear to recover functionally from a physical and psychological perspective. However, future research should investigate the risk for psychiatric illness.", "author" : [ { "dropping-particle" : "", "family" : "Keightley", "given" : "Michelle L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "C\u00f4t\u00e9", "given" : "Pierre", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rumney", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hung", "given" : "Ryan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carroll", "given" : "Linda J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cancelliere", "given" : "Carol", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cassidy", "given" : "J David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of physical medicine and rehabilitation", "id" : "ITEM-1", "issue" : "3 Suppl", "issued" : { "date-parts" : [ [ "2014", "3" ] ] }, "page" : "S192-200", "title" : "Psychosocial consequences of mild traumatic brain injury in children: results of a systematic review by the International Collaboration on Mild Traumatic Brain Injury Prognosis.", "type" : "article-journal", "volume" : "95" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Keightley et al., 2014)", "plainTextFormattedCitation" : "(Keightley et al., 2014)", "previouslyFormattedCitation" : "(Keightley et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Keightley et al., 2014). Research into the psychosocial impact of concussion in children is advancing rapidly. Recent studies have reported on a higher likelihood for future depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jadohealth.2013.10.006", "ISBN" : "1879-1972", "ISSN" : "18791972", "PMID" : "24355628", "abstract" : "Purpose: Previous studies in adults have suggested concussion and other brain injury presents a risk factor for depression. The goal of our study was to analyze the association between previous concussion and current depression diagnosis in a large nationally representative adolescent data set. Methods: Retrospective cohort study using the National Survey of Children's Health 2007-2008, a nationally representative survey conducted via random digit dialing. Data were obtained by parental report. We included youth 12-17 years old without a current concussion (N = 36,060), and evaluated the association between previous concussion (binary) and current depression diagnosis (binary) using multiple logistic regression to control for age, sex, parental mental health, and socioeconomic status. Results: After controlling for age, sex, parental mental health, and socioeconomic status, history of concussion was associated with a 3.3-fold greater risk for depression diagnosis (95% CI: 2.0-5.5). Other factors significantly associated with depression diagnosis included poor or fair parental mental health (OR: 3.7, 95% CI: 2.8-4.9), and older age (15-17 years vs. 12-14 years, OR: 1.4, 95% CI: 1.1-1.8). Sex of the subject was not significantly related to depression diagnosis. Being above 200% of the poverty level was associated with approximately a 50% decreased risk of depression diagnosis (95% CI: 35%-70%). Conclusions: History of concussion was associated with a higher prevalence of diagnosed depression in a large nationally representative adolescent data set. Clinicians should screen for depression in their adolescent patients with concussion. Future studies should confirm this association using prospective methodology and examine potential treatment approaches. ?? 2014 Society for Adolescent Health and Medicine. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Chrisman", "given" : "Sara P D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Richardson", "given" : "Laura P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Adolescent Health", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "582-586", "publisher" : "Elsevier Ltd", "title" : "Prevalence of diagnosed depression in adolescents with history of concussion", "type" : "article-journal", "volume" : "54" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.jpeds.2013.08.042", "ISBN" : "0022-3476 DO - ", "ISSN" : "1097-6833", "PMID" : "24112864", "abstract" : "OBJECTIVE: To delineate the relationship between traumatic brain injury (TBI) and mood disorders from population-based data in Taiwan.\\n\\nSTUDY DESIGN: This prospectively followed cohort study involved a subset of the National Health Insurance Research Database containing complete inpatient and outpatient data of 1 million randomly drawn beneficiaries. We included 10- to 24-year-old patients (n = 15,203) receiving the diagnosis of TBI in ambulatory visits or hospitalization from 2000-2004 and their age- and sex-matched comparison insureds using health service in the same year (n = 76,015). Diagnosis of mood disorders was recorded within 5 years after the traumatic event or index use of health service. Baseline demographics, clinical characteristics, and premorbid psychiatric conditions were compared using \u03c7(2) analysis. Increased risk during the 5-year follow-up period was represented by crude and adjusted hazard ratios with 95% CI using a Cox proportional hazard regression.\\n\\nRESULTS: A total of 451/15,203 patients with TBI (2.97%) received a diagnosis of mood disorders in the 5-year follow-up period compared with 1153/97,445 individuals (1.52%) without antecedent TBI. After adjusting for select premorbid comorbidities, TBI remained a significant predisposing factor with a 1.96-fold (95% CI 1.74-2.22) increase in risk of mood disorders.\\n\\nCONCLUSIONS: Our findings show a higher likelihood of manifesting mood disorders in adolescents and young adults who sustained a prior TBI. Health professionals should carefully monitor both the physical and psychological impacts of head trauma.", "author" : [ { "dropping-particle" : "", "family" : "Tsai", "given" : "Meng-Che", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tsai", "given" : "Kuen-Jer", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wang", "given" : "Hao-Kuang", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sung", "given" : "Pi-Shan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wu", "given" : "Ming-Hsiu", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hung", "given" : "Kuo-Wei", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lin", "given" : "Sheng-Hsiang", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "136-141.e1", "publisher" : "Elsevier Ltd", "title" : "Mood disorders after traumatic brain injury in adolescents and young adults: a nationwide population-based cohort study.", "type" : "article-journal", "volume" : "164" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Chrisman & Richardson, 2014; Tsai et al., 2014)", "plainTextFormattedCitation" : "(Chrisman & Richardson, 2014; Tsai et al., 2014)", "previouslyFormattedCitation" : "(Chrisman & Richardson, 2014; Tsai et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Chrisman & Richardson, 2014; Tsai et al., 2014), conduct disorder, bullying and adverse psychosocial outcomes ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1371/journal.pone.0094936", "ISBN" : "1932-6203 (Electronic) 1932-6203 (Linking)", "ISSN" : "19326203", "PMID" : "24736613", "abstract" : "OBJECTIVE: Our knowledge on the adverse correlates of traumatic brain injuries (TBI), including non-hospitalized cases, among adolescents is limited to case studies. We report lifetime TBI and adverse mental health and conduct behaviours associated with TBI among adolescents from a population-based sample in Ontario.\\n\\nMETHOD AND FINDINGS: Data were derived from 4,685 surveys administered to adolescents in grades 7 through 12 as part of the 2011 population-based cross-sectional Ontario Student Drug Use and Health Survey (OSDUHS). Lifetime TBI was defined as head injury that resulted in being unconscious for at least 5 minutes or being retained in the hospital for at least one night, and was reported by 19.5% (95%CI:17.3,21.9) of students. When holding constant sex, grade, and complex sample design, students with TBI had significantly greater odds of reporting elevated psychological distress (AOR\u200a=\u200a1.52), attempting suicide (AOR\u200a=\u200a3.39), seeking counselling through a crisis help-line (AOR\u200a=\u200a2.10), and being prescribed medication for anxiety, depression, or both (AOR\u200a=\u200a2.45). Moreover, students with TBI had higher odds of being victimized through bullying at school (AOR\u200a=\u200a1.70), being cyber-bullied (AOR\u200a=\u200a2.05), and being threatened with a weapon at school (AOR\u200a=\u200a2.90), compared with students who did not report TBI. Students with TBI also had higher odds of victimizing others and engaging in numerous violent as well as nonviolent conduct behaviours.\\n\\nCONCLUSIONS: Significant associations between TBI and adverse internalizing and externalizing behaviours were found in this large population-based study of adolescents. Those who reported lifetime TBI were at a high risk for experiencing mental and physical health harms in the past year than peers who never had a head injury. Primary physicians should be vigilant and screen for potential mental heath and behavioural harms in adolescent patients with TBI. Efforts to prevent TBI during adolescence and intervene at an early stage may reduce injuries and comorbid problems in this age group.", "author" : [ { "dropping-particle" : "", "family" : "Ilie", "given" : "Gabriela", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mann", "given" : "Robert E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boak", "given" : "Angela", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adlaf", "given" : "Edward M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hamilton", "given" : "Hayley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Asbridge", "given" : "Mark", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rehm", "given" : "J\u00fcrgen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cusimano", "given" : "Michael D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "PLoS ONE", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "10-15", "title" : "Suicidality, bullying and other conduct and mental health correlates of traumatic brain injury in adolescents", "type" : "article-journal", "volume" : "9" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ilie et al., 2014)", "plainTextFormattedCitation" : "(Ilie et al., 2014)", "previouslyFormattedCitation" : "(Ilie et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Ilie et al., 2014) in children when there is a past history of concussion. Much less is known about whether depression complicates and possibly lengthens recovery from concussion when it occurs shortly after injury. Some of the unanswered questions include: How common is it for children to have significant depressive symptoms?; What influences depression?; How does depression manifest after concussion?; and Who may be at risk? Research in this area is needed to guide prevention and early identification efforts in order to decrease the morbidity subsequent to the onset of depression. To that end, this dissertation will focus on understanding more about the extent of this mental health problem and what may help explain or predict those children who develop symptoms of depression in the course of their recovery from concussion. This thesis presents two manuscripts; the first manuscript (Chapter Two) reports the results of a study of depression assessed in a cohort of post-concussive youth followed at a tertiary care centre. The second manuscript (Chapter Three) examines the experience of children and families who are living with prolonged recovery from concussion with depressive symptoms. This introductory chapter will provide the background and literature that helped to formulate the research questions. An overview of our current understanding of concussion and of childhood depression is provided along with a discussion of the theoretical rationale and the current evidence addressing depression that occurs post-concussion. ConcussionConcussion, or mild traumatic brain injury (mTBI), results in a complex pathophysiological response from a force to the body that transmits to the head or from a direct blow to the head which results in impairment of neurological function that resolves spontaneously ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/bjsports-2013-092313", "ISSN" : "0306-3674", "author" : [ { "dropping-particle" : "", "family" : "McCrory", "given" : "P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meeuwisse", "given" : "W. 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Here we review the definition, epidemiology, and sequelae of concussion within the developing brain, during childhood and adolescence, with current data derived from studies of pathophysiology and neuroimaging. These findings may contribute to a better understanding of the neurological consequences of traumatic brain injuries, which in turn, may lead to the development of brain biomarkers to improve identification, management and prognosis of pediatric patients suffering from concussion.", "author" : [ { "dropping-particle" : "", "family" : "Toledo", "given" : "Esteban", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lebel", "given" : "Alyssa", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Becerra", "given" : "Lino", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Minster", "given" : "Anna", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Linnman", "given" : "Clas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maleki", "given" : "Nasim", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dodick", "given" : "David W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Borsook", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Neuroscience and biobehavioral reviews", "id" : "ITEM-2", "issue" : "6", "issued" : { "date-parts" : [ [ "2012", "7" ] ] }, "page" : "1510-31", "publisher" : "Elsevier Ltd", "title" : "The young brain and concussion: imaging as a biomarker for diagnosis and prognosis.", "type" : "article-journal", "volume" : "36" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(McCrory et al., 2013; Toledo et al., 2012)", "plainTextFormattedCitation" : "(McCrory et al., 2013; Toledo et al., 2012)", "previouslyFormattedCitation" : "(McCrory et al., 2013; Toledo et al., 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(McCrory et al., 2013; Toledo et al., 2012). The diagnosis and determination of the effects of concussion on the brain are difficult, as common imaging techniques often show no signs of injury since it is considered a functional disturbance rather than a structural injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2010-2005", "ISSN" : "1098-4275", "PMID" : "20805152", "abstract" : "Sport-related concussion is a \"hot topic\" in the media and in medicine. It is a common injury that is likely underreported by pediatric and adolescent athletes. Football has the highest incidence of concussion, but girls have higher concussion rates than boys do in similar sports. A clear understanding of the definition, signs, and symptoms of concussion is necessary to recognize it and rule out more severe intracranial injury. Concussion can cause symptoms that interfere with school, social and family relationships, and participation in sports. Recognition and education are paramount, because although proper equipment, sport technique, and adherence to rules of the sport may decrease the incidence or severity of concussions, nothing has been shown to prevent them. Appropriate management is essential for reducing the risk of long-term symptoms and complications. Cognitive and physical rest is the mainstay of management after diagnosis, and neuropsychological testing is a helpful tool in the management of concussion. Return to sport should be accomplished by using a progressive exercise program while evaluating for any return of signs or symptoms. 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A neurometabolic cascade has been described that occurs as axons are stretched and misfire and cells are clogged with calcium ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "PMID" : "12937489", "author" : [ { "dropping-particle" : "", "family" : "Giza", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hovda", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of athletic training", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "228-235", "title" : "The Neurometabolic Cascade of Concussion", "type" : "article-journal", "volume" : "36" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Giza & Hovda, 2001)", "plainTextFormattedCitation" : "(Giza & Hovda, 2001)", "previouslyFormattedCitation" : "(Giza & Hovda, 2001)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Giza & Hovda, 2001). The energy crisis that results causes decreased cerebral blood flow and results in symptoms of headache, dizziness, poor balance, fogginess, and difficulty with memory, sensory sensitivities and fatigue among many others ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "PMID" : "12937489", "author" : [ { "dropping-particle" : "", "family" : "Giza", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hovda", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of athletic training", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "228-235", "title" : "The Neurometabolic Cascade of Concussion", "type" : "article-journal", "volume" : "36" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Giza & Hovda, 2001)", "plainTextFormattedCitation" : "(Giza & Hovda, 2001)", "previouslyFormattedCitation" : "(Giza & Hovda, 2001)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Giza & Hovda, 2001). The most current and straightforward definition of concussion from the Zurich Consensus guidelines consists of a Glasgow Coma Scale score between 13 and 15, with or without loss of consciousness; altered mental status or disorientation; plus the presence of one or more of the common symptoms mentioned previously ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/bjsports-2013-092313", "ISSN" : "0306-3674", "author" : [ { "dropping-particle" : "", "family" : "McCrory", "given" : "P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meeuwisse", "given" : "W. 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Symptoms may be apparent immediately after the injury, but sometimes do not appear for several hours or days.Recovery from ConcussionHealing after concussion generally occurs rapidly and spontaneously with full recovery in days to weeks; however some patients experience persistent negative symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Berrigan", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marshall", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Velikonja", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bayley", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain Injury", "id" : "ITEM-1", "issue" : "7-8", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "742-751", "title" : "Quality of clinical practice guidelines for persons who have sustained a mild traumatic brain injury", "type" : "article-journal", "volume" : "25" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Berrigan, Marshall, Velikonja, & Bayley, 2011)", "plainTextFormattedCitation" : "(Berrigan, Marshall, Velikonja, & Bayley, 2011)", "previouslyFormattedCitation" : "(Berrigan, Marshall, Velikonja, & Bayley, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Berrigan, Marshall, Velikonja, & Bayley, 2011). Studies report anywhere from 25% to 50% of children experiencing symptoms one month post injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2013-0432", "author" : [ { "dropping-particle" : "", "family" : "Eisenberg", "given" : "Matthew A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Andrea", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meehan", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mannix", "given" : "Rebekah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "title" : "Time Interval Between Concussions and Symptom Duration", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1542/peds.2011-1742", "ISBN" : "1098-4275 (Electronic)\\r0031-4005 (Linking)", "ISSN" : "0031-4005", "PMID" : "22144708", "abstract" : "OBJECTIVE: To determine the prevalence of headache 3 and 12 months after pediatric traumatic brain injury (TBI). METHODS: This is a prospective cohort study of children ages 5 to 17 years in which we analyzed the prevalence of headache 3 and 12 months after mild TBI (mTBI; n = 402) and moderate/severe TBI (n = 60) compared with controls with arm injury (AI; n = 122). RESULTS: The prevalence of headache 3 months after injury was significantly higher after mTBI than after AI overall (43% vs 26%, relative risk [RR]: 1.7 [95% confidence interval (CI): 1.2-2.3]), in adolescents (13-17 years; 46% vs 25%, RR: 1.8 [95% CI: 1.1-3.1]), and in girls (59% vs 24%, RR: 2.4 [95% CI: 1.4-4.2]). The prevalence of headache at 3 months was also higher after moderate/severe TBI than AI in younger children (5-12 years; 60% vs 27%; RR: 2.0 [95% CI: 1.2-3.4]). Twelve months after injury, TBI was not associated with a significantly increased frequency of headache. However, girls with mTBI reported serious headache (>/= 5 of 10 pain scale rating) more often than controls (27% vs 10%, RR: 2.2 [95% CI: 0.9-5.6]). CONCLUSIONS: Pediatric TBI is associated with headache. A substantial number of children suffer from headaches months after their head injury. The prevalence of headache during the year after injury is related to injury severity, time after injury, age, and gender. Girls and adolescents appear to be at highest risk of headache in the months after TBI.", "author" : [ { "dropping-particle" : "", "family" : "Blume", "given" : "H. K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vavilala", "given" : "M. S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jaffe", "given" : "K. M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Koepsell", "given" : "T. 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Eleven to 30% of children have symptoms after three months ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2009-0925", "ISSN" : "1098-4275", "PMID" : "20660554", "abstract" : "Much disagreement exists as to whether postconcussion syndrome (PCS) is attributable to brain injury or to other factors such as trauma alone, preexisting psychosocial problems, or medicolegal issues. 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When symptomatic, children are advised to rest both physically and cognitively which includes no screens or smart phones, reading or homework; however there is no rigorous research defining exactly how much rest is necessary ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/HTR.0b013e31825ad658", "author" : [ { "dropping-particle" : "", "family" : "Silverberg", "given" : "Noah D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J Head Trauma Rehabil", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "250-259", "title" : "Is Rest After Concussion \u201c The Best Medicine ?\u201d: Recommendations for Activity Resumption Following Concussion in Athletes , Civilians , and Military Service Members", "type" : "article-journal", "volume" : "28" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Silverberg & Iverson, 2013)", "plainTextFormattedCitation" : "(Silverberg & Iverson, 2013)", "previouslyFormattedCitation" : "(Silverberg & Iverson, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Silverberg & Iverson, 2013). There is controversy, therefore, about the amount of prescribed rest as a management tool in concussion. Prolonged rest can lead to social isolation, depression and deconditioning ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/JSM.0b013e3181c6c22c", "ISSN" : "1536-3724", "PMID" : "20051730", "abstract" : "To evaluate the safety and effectiveness of subsymptom threshold exercise training for the treatment of post-concussion syndrome (PCS).", "author" : [ { "dropping-particle" : "", "family" : "Leddy", "given" : "John J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kozlowski", "given" : "Karl", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Donnelly", "given" : "James P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pendergast", "given" : "David R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Epstein", "given" : "Leonard H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Willer", "given" : "Barry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010", "1" ] ] }, "page" : "21-7", "title" : "A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome.", "type" : "article-journal", "volume" : "20" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Leddy et al., 2010)", "plainTextFormattedCitation" : "(Leddy et al., 2010)", "previouslyFormattedCitation" : "(Leddy et al., 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Leddy et al., 2010); however, going back to activity too soon can exacerbate symptoms or cause symptom return and lengthens time to recovery ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2013-2125", "ISSN" : "1098-4275", "PMID" : "24394679", "abstract" : "OBJECTIVE: To determine the effect of cognitive activity level on duration of post-concussion symptoms.\n\nMETHODS: We conducted a prospective cohort study of patients who presented to a Sports Concussion Clinic within 3 weeks of injury between October 2009 and July 2011. At each visit, patients completed a scale that recorded their average level of cognitive activity since the previous visit. The product of cognitive activity level and days between visits (cognitive activity-days) was calculated and divided into quartiles. Kaplan-Meier Product Limit method was used to generate curves of symptom duration based on cognitive activity level. To adjust for other possible predictors of concussion recovery, we constructed a Cox proportional hazard model with cognitive activity-days as the main predictor.\n\nRESULTS: Of the 335 patients included in the study, 62% were male, 19% reported a loss of consciousness, and 37% reported experiencing amnesia at the time of injury. The mean age of participants was 15 years (range, 8-23) and the mean number of previous concussions was 0.76; 39% of athletes had sustained a previous concussion. The mean Post-Concussion Symptom Scale score at the initial visit was 30 (SD, 26). The overall mean duration of symptoms was 43 days (SD, 53). Of all variables assessed, only total symptom burden at initial visit and cognitive activity level were independently associated with duration of symptoms.\n\nCONCLUSIONS: Increased cognitive activity is associated with longer recovery from concussion. This study supports the use of cognitive rest and adds to the current consensus opinion.", "author" : [ { "dropping-particle" : "", "family" : "Brown", "given" : "Naomi J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mannix", "given" : "Rebekah C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Brien", "given" : "Michael J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gostine", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meehan", "given" : "William P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2014", "2" ] ] }, "page" : "e299-304", "title" : "Effect of cognitive activity level on duration of post-concussion symptoms.", "type" : "article-journal", "volume" : "133" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.jpeds.2012.04.012", "ISSN" : "1097-6833", "PMID" : "22622050", "abstract" : "To evaluate the efficacy of cognitive and physical rest for the treatment of concussion.", "author" : [ { "dropping-particle" : "", "family" : "Moser", "given" : "Rosemarie Scolaro", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Glatts", "given" : "Colette", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schatz", "given" : "Philip", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-2", "issue" : "5", "issued" : { "date-parts" : [ [ "2012", "11" ] ] }, "page" : "922-6", "publisher" : "Mosby, Inc.", "title" : "Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion.", "type" : "article-journal", "volume" : "161" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Guskiewicz", "given" : "Kevin M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCrea", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marshall", "given" : "Stephen W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Randolph", "given" : "Christopher", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barr", "given" : "William B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Onate", "given" : "James A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kelly", "given" : "James P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "JAMA: The Journal of the American Medical Association", "id" : "ITEM-3", "issue" : "19", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "2549-2555", "title" : "Cumulative Effects Associated with Recurrent Concussion in Collegiate Football Players The NCAA Concussion Study", "type" : "article-journal", "volume" : "290" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Brown et al., 2014; Guskiewicz et al., 2003; Moser, Glatts, & Schatz, 2012)", "plainTextFormattedCitation" : "(Brown et al., 2014; Guskiewicz et al., 2003; Moser, Glatts, & Schatz, 2012)", "previouslyFormattedCitation" : "(Brown et al., 2014; Guskiewicz et al., 2003; Moser, Glatts, & Schatz, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Brown et al., 2014; Guskiewicz et al., 2003; Moser, Glatts, & Schatz, 2012). An evidence-based and balanced approach to managing this complex issue has been advocated as the most practical and guidelines for return to activity ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/0009922814558256", "ISBN" : "0009922814", "ISSN" : "0009-9228", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stazyk", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Singh", "given" : "S. 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DeMatteo et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(DeMatteo et al., 2014) and return to school ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/0009922814567305", "ISBN" : "0009922814", "ISSN" : "0009-9228", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stazyk", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giglia", "given" : "L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mahoney", "given" : "W.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Singh", "given" : "S. 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DeMatteo et al., 2015)", "manualFormatting" : "(DeMatteo et al., 2015)", "plainTextFormattedCitation" : "(C. DeMatteo et al., 2015)", "previouslyFormattedCitation" : "(C. DeMatteo et al., 2015)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(DeMatteo et al., 2015) have now been developed. Appropriate management of concussion is key in preventing further injury. Having a head injury is a risk factor for sustaining another similar injury within a year ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2006-1186", "ISSN" : "1098-4275", "PMID" : "17403846", "abstract" : "OBJECTIVE: The objective of this study was to determine whether children who sought care for a head injury were at greater risk of having a subsequent head injury within the following 6 and 12 months compared with children who sought care for an injury other than to the head. DESIGN/SETTING: This was a longitudinal cohort study conducted in the emergency departments of 2 Montreal (Quebec, Canada) pediatric hospitals. PARTICIPANTS: The parents of 11,867 injured children aged 1 to 18 years were interviewed by telephone at 6 (n = 10,315) and 12 (n = 9486) months after their child's injury to ascertain outcome (ie, subsequent head injury) and to provide information on potential risk factors (age, gender, chronic medical condition, activity level, and socioeconomic status). MAIN OUTCOME MEASURE: The outcome of interest was a head injury requiring medical attention within the following year ascertained by parental recall or physician claims data. RESULTS: A total of 245 and 386 previously head-injured children sustained a subsequent head injury within 6 and 12 months, respectively. Children who sought care for an initial head injury (n = 3599) were at higher risk of having a subsequent head injury within 6 months than children who sought care for an injury not to the head (n = 6716). The adjusted odds ratio suggested weak confounding by age, gender, and history of previous head injury. Results were consistent on the basis of physician claims data and 12-month follow-up interview data. CONCLUSIONS: These results provide evidence that having a head injury increases a child's risk of having a subsequent head injury. Although age, gender, and history of previous head injury confound the relationship, the effect remains substantial.", "author" : [ { "dropping-particle" : "", "family" : "Swaine", "given" : "Bonnie R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tremblay", "given" : "Camille", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Platt", "given" : "Robert W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grimard", "given" : "Guy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zhang", "given" : "Xun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pless", "given" : "I Barry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2007" ] ] }, "page" : "749-758", "title" : "Previous head injury is a risk factor for subsequent head injury in children: a longitudinal cohort study.", "type" : "article-journal", "volume" : "119" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Guskiewicz", "given" : "Kevin M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCrea", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marshall", "given" : "Stephen W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Randolph", "given" : "Christopher", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barr", "given" : "William B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Onate", "given" : "James A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kelly", "given" : "James P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "JAMA: The Journal of the American Medical Association", "id" : "ITEM-2", "issue" : "19", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "2549-2555", "title" : "Cumulative Effects Associated with Recurrent Concussion in Collegiate Football Players The NCAA Concussion Study", "type" : "article-journal", "volume" : "290" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Guskiewicz et al., 2003; Swaine et al., 2007)", "plainTextFormattedCitation" : "(Guskiewicz et al., 2003; Swaine et al., 2007)", "previouslyFormattedCitation" : "(Guskiewicz et al., 2003; Swaine et al., 2007)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Guskiewicz et al., 2003; Swaine et al., 2007). Multiple injuries have also been identified as a risk factor for increased symptom reporting, prolonged recovery, neurocognitive changes and depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/acn3.70", "ISSN" : "2328-9503", "PMID" : "25356413", "abstract" : "OBJECTIVES: The purpose of this study was to evaluate the association of prior concussion on baseline computerized neurocognitive testing in a large cohort of high school athletes.\n\nMETHODS: This is a retrospective cohort study of student athletes from 49 Maine High Schools in 2010 who underwent baseline computerized neurocognitive evaluation with Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT\u00ae). As part of the ImPACT\u00ae, subjects reported a prior history of concussion as well as demographic information and a symptom questionnaire. We used linear regression to evaluate the association of prior concussion with baseline: (1) ImPACT\u00ae composite scores; and (2) symptom scores.\n\nRESULTS: Six thousand seventy-five subjects were included in the study, of whom 57% were boys. The majority of student athletes (85.3%) reported no prior history of concussion while 4.6% reported having sustained two or more prior concussions. On simple linear regression, increasing number of concussions was related to worse performance in verbal memory (P = 0.039) and greater symptoms scores (P < 0.001). On multivariate modeling, only the association with baseline symptoms remained (P < 0.001). Other factors associated with baseline symptom reporting in the multivariate model included mental health history, headache/migraine history, gender, developmental and/or learning problems, and number of prior concussions.\n\nINTERPRETATION: In this large-scale, retrospective survey study, history of multiple prior concussions was associated with higher symptom burden but not baseline computerized neurocognitive testing. The association between baseline symptom reporting and clinical and demographic factors was greater than the association with a history of multiple concussions.", "author" : [ { "dropping-particle" : "", "family" : "Mannix", "given" : "Rebekah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maxwell", "given" : "Bruce", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Atkins", "given" : "Joseph E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zafonte", "given" : "Ross", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berkner", "given" : "Paul D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of clinical and translational neurology", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2014", "6" ] ] }, "page" : "433-8", "title" : "Multiple prior concussions are associated with symptoms in high school athletes.", "type" : "article-journal", "volume" : "1" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.jpeds.2014.08.034", "ISSN" : "1097-6833", "PMID" : "25262302", "abstract" : "OBJECTIVE: To identify pre-existing characteristics associated with prolonged recovery from concussion in a sample of patients referred to a pediatric sports medicine clinic.\n\nSTUDY DESIGN: This was a retrospective, exploratory cohort study of 247 patients age 5-18\u00a0years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010, through December 31, 2011. A random sample of all eligible patient visits (3740) was chosen for further review and abstraction. Statistical comparisons between subsets of patients were conducted using exact \u03c7(2) tests, logistic regression, quantile regression, and Kaplan-Meier survival curves.\n\nRESULTS: The median time until returning to school part-time was 12\u00a0days (IQR 6-21); until returning to school full-time without accommodations was 35\u00a0days (IQR 11-105); until becoming symptom-free was 64\u00a0days (IQR 18-119); and until being fully cleared to return to sports was 75\u00a0days (IQR 30-153). Furthermore, 73% of all patients were symptomatic for >4\u00a0weeks, 73% were prescribed some form of school accommodation, and 61% reported a decline in grades. Characteristics associated with a prolonged recovery included a history of depression or anxiety; an initial complaint of dizziness; abnormal convergence or symptom provocation following oculomotor examination on physical examination; and history of prior concussion.\n\nCONCLUSIONS: Pediatric and adolescent patients with concussion may experience cognitive and emotional morbidity that can last for several months following injury. Clinicians should consider specific pre-existing characteristics and presenting symptoms that may be associated with a more complicated recovery for concussion patients.", "author" : [ { "dropping-particle" : "", "family" : "Corwin", "given" : "Daniel J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zonfrillo", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Master", "given" : "Christina L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Arbogast", "given" : "Kristy B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grady", "given" : "Matthew F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "Roni L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goodman", "given" : "Arlene M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wiebe", "given" : "Douglas J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2014", "9", "25" ] ] }, "page" : "1-9", "publisher" : "Elsevier\u00a0Inc", "title" : "Characteristics of Prolonged Concussion Recovery in a Pediatric Subspecialty Referral Population.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Corwin et al., 2014a; Mannix et al., 2014)", "plainTextFormattedCitation" : "(Corwin et al., 2014a; Mannix et al., 2014)", "previouslyFormattedCitation" : "(Corwin et al., 2014a; Mannix et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Corwin et al., 2014a; Mannix et al., 2014). The implication for appropriate education and management of concussion is, therefore, crucial in preventing poor long-term outcomes, which may include more head injuries, extended recovery periods and secondary mental health sequelae. Incidence of Concussion in ChildrenChildren have the highest incidence of all those sustaining traumatic brain injuries (TBI) through sports, falls, motor vehicle accidents and non-accidental injuries ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.004", "ISSN" : "1558-1381", "PMID" : "22050939", "abstract" : "Concussions occur as a result of forces directed to the head or neck, or from impulsive forces transmitted from the body to the head. They result in the rapid onset and spontaneous recovery of short-lived impairment of neurologic function. Concussions represent a functional, rather than structural, disturbance, and do not result in abnormalities on standard structural imaging. This article discusses a comprehensive approach to return to play in sports concussion, including managing athletes returning after prolonged postconcussion syndrome, multiple concussions, and intracranial hematomas and craniotomy.", "author" : [ { "dropping-particle" : "", "family" : "Laker", "given" : "Scott R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Physical medicine and rehabilitation clinics of North America", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2011", "11" ] ] }, "page" : "619-34, viii", "publisher" : "Elsevier Inc", "title" : "Return-to-play decisions.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.emc.2013.05.007", "ISSN" : "1558-0539", "PMID" : "23915598", "abstract" : "Children with head injuries frequently present to emergency departments. Even though most of these children have minor injuries, head injury is the most common cause of traumatic deaths in pediatric patients. The pediatric GCS and decision rules for obtaining head CT imaging help the provider evaluate head-injured infants and children. The provider must be vigilant to diagnose those who have life-threatening intracranial injuries or are victims of abusive head trauma. The goal of the emergency physician is to diagnose and treat the consequences of the primary injury and to limit or prevent secondary injury.", "author" : [ { "dropping-particle" : "", "family" : "Wing", "given" : "Robyn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "James", "given" : "Catherine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Emergency medicine clinics of North America", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2013", "8" ] ] }, "page" : "653-75", "publisher" : "Elsevier Inc", "title" : "Pediatric head injury and concussion.", "type" : "article-journal", "volume" : "31" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Laker, 2011; Wing & James, 2013)", "plainTextFormattedCitation" : "(Laker, 2011; Wing & James, 2013)", "previouslyFormattedCitation" : "(Laker, 2011; Wing & James, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Laker, 2011; Wing & James, 2013). An accurate figure representing the incidence of concussion in children is difficult to obtain due to the under-reported nature of this injury and the lack of a consistency in diagnosis. Awareness and recognition, however, is growing and has resulted in a sharp rise in those with concussion presenting to emergency departments ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/archdischild-2012-303588", "ISBN" : "0003-9888", "ISSN" : "1468-2044", "PMID" : "23852997", "abstract" : "OBJECTIVES: To describe the number of hospital admissions for concussion at paediatric hospitals in the USA. To describe the use of imaging and medications for acute concussion paediatric patients.\\n\\nDESIGN: Cross-sectional study.\\n\\nSETTING: Children's hospitals participating in the Pediatric Health Information System in the USA during a 10-year period.\\n\\nPATIENTS: All emergency department (ED) visits and inpatient admissions with the primary diagnosis of concussion, defined as International Classification of Diseases, Ninth Revision, Clinical Modification codes for: (1) concussion, (2) postconcussion syndrome or (3) skull fracture without mention of intracranial injury with concussion.\\n\\nMAIN OUTCOME MEASURES: The proportion of concussion patients who were hospitalised, underwent imaging or received medication, and the adjusted costs of visits for concussion.\\n\\nRESULTS: The number of ED visits for concussion increased between 2001 and 2010 (2126 (0.36% of all ED visits) vs 4967 (0.62% of all ED visits); p<0.001), while the number of admissions remained stable. Of ED visits for concussion, 59.9% received CT and 47.7% received medications or intravenous fluids. Non-narcotic analgesics were the most common medication administered. Adjusted costs of patient visits were significantly higher when imaging was obtained (US$695, IQR US$472-$1009, vs US$191, IQR US$114-$287). An ED visit with CT, however, cost less than a hospitalisation without CT (US$1907, IQR US$1292-$3770).\\n\\nCONCLUSIONS: Although the number of ED patients diagnosed with concussion has increased, the number admitted has remained stable. Concussion patients at paediatric hospitals in the USA commonly undergo CT imaging and receive medication.", "author" : [ { "dropping-particle" : "", "family" : "Colvin", "given" : "Jeffrey D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Thurm", "given" : "Cary", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pate", "given" : "Brian M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Newland", "given" : "Jason G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hall", "given" : "Matt", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meehan", "given" : "William P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of disease in childhood", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "934-8", "title" : "Diagnosis and acute management of patients with concussion at children's hospitals.", "type" : "article-journal", "volume" : "98" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISBN" : "4167365774", "author" : [ { "dropping-particle" : "", "family" : "Macpherson", "given" : "Alison", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fridman", "given" : "Liraz", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ba", "given" : "Michal Scolnik", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Corallo", "given" : "Ashley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mdcm", "given" : "Astrid Guttmann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Macpherson", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fridman", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Scolnik", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Corallo", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Guttmann", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatric Child Health", "id" : "ITEM-2", "issue" : "10", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "543-546", "title" : "Emergency department and office visits for", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Colvin et al., 2013; Macpherson et al., 2014)", "plainTextFormattedCitation" : "(Colvin et al., 2013; Macpherson et al., 2014)", "previouslyFormattedCitation" : "(Colvin et al., 2013; Macpherson et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Colvin et al., 2013; Macpherson et al., 2014). Recent figures from sports injuries alone show that the prevalence of concussions that are recognized has doubled in the 8-19 year-old age group ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpeds.2012.04.012", "ISSN" : "1097-6833", "PMID" : "22622050", "abstract" : "To evaluate the efficacy of cognitive and physical rest for the treatment of concussion.", "author" : [ { "dropping-particle" : "", "family" : "Moser", "given" : "Rosemarie Scolaro", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Glatts", "given" : "Colette", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schatz", "given" : "Philip", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2012", "11" ] ] }, "page" : "922-6", "publisher" : "Mosby, Inc.", "title" : "Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion.", "type" : "article-journal", "volume" : "161" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Moser et al., 2012)", "plainTextFormattedCitation" : "(Moser et al., 2012)", "previouslyFormattedCitation" : "(Moser et al., 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Moser et al., 2012). In Ontario in 2010 14,886 children with concussion were treated in local emergency departments (ED) or by family physicians ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "4167365774", "author" : [ { "dropping-particle" : "", "family" : "Macpherson", "given" : "Alison", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fridman", "given" : "Liraz", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ba", "given" : "Michal Scolnik", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Corallo", "given" : "Ashley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mdcm", "given" : "Astrid Guttmann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Macpherson", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fridman", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Scolnik", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Corallo", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Guttmann", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatric Child Health", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "543-546", "title" : "Emergency department and office visits for", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Macpherson et al., 2014)", "plainTextFormattedCitation" : "(Macpherson et al., 2014)", "previouslyFormattedCitation" : "(Macpherson et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Macpherson et al., 2014). Even if a small proportion of these children suffer persistent negative outcomes, such as the 11 – 30% previously cited as having prolonged recoveries, then this is a serious public health problem ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "PMID" : "15799131", "abstract" : "The vast majority of closed-head injuries (CHI) in children are of mild severity. Even if only a small proportion of children with mild CHI suffer persistent negative outcomes, then mild CHI is a serious public health problem. This paper summarizes the existing literature regarding the neurobehavioural outcomes associated with mild CHI in children and adolescents, focusing on the longstanding debate regarding post-concussive syndrome. The paper also discusses conceptual and methodological issues that arise in research on the outcomes of mild CHI, including the definition of mild CHI; selection of comparison groups; measurement of outcomes; assessment of risk factors; timing of outcome assessments; and prediction of outcomes for individual children. The paper describes an ongoing research project that may help to resolve some of the longstanding controversies and uncertainties regarding the outcomes of mild CHI in children and concludes with a review of likely future directions for research on the outcomes of mild CHI. The long-term goal of research in this area is to develop a comprehensive and integrated biopsychosocial model of outcomes that can help guide clinical management", "author" : [ { "dropping-particle" : "", "family" : "Yeates", "given" : "K O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "H G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatric Rehabilitation", "id" : "ITEM-1", "issue" : "1363-8491 (Print)", "issued" : { "date-parts" : [ [ "2005" ] ] }, "language" : "eng PT - Journal Article PT - Research Support, U.S. Gov't, P.H.S SB - IM", "note" : "DA - 20050331", "page" : "5-16", "publisher-place" : "Columbus Children's Research Institute, Department of Pediatrics, Ohio State University, OH, USA. yeatesk@chi.osu.edu", "title" : "Neurobehavioural outcomes of mild head injury in children and adolescents", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Yeates & Taylor, 2005)", "plainTextFormattedCitation" : "(Yeates & Taylor, 2005)", "previouslyFormattedCitation" : "(Yeates & Taylor, 2005)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Yeates & Taylor, 2005). Outcomes of ConcussionConcussion, and particularly repeated concussion, can lead to long term outcomes that include: 1) changes in neurocognitive functioning including processing speed, memory and concentration ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Lau", "given" : "BC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lovell", "given" : "MR", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Neurosurgery", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2012" ] ] }, "note" : "Neurosurgery. 2012 Feb;70(2):371-9; discussion 379.", "page" : "371-379", "title" : "Cutoff scores in neurocognitive testing and symptom clusters that predict protracted recovery from concussions in high school athletes", "type" : "article-journal", "volume" : "70" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(B. Lau, Collins, & Lovell, 2012)", "manualFormatting" : "(Lau, Collins, & Lovell, 2012)", "plainTextFormattedCitation" : "(B. Lau, Collins, & Lovell, 2012)", "previouslyFormattedCitation" : "(B. Lau, Collins, & Lovell, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Lau, Collins, & Lovell, 2012); 2) psychiatric illness such as mood disorders, post-traumatic stress disorder, anxiety and obsessive compulsive disorder ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Bryant", "given" : "R A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Donnell", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Creamer", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McFarlane", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Clark", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Silove", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Am J Psychiatry", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "312-320", "title" : "The Psychiatric sequelaie of traumatic injury", "type" : "article-journal", "volume" : "167" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Bryant et al., 2010)", "plainTextFormattedCitation" : "(Bryant et al., 2010)", "previouslyFormattedCitation" : "(Bryant et al., 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Bryant et al., 2010); 3) behavioural changes that can include difficulties with attention, initiation, impulse control and organizational skills ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "PMID" : "12185159", "abstract" : "OBJECTIVES: The question of whether any adverse cognitive or psychosocial outcomes occur after mild head injury in early childhood has evoked considerable controversy. This study examined mild head injury before age 10 and potential differences in late childhood/early adolescence as a function of severity of mild injury and age at injury. METHODS: A fully prospective longitudinal design tracked a large birth cohort of children. Confirmed cases of mild head injury before age 10 were divided on the basis of outpatient medical attention (n=64-84) or inpatient observation (hospital overnight; n=26-28 ) and compared with the non-injured remainder of the cohort (reference group; n=613-807). A range of pre-injury and post-injury child and family characteristics were used to control for any potential confounds. Outcome after injury before and after age 5 was also assessed. RESULTS: After accounting for several demographic, family, and pre-injury characteristics, the inpatient but not the outpatient group displayed increased hyperactivity/inattention and conduct disorder between ages 10 to 13, as rated by both mothers and teachers. Psychosocial deficits were more prevalent in the inpatient subgroup injured before age 5. No clear effects were evident for various cognitive/academic measures, irrespective of severity of mild injury or age at injury. CONCLUSIONS: Most cases of mild head injury in young children do not produce any adverse effects, but long term problems in psychosocial function are possible in more severe cases, perhaps especially when this event occurs during the preschool years. The view that all mild head injuries in children are benign events requires revision and more objective measures are required to identify cases at risk", "author" : [ { "dropping-particle" : "", "family" : "McKinlay", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dalrymple-Alford", "given" : "J C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Horwood", "given" : "L J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fergusson", "given" : "D M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Neurology, Neurosurgery and Psychiatry", "id" : "ITEM-1", "issue" : "0022-3050 (Print)", "issued" : { "date-parts" : [ [ "2002" ] ] }, "language" : "eng PT - Journal Article PT - Research Support, Non-U.S. Gov't SB - IM", "note" : "DA - 20020819", "page" : "281-288", "publisher-place" : "Department of Psychology, University of Canterbury, and Christchurch Movement Disorders and Brain Research Group, Christchurch, New Zealand. aco24@student.canterbury.ac.nz", "title" : "Long term psychosocial outcomes after mild head injury in early childhood", "type" : "article-journal", "volume" : "73" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.009", "ISSN" : "1558-1381", "PMID" : "22050943", "abstract" : "Each year in the United States, approximately 1.7 million people are diagnosed with a traumatic brain injury (TBI), about 75% of which are classified as mild TBIs or concussions. Although symptoms typically resolve in a matter of weeks, both children and adults may suffer from postconcussion syndrome for months or longer. A progressive tauopathy, chronic traumatic encephalopathy, is believed to stem from repeated brain trauma. Alzheimer-like dementia, Parkinsonism, and motor neuron disease are also associated with repetitive brain trauma. Effective diagnoses, treatments, and education plans are required to reduce the future burden and incidence of long-term effects of head injuries.", "author" : [ { "dropping-particle" : "", "family" : "Daneshvar", "given" : "Daniel H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Riley", "given" : "David O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nowinski", "given" : "Christopher J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McKee", "given" : "Ann C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stern", "given" : "Robert a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Physical medicine and rehabilitation clinics of North America", "id" : "ITEM-2", "issue" : "4", "issued" : { "date-parts" : [ [ "2011", "11" ] ] }, "page" : "683-700, ix", "title" : "Long-term consequences: effects on normal development profile after concussion.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Daneshvar et al., 2011; McKinlay, Dalrymple-Alford, Horwood, & Fergusson, 2002)", "plainTextFormattedCitation" : "(Daneshvar et al., 2011; McKinlay, Dalrymple-Alford, Horwood, & Fergusson, 2002)", "previouslyFormattedCitation" : "(Daneshvar et al., 2011; McKinlay, Dalrymple-Alford, Horwood, & Fergusson, 2002)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Daneshvar et al., 2011; McKinlay, Dalrymple-Alford, Horwood, & Fergusson, 2002) and 4) post-concussive syndrome or protracted symptoms of at least 3 months ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.009", "ISSN" : "1558-1381", "PMID" : "22050943", "abstract" : "Each year in the United States, approximately 1.7 million people are diagnosed with a traumatic brain injury (TBI), about 75% of which are classified as mild TBIs or concussions. Although symptoms typically resolve in a matter of weeks, both children and adults may suffer from postconcussion syndrome for months or longer. A progressive tauopathy, chronic traumatic encephalopathy, is believed to stem from repeated brain trauma. Alzheimer-like dementia, Parkinsonism, and motor neuron disease are also associated with repetitive brain trauma. Effective diagnoses, treatments, and education plans are required to reduce the future burden and incidence of long-term effects of head injuries.", "author" : [ { "dropping-particle" : "", "family" : "Daneshvar", "given" : "Daniel H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Riley", "given" : "David O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nowinski", "given" : "Christopher J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McKee", "given" : "Ann C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stern", "given" : "Robert a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Physical medicine and rehabilitation clinics of North America", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2011", "11" ] ] }, "page" : "683-700, ix", "title" : "Long-term consequences: effects on normal development profile after concussion.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Daneshvar et al., 2011)", "plainTextFormattedCitation" : "(Daneshvar et al., 2011)", "previouslyFormattedCitation" : "(Daneshvar et al., 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Daneshvar et al., 2011). These outcomes often result in functional difficulties that include decreased participation, school performance difficulties and decreased quality of life ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.3109/02699052.2013.848380", "ISSN" : "1362-301X", "PMID" : "24328806", "abstract" : "OBJECTIVE: Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI.\n\nMETHODS: The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL.\n\nRESULTS: The QoL of children with ABI was significantly poorer (p < 0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS.\n\nCONCLUSIONS: QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "Carol a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hanna", "given" : "Steven E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yousefi-Nooraie", "given" : "Reza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lin", "given" : "Chia-Yu a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mahoney", "given" : "William J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Law", "given" : "Mary C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCauley", "given" : "Dayle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain injury : [BI]", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "114-21", "title" : "Quality-of-life after brain injury in childhood: time, not severity, is the significant factor.", "type" : "article-journal", "volume" : "28" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Parsons", "given" : "JT", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bay", "given" : "RC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Valovich-McLeod", "given" : "TC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Br J Sports Med", "id" : "ITEM-2", "issue" : "5", "issued" : { "date-parts" : [ [ "2013" ] ] }, "title" : "School absence, academic accommodation and health-related quality of life in adolescents with sport-related concussion", "type" : "article-journal", "volume" : "47" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Carol a DeMatteo et al., 2014; Parsons, Bay, & Valovich-McLeod, 2013)", "manualFormatting" : "(DeMatteo et al., 2014; Parsons, Bay, & Valovich-McLeod, 2013)", "plainTextFormattedCitation" : "(Carol a DeMatteo et al., 2014; Parsons, Bay, & Valovich-McLeod, 2013)", "previouslyFormattedCitation" : "(Carol a DeMatteo et al., 2014; Parsons, Bay, & Valovich-McLeod, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(DeMatteo et al., 2014; Parsons, Bay, & Valovich-McLeod, 2013).Post-concussive syndrome. A discussion of Post-Concussive Syndrome (PCS) as one of the possible negative outcomes from concussion is central to understanding the dilemma of disentangling the prolonged symptoms that occur post-concussion from clinical depression: this is the focus of much debate in the literature ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/HTR.0b013e3181e4622a", "ISSN" : "1550-509X", "PMID" : "20631632", "abstract" : "OBJECTIVE: To examine the influence of depression on postconcussion symptom reporting in patients following mild traumatic brain injury (MTBI).\n\nPARTICIPANTS: Sixty patients referred to a specialty clinic following MTBI, 58 outpatients with Structured Clinical Interview for DSM-diagnosed depression, and 72 healthy community control participants.\n\nPROCEDURE: Participants with MTBI were divided into 2 subgroups on the basis of self-reported symptoms of depression (23 MTBI-depressed, 37 MTBI-not depressed). All participants completed a postconcussion symptom questionnaire.\n\nMAIN OUTCOME MEASURE: British Columbia Post-concussion Symptom Inventory.\n\nRESULTS: There were significant differences in total reported postconcussion symptoms among all 4 groups (all P < .002; Cohen's d = 0.68-3.24, large to very large effect sizes; MTBI-depressed > depressed outpatients > MTBI-no depression > healthy controls). There were significant differences in the number of symptoms endorsed (P < .05), with the highest number of symptoms endorsed by the MTBI-depressed group, followed by depressed outpatients, MTBI-no depression, and healthy controls.\n\nCONCLUSIONS: Patients who experience MTBIs and who have a postinjury recovery course complicated by significant depression report more postconcussion symptoms, and more severe symptoms, than (a) outpatients with depression, and (b) patients with MTBIs who do not have significant symptoms of depression.", "author" : [ { "dropping-particle" : "", "family" : "Lange", "given" : "Rael T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Alice", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of head trauma rehabilitation", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "127-37", "title" : "Depression strongly influences postconcussion symptom reporting following mild traumatic brain injury.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "PMID" : "16537266", "abstract" : "PRIMARY OBJECTIVE: The purpose of this study was to illustrate the serial use of computerized neuropsychological screening with ImPACT to monitor recovery in a clinical case series of injured athletes. METHODS AND PROCEDURES: Amateur athletes with concussions (n= 30, average age= 16.1, SD= 2.1 years) underwent pre-season testing and three post-concussion evaluations within the following intervals: 1-2 days, 3-7 days (M= 5.2 days) and 1-3 weeks (M= 10.3 days). The study selection criteria increased the probability of including athletes with slow recovery. RESULTS: Repeated measures ANOVAs revealed significant main effects for all five composite scores (verbal memory, visual memory, reaction time, processing speed and total symptoms). In group analyses, performance decrements and symptoms relating to concussion appeared to largely resolve by 5 days post-injury and fully resolve by 10 days. Athletes' scores were examined individually using the reliable change methodology. At 1 day post-injury, 90% had two or more reliable declines in performance or increases in symptom reporting. At 10 days, 37% were still showing two or more reliable changes from pre-season levels. CONCLUSIONS: This study illustrates the importance of analysing individual athletes' test data because group analyses can obscure slow recovery in a substantial minority of athletes", "author" : [ { "dropping-particle" : "", "family" : "Iverson", "given" : "G L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brooks", "given" : "B L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "M W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lovell", "given" : "M R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain Injury", "id" : "ITEM-2", "issue" : "0269-9052 (Print)", "issued" : { "date-parts" : [ [ "2006" ] ] }, "language" : "eng PT - Journal Article SB - IM", "note" : "DA - 20060315", "page" : "245-252", "publisher-place" : "University of British Columbia & Riverview Hospital, Vancouver, BC, Canada. giverson@interchange.ubc.ca", "title" : "Tracking neuropsychological recovery following concussion in sport", "type" : "article-journal", "volume" : "20" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1177/1941738111433673", "ISSN" : "1941-0921", "PMID" : "23016082", "abstract" : "Prolonged symptoms after concussion are called post-concussion syndrome (PCS), which is a controversial disorder with a wide differential diagnosis.", "author" : [ { "dropping-particle" : "", "family" : "Leddy", "given" : "John J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Harkeet", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sodhi", "given" : "Vikram", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baker", "given" : "John G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Willer", "given" : "Barry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Sports health", "id" : "ITEM-3", "issue" : "2", "issued" : { "date-parts" : [ [ "2012", "3" ] ] }, "page" : "147-54", "title" : "Rehabilitation of Concussion and Post-concussion Syndrome.", "type" : "article-journal", "volume" : "4" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Iverson, Brooks, Collins, & Lovell, 2006; Lange et al., 2011; Leddy, Sandhu, Sodhi, Baker, & Willer, 2012)", "plainTextFormattedCitation" : "(Iverson, Brooks, Collins, & Lovell, 2006; Lange et al., 2011; Leddy, Sandhu, Sodhi, Baker, & Willer, 2012)", "previouslyFormattedCitation" : "(Iverson, Brooks, Collins, & Lovell, 2006; Lange et al., 2011; Leddy, Sandhu, Sodhi, Baker, & Willer, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Iverson, Brooks, Collins, & Lovell, 2006; Lange et al., 2011; Leddy, Sandhu, Sodhi, Baker, & Willer, 2012). Persistent negative symptoms of concussion are, in fact, diagnostic criteria for PCS that were described in both the International Classification of Diseases-10 (ICD-10; ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Organization", "given" : "World Health", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issue" : "1-3", "issued" : { "date-parts" : [ [ "1992" ] ] }, "publisher" : "World Health Organization", "publisher-place" : "Geneva, Switzerland", "title" : "International statistical classification of diseases and related health problems: Tenth Revision", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Organization, 1992)", "manualFormatting" : "World Health Organization, 1992)", "plainTextFormattedCitation" : "(Organization, 1992)", "previouslyFormattedCitation" : "(Organization, 1992)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }World Health Organization, 1992) and Diagnostic and Statistical Manual-IV-Revised (DSM IV-R, ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Association", "given" : "American Psychiatric", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "4th", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2000" ] ] }, "publisher-place" : "Washington, DC", "title" : "Diagnostic and statistical manual of mental disorders", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Association, 2000)", "manualFormatting" : "(American Psychiatric Association, 2000)", "plainTextFormattedCitation" : "(Association, 2000)", "previouslyFormattedCitation" : "(Association, 2000)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(American Psychiatric Association, 2000). These definitions of PCS involve the presence of persistent cognitive, somatic and behavioural symptoms leading to deficits in functioning ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.009", "ISSN" : "1558-1381", "PMID" : "22050943", "abstract" : "Each year in the United States, approximately 1.7 million people are diagnosed with a traumatic brain injury (TBI), about 75% of which are classified as mild TBIs or concussions. Although symptoms typically resolve in a matter of weeks, both children and adults may suffer from postconcussion syndrome for months or longer. A progressive tauopathy, chronic traumatic encephalopathy, is believed to stem from repeated brain trauma. Alzheimer-like dementia, Parkinsonism, and motor neuron disease are also associated with repetitive brain trauma. Effective diagnoses, treatments, and education plans are required to reduce the future burden and incidence of long-term effects of head injuries.", "author" : [ { "dropping-particle" : "", "family" : "Daneshvar", "given" : "Daniel H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Riley", "given" : "David O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nowinski", "given" : "Christopher J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McKee", "given" : "Ann C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stern", "given" : "Robert a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Physical medicine and rehabilitation clinics of North America", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2011", "11" ] ] }, "page" : "683-700, ix", "title" : "Long-term consequences: effects on normal development profile after concussion.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Daneshvar et al., 2011)", "plainTextFormattedCitation" : "(Daneshvar et al., 2011)", "previouslyFormattedCitation" : "(Daneshvar et al., 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Daneshvar et al., 2011). The more recent DSM-5 has subsumed PCS under the heading Neurocognitive Disorders and it is now called “minor neurocognitive disorder due to traumatic brain injury” ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Association", "given" : "American Psychiatric", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "5th", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "publisher-place" : "Washington, DC", "title" : "Diagnostic and statistical manual of mental disorders", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Association, 2013)", "manualFormatting" : "(American Psychiatric Association, 2013)", "plainTextFormattedCitation" : "(Association, 2013)", "previouslyFormattedCitation" : "(Association, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(American Psychiatric Association, 2013). A decline in abilities in at least one of the following cognitive processes are needed to meet diagnostic criteria: complex attention, executive function, learning, memory, language or social difficulties confirmed by a family member, clinician or from a deterioration in neurocognitive testing ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Association", "given" : "American Psychiatric", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "5th", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "publisher-place" : "Washington, DC", "title" : "Diagnostic and statistical manual of mental disorders", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Association, 2013)", "manualFormatting" : "(American Psychiatric Association, 2013)", "plainTextFormattedCitation" : "(Association, 2013)", "previouslyFormattedCitation" : "(Association, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(American Psychiatric Association, 2013). Symptoms of the brain injury must persist past the acute post-injury phase, usually defined as a period of three months. The ensuing cognitive deficits do not necessarily have to interfere with everyday independence to qualify for this diagnosis. This diagnostic category, with its tighter definition of persistent cognitive symptoms, may make it easier to discern the difference between depression and minor cognitive disorder due to traumatic brain injury. However, because most of the literature reviewed here uses this terminology, minor neurocognitive disorder due to brain injury will continue to be referred to as PCS in this thesis.Current PCS research. Research directed at predicting PCS or determining the underlying cause has shown that both premorbid and injury factors have a role in determining who experiences protracted symptoms. ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1037/a0027888", "ISSN" : "1931-1559", "PMID" : "22468823", "abstract" : "There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury (mTBI). This study aimed to prospectively examine the influence of preinjury factors, injury-related factors, and postinjury factors on outcome following mTBI.", "author" : [ { "dropping-particle" : "", "family" : "Ponsford", "given" : "Jennie", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cameron", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fitzgerald", "given" : "Mark", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grant", "given" : "Michele", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mikocka-Walus", "given" : "Antonina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sch\u00f6nberger", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Neuropsychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2012", "5" ] ] }, "page" : "304-13", "title" : "Predictors of postconcussive symptoms 3 months after mild traumatic brain injury.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ponsford et al., 2012)", "manualFormatting" : "Ponsford et al. (2012)", "plainTextFormattedCitation" : "(Ponsford et al., 2012)", "previouslyFormattedCitation" : "(Ponsford et al., 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }Ponsford et al. (2012) examined predictors in adults with concussion in a prospective cohort with trauma controls and found that premorbid physical and psychiatric problems as well as concurrent anxiety had more influence on persistent symptoms than the injury itself. Studies conducted with children found that 29.3% of those presenting to emergency rooms with concussion had PCS at three months. Predictors of PCS, although limited by the available variables collected on presentation to ED, included headache and hospital admission ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1001/jamapediatrics.2013.434", "ISSN" : "2168-6211", "PMID" : "23247384", "abstract" : "To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Babcock", "given" : "Lynn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Byczkowski", "given" : "Terri", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wade", "given" : "Shari L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ho", "given" : "Mona", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mookerjee", "given" : "Sohug", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bazarian", "given" : "Jeffrey J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "JAMA pediatrics", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "2" ] ] }, "page" : "156-61", "title" : "Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department.", "type" : "article-journal", "volume" : "167" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Babcock et al., 2013)", "plainTextFormattedCitation" : "(Babcock et al., 2013)", "previouslyFormattedCitation" : "(Babcock et al., 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Babcock et al., 2013). Other predictors in children that have been documented in the literature include initial symptom presentations of dizziness, headache or amnesia ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1001/jamapediatrics.2013.434", "ISSN" : "2168-6211", "PMID" : "23247384", "abstract" : "To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Babcock", "given" : "Lynn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Byczkowski", "given" : "Terri", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wade", "given" : "Shari L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ho", "given" : "Mona", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mookerjee", "given" : "Sohug", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bazarian", "given" : "Jeffrey J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "JAMA pediatrics", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "2" ] ] }, "page" : "156-61", "title" : "Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department.", "type" : "article-journal", "volume" : "167" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1177/0363546511410655", "ISSN" : "1552-3365", "PMID" : "21712482", "abstract" : "There has been increasing attention and understanding of sport-related concussions. Recent studies show that neurocognitive testing and symptom clusters may predict protracted recovery in concussed athletes. On-field signs and symptoms have not been examined empirically as possible predictors of protracted recovery.", "author" : [ { "dropping-particle" : "", "family" : "Lau", "given" : "Brian C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kontos", "given" : "Anthony P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mucha", "given" : "Anne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lovell", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The American journal of sports medicine", "id" : "ITEM-2", "issue" : "11", "issued" : { "date-parts" : [ [ "2011", "11" ] ] }, "page" : "2311-8", "title" : "Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players?", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Babcock et al., 2013; B. C. Lau, Kontos, Collins, Mucha, & Lovell, 2011)", "manualFormatting" : "(Babcock et al., 2013; Lau, Kontos, Collins, Mucha, & Lovell, 2011)", "plainTextFormattedCitation" : "(Babcock et al., 2013; B. C. Lau, Kontos, Collins, Mucha, & Lovell, 2011)", "previouslyFormattedCitation" : "(Babcock et al., 2013; B. C. Lau, Kontos, Collins, Mucha, & Lovell, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Babcock et al., 2013; Lau, Kontos, Collins, Mucha, & Lovell, 2011) as well as having a history of more than one concussion, having learning difficulties and the presence of family stressors or psychological problems ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.007", "ISSN" : "1558-1381", "PMID" : "22050942", "abstract" : "Most athletes who experience a sports-related concussion recover from the acute effects within a few weeks. However, some children and adolescents with concussion experience symptoms for many weeks, or even months after the injury. Subacute and chronic symptoms related to concussion are particularly concerning in children, because cognitive deficits, headache or neck pain, sleep dysfunction, and emotional dysregulation can affect school performance and social function at a critical period of development and maturation. 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This study aimed to prospectively examine the influence of preinjury factors, injury-related factors, and postinjury factors on outcome following mTBI.", "author" : [ { "dropping-particle" : "", "family" : "Ponsford", "given" : "Jennie", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cameron", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fitzgerald", "given" : "Mark", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grant", "given" : "Michele", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mikocka-Walus", "given" : "Antonina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sch\u00f6nberger", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Neuropsychology", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2012", "5" ] ] }, "page" : "304-13", "title" : "Predictors of postconcussive symptoms 3 months after mild traumatic brain injury.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Heidi K Blume, Lucas, & Bell, 2011; Ponsford et al., 2012)", "plainTextFormattedCitation" : "(Heidi K Blume, Lucas, & Bell, 2011; Ponsford et al., 2012)", "previouslyFormattedCitation" : "(Heidi K Blume, Lucas, & Bell, 2011; Ponsford et al., 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Heidi K Blume, Lucas, & Bell, 2011; Ponsford et al., 2012). The consequences of PCS have been reported as functional deficits; subtle cognitive differences that require educational supports 12 months after injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Yeates", "given" : "K O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kaizar", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rusin", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bangert", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dietrich", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nuss", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wright", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Arch Pediatr Adolesc Med", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "E1-E8", "title" : "Reliable Change in Postconcussive Symptmos and Its Functional Consequences Among Children With Mild Traumatic Brain Injury", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Yeates et al., 2012)", "plainTextFormattedCitation" : "(Yeates et al., 2012)", "previouslyFormattedCitation" : "(Yeates et al., 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Yeates et al., 2012), behavioural impairments ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "McKinlay", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grace", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Horwood", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fergusson", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McFarlane", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Franzcr", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Head Trauma and Rehabilitation", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "221-227", "title" : "Adolescent Psychiatric Symptoms Following Preschool Childhood Mild Traumatic Brain", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(McKinlay et al., 2009)", "plainTextFormattedCitation" : "(McKinlay et al., 2009)", "previouslyFormattedCitation" : "(McKinlay et al., 2009)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(McKinlay et al., 2009); and reduced quality of life (QOL; ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Duffy A", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012", "9", "26" ] ] }, "publisher-place" : "Ottawa", "title" : "Concussions ruin quality of life for young athletes", "type" : "article-newspaper" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.3109/02699052.2013.848380", "ISSN" : "1362-301X", "PMID" : "24328806", "abstract" : "OBJECTIVE: Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI.\n\nMETHODS: The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL.\n\nRESULTS: The QoL of children with ABI was significantly poorer (p < 0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS.\n\nCONCLUSIONS: QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "Carol a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hanna", "given" : "Steven E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yousefi-Nooraie", "given" : "Reza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lin", "given" : "Chia-Yu a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mahoney", "given" : "William J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Law", "given" : "Mary C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCauley", "given" : "Dayle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain injury : [BI]", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "114-21", "title" : "Quality-of-life after brain injury in childhood: time, not severity, is the significant factor.", "type" : "article-journal", "volume" : "28" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Carol a DeMatteo et al., 2014; Duffy A, 2012)", "manualFormatting" : "DeMatteo et al., 2014)", "plainTextFormattedCitation" : "(Carol a DeMatteo et al., 2014; Duffy A, 2012)", "previouslyFormattedCitation" : "(Carol a DeMatteo et al., 2014; Duffy A, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }DeMatteo et al., 2014). In a pilot study of 25 adolescents who had symptoms beyond three months, patients reported their QOL to be at the same level as peers who were undergoing chemotherapy. Investigators found that symptom reporting quadrupled in adolescents with a history of more than one concussion ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Duffy A", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012", "9", "26" ] ] }, "publisher-place" : "Ottawa", "title" : "Concussions ruin quality of life for young athletes", "type" : "article-newspaper" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Duffy A, 2012)", "manualFormatting" : "(Duffy, 2012)", "plainTextFormattedCitation" : "(Duffy A, 2012)", "previouslyFormattedCitation" : "(Duffy A, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Duffy, 2012). Increased symptom reporting has also been associated with the development of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1176/appi.neuropsych.22.1.100.Predictors", "author" : [ { "dropping-particle" : "", "family" : "Rao", "given" : "Vani", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bertrand", "given" : "Melaine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rosenberg", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Makley", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schretlen", "given" : "David J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brandt", "given" : "Jason", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mielke", "given" : "Michelle M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J. Neuropsychiatry Clin Neurosci.", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "100-104", "title" : "Predictors of new-onset depression after mild traumatic brain injury", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Rao et al., 2010)", "plainTextFormattedCitation" : "(Rao et al., 2010)", "previouslyFormattedCitation" : "(Rao et al., 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Rao et al., 2010). PCS significantly impacts children’s relationships, school performance, sport, leisure and social activities and can be a heavy burden on both the child and family ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2014-0158", "author" : [ { "dropping-particle" : "", "family" : "Eisenberg", "given" : "Matthew A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meehan", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mannix", "given" : "Rebekah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "title" : "Duration and Course of Post-Concussive Symptoms", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1093/jpepsy/jsm133", "ISBN" : "1465-735X (Electronic)\\r0146-8693 (Linking)", "ISSN" : "01468693", "PMID" : "18227110", "abstract" : "OBJECTIVE: To examine the relationship of mild traumatic brain injuries (TBI) and post-concussive symptoms (PCS) to post injury family burden and parental distress, using data from a prospective, longitudinal study. METHODS: Participants included 71 children with mild TBI with loss of consciousness (LOC), 110 with mild TBI without LOC, and 97 controls with orthopedic injuries not involving the head (OI), and their parents. Shortly after injury, parents and children completed a PCS interview and questionnaire, and parents rated premorbid family functioning. Parents also rated family burden and parental distress shortly after injury and at 3 months post injury. RESULTS: Mild TBI with LOC was associated with greater family burden at 3 months than OI, independent of socioeconomic status and premorbid family functioning. Higher PCS shortly after injury was related to higher ratings of family burden and distress at 3 months. CONCLUSIONS: Mild TBI are associated with family burden and distress more than mild injuries not involving the head, although PCS may influence post injury family burden and distress more than the injury per se. Clinical implications of the current findings are noted in the Discussion section.", "author" : [ { "dropping-particle" : "", "family" : "Ganesalingam", "given" : "Kalaichelvi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yeates", "given" : "Keith Owen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ginn", "given" : "Melissa Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "H. 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Depression in ChildrenDepression is a highly complex diagnosis or label of an affective state that overwhelms the individual with helplessness and hopeless emotions ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Robertson", "given" : "Alan Charles", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issue" : "November", "issued" : { "date-parts" : [ [ "2006" ] ] }, "publisher" : "University of South Africa", "title" : "Spirituality and depression: A qualitative approach", "type" : "thesis" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Robertson, 2006)", "plainTextFormattedCitation" : "(Robertson, 2006)", "previouslyFormattedCitation" : "(Robertson, 2006)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Robertson, 2006). It results in a decline in function affecting occupational or school performance, relationships and can lead to suicidal behavior, substance abuse, physical illness and exposure to negative life events ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Children's Mental Health", "given" : "Ontario", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "number-of-pages" : "1 - 27", "title" : "Evidence based practices for depression in children and adolescents", "type" : "report" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Children\u2019s Mental Health, 2001)", "plainTextFormattedCitation" : "(Children\u2019s Mental Health, 2001)", "previouslyFormattedCitation" : "(Children\u2019s Mental Health, 2001)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Children’s Mental Health, 2001). Unipolar major depressive disorder across age groups is ranked as the fourth leading reason for disease burden and is the world’s leading cause of disability ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Patten", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "chapter-number" : "6", "container-title" : "Mental Disorder in Canada: an epidemiological perspective", "editor" : [ { "dropping-particle" : "", "family" : "Cairney", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Streiner", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "107-125", "publisher" : "University Toronto Press", "publisher-place" : "Toronto", "title" : "Affective disorders in Canada", "type" : "chapter" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Patten, 2010)", "plainTextFormattedCitation" : "(Patten, 2010)", "previouslyFormattedCitation" : "(Patten, 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Patten, 2010).EpidemiologyPrevalence of depressive disorders is difficult to determine as there is confusion about definitions. Clinical depression or major depressive disorder in the general population is reported to be 2 – 4% in childhood, 4 – 8% in adolescence (approaching adult rates in late adolescence) and 17% in adults ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kessler", "given" : "RC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Avenevoli", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Merikangas", "given" : "KR", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Biological Psychiatry", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "1002-1014", "title" : "Mood disorders in children and adolescents: an epidemiologic perspective", "type" : "article-journal", "volume" : "49" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "editor" : [ { "dropping-particle" : "", "family" : "Ahmoi", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Petermann", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "1999" ] ] }, "publisher" : "Library of Congress", "publisher-place" : "New Jersey, NJ", "title" : "Depressive Disorders in Children and Adolescents: Epidemiology, Risk Facors and Treatment", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ahmoi & Petermann, 1999; Kessler, Avenevoli, & Merikangas, 2001)", "plainTextFormattedCitation" : "(Ahmoi & Petermann, 1999; Kessler, Avenevoli, & Merikangas, 2001)", "previouslyFormattedCitation" : "(Ahmoi & Petermann, 1999; Kessler, Avenevoli, & Merikangas, 2001)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Ahmoi & Petermann, 1999; Kessler, Avenevoli, & Merikangas, 2001). Many studies report on depressive symptoms rather than diagnosis (Horowitz & Garber, 2006) and report that 10 -17% of children have a moderate to severe level of depressive symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1037/0021-843X.101.3.405", "ISBN" : "0021-843X", "ISSN" : "0021-843X", "PMID" : "1500598", "abstract" : "A 5-year longitudinal study investigated the interrelationships among children's experiences of depressive symptoms, negative life events, explanatory style, and helplessness behaviors in social and achievement situations. The results revealed that early in childhood, negative events, but not explanatory style, predicted depressive symptoms; later in childhood, a pessimistic explanatory style emerged as a significant predictor of depressive symptoms, alone and in conjunction with negative events. When children suffered periods of depression, their explanatory styles not only deteriorated but remained pessimistic even after their depression subsided, presumably putting them at risk for future episodes of depression. Some children seem repeatedly prone to depressive symptoms over periods of at least 2 years. Depressed children consistently showed helpless behaviors in social and achievement settings.", "author" : [ { "dropping-particle" : "", "family" : "Nolen-Hoeksema", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Girgus", "given" : "J S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seligman", "given" : "M E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of abnormal psychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1992" ] ] }, "page" : "405-422", "title" : "Predictors and consequences of childhood depressive symptoms: a 5-year longitudinal study.", "type" : "article-journal", "volume" : "101" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISBN" : "978-1-59385-582-6", "author" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "editor" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2008" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New York", "title" : "Handbook of Depression in Children and Adolescents", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Abela & Hankin, 2008; Nolen-Hoeksema, Girgus, & Seligman, 1992)", "plainTextFormattedCitation" : "(Abela & Hankin, 2008; Nolen-Hoeksema, Girgus, & Seligman, 1992)", "previouslyFormattedCitation" : "(Abela & Hankin, 2008; Nolen-Hoeksema, Girgus, & Seligman, 1992)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Abela & Hankin, 2008; Nolen-Hoeksema, Girgus, & Seligman, 1992). Adolescents who score high on depressive measures, but do not meet criteria for a clinical depression demonstrate equivalent psychosocial dysfunction as those who were diagnosed with depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1037//0021-843X.111.4.578", "ISBN" : "0021-843X", "ISSN" : "0021-843X", "PMID" : "12428771", "abstract" : "A within-scale meta-analysis was performed on 310 samples of children (ages 8-16; N = 61,424) responding to the Children's Depression Inventory (CDI). Girls' depression scores stayed steady from ages 8 to 11 and then increased between ages 12 and 16. Boys' CDI scores were stable from ages 8 to 16 except for a high CDI score at age 12. Girls' scores were slightly lower than boys' during childhood, but girls scored higher beginning at age 13. There were no socioeconomic status effects and no differences between White and Black samples. However, Hispanic samples scored significantly higher on the CDI. Analyses for birth cohort showed a slight decrease in boys' CDI scores over time and no change for girls. Longitudinal studies demonstrated a marked testing effect.", "author" : [ { "dropping-particle" : "", "family" : "Twenge", "given" : "Jean M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nolen-Hoeksema", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of abnormal psychology", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "578-588", "title" : "Age, gender, race, socioeconomic status, and birth cohort differences on the children's depression inventory: a meta-analysis.", "type" : "article-journal", "volume" : "111" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)", "plainTextFormattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)", "previouslyFormattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Twenge & Nolen-Hoeksema, 2002). In community epidemiological surveys 20% to 50% of adolescents self-report significant sub-threshold levels of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kessler", "given" : "RC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Avenevoli", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Merikangas", "given" : "KR", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Biological Psychiatry", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "1002-1014", "title" : "Mood disorders in children and adolescents: an epidemiologic perspective", "type" : "article-journal", "volume" : "49" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Kessler et al., 2001)", "plainTextFormattedCitation" : "(Kessler et al., 2001)", "previouslyFormattedCitation" : "(Kessler et al., 2001)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Kessler et al., 2001). Sub-threshold depressive symptoms put adolescents at elevated risk for later major depression and suicidal behaviours ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1001/archpsyc.62.1.66", "ISBN" : "1538-3636\\r0003-990X", "ISSN" : "0003-990X", "PMID" : "15630074", "abstract" : "BACKGROUND: There is increasing interest in the extent to which individuals with subthreshold depression face increased risks of subsequent major depression and other disorders. OBJECTIVE: To examine linkages between the extent of depressive symptoms (asymptomatic, subthreshold, major depression) at ages 17 to 18 years and mental health outcomes up to age 25 years in a New Zealand birth cohort. DESIGN: Data were gathered during the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of 1265 New Zealand children (635 males, 630 females). SETTING: General community sample. PARTICIPANTS: The analysis was based on 1006 participants who represented 80% of the original cohort. MAIN OUTCOME MEASURES: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptom criteria for major depression and anxiety disorder, treatment-seeking, suicidal ideation, and suicide attempt. RESULTS: There were significant associations (P<.01) between the extent of depression at ages 17 to 18 years and rates of subsequent depressive symptoms, major depression, treatment for depression, anxiety disorder, treatment for anxiety disorder, suicidal ideation, and suicide attempts. After adjustment for covariate factors, the extent of depression at ages 17 to 18 years remained associated with later depression and suicidal tendencies. Planned comparisons showed that sample members with subthreshold depression had a similar prognosis to those meeting criteria for major depression. CONCLUSIONS: Findings suggest that sample members with subthreshold depression are a group with elevated risks of later depression and suicidal behaviors. Current diagnostic procedures, which classify people with subthreshold depression into complex discrete groups, might obscure the fact that depressive symptoms are dimensional and range from none to severe.", "author" : [ { "dropping-particle" : "", "family" : "Fergusson", "given" : "David M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Horwood", "given" : "L John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ridder", "given" : "Elizabeth M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Beautrais", "given" : "Annette L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of general psychiatry", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2005" ] ] }, "page" : "66-72", "title" : "Subthreshold depression in adolescence and mental health outcomes in adulthood.", "type" : "article-journal", "volume" : "62" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Fergusson, Horwood, Ridder, & Beautrais, 2005)", "plainTextFormattedCitation" : "(Fergusson, Horwood, Ridder, & Beautrais, 2005)", "previouslyFormattedCitation" : "(Fergusson, Horwood, Ridder, & Beautrais, 2005)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Fergusson, Horwood, Ridder, & Beautrais, 2005). One study has shown sub-threshold depressive disorder escalates to full syndrome depressive disorder in 67% of cases within the following ten years ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Klein", "given" : "Daniel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shankman", "given" : "Stewart", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lewinsohn", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seeley", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J. Am. Acad. child J. Am. Acad. Child Adolesc. Psychiatry", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "703-710", "title" : "Sub threshold depressive disorder in adolescents: Predictors of escalation to full-syndrome depressive disorders", "type" : "article-journal", "volume" : "48" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Klein, Shankman, Lewinsohn, & Seeley, 2009)", "plainTextFormattedCitation" : "(Klein, Shankman, Lewinsohn, & Seeley, 2009)", "previouslyFormattedCitation" : "(Klein, Shankman, Lewinsohn, & Seeley, 2009)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Klein, Shankman, Lewinsohn, & Seeley, 2009). At about 12 to 13 years of age, girls begin to report more depression than boys and this sex difference becomes a 2:1 ratio in later adolescence and adulthood ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "978-1-59385-582-6", "author" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "editor" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New York", "title" : "Handbook of Depression in Children and Adolescents", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Abela & Hankin, 2008)", "plainTextFormattedCitation" : "(Abela & Hankin, 2008)", "previouslyFormattedCitation" : "(Abela & Hankin, 2008)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Abela & Hankin, 2008). Depression is more common among clinical populations ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1080/17518420701536095", "ISSN" : "1751-8423", "author" : [ { "dropping-particle" : "", "family" : "Carr", "given" : "Alan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental Neurorehabilitation", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "page" : "3-15", "title" : "Depression in young people: Description, assessment and evidence-based treatment", "type" : "article-journal", "volume" : "11" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISBN" : "0719051096", "author" : [ { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "First", "editor" : [ { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2005" ] ] }, "publisher" : "Sage Pub. Inc.", "publisher-place" : "Thousand Oaks, California", "title" : "Development of Psychopathology: A Vulnerability Stress Perspective", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Carr, 2008; B. Hankin & Abela, 2005)", "manualFormatting" : "(Carr, 2008; Hankin & Abela, 2005)", "plainTextFormattedCitation" : "(Carr, 2008; B. Hankin & Abela, 2005)", "previouslyFormattedCitation" : "(Carr, 2008; B. Hankin & Abela, 2005)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Carr, 2008; Hankin & Abela, 2005). While the literature has reported rising rates of depression in the pediatric population ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "978-1-59385-582-6", "author" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "editor" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New York", "title" : "Handbook of Depression in Children and Adolescents", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Abela & Hankin, 2008)", "plainTextFormattedCitation" : "(Abela & Hankin, 2008)", "previouslyFormattedCitation" : "(Abela & Hankin, 2008)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Abela & Hankin, 2008), a recent systematic review investigating whether adolescent mental health problems are actually increasing identified that the rates of internalizing and externalizing problems remain stable other than for recent cohorts of adolescent girls who have significantly more internalizing symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/0004867414533834", "ISSN" : "1440-1614", "PMID" : "24829198", "abstract" : "OBJECTIVE: Up to one in five children experience mental health problems. Social and cultural factors may influence emergence of mental health problems. The 21st century has led to changes in many of these factors, but it is unclear whether rates of internalizing and externalizing problems have also changed in recent cohorts of young people.\\n\\nMETHODS: A comprehensive literature search was undertaken to locate cohort or population studies that examined changes in mental health of children over time, where participants were aged 18 years and under, and the time frame for change was at least 10 years, with data for at least one time point in the 21st century being statistically compared to at least one time point in the 20th century. Studies were reviewed for quality and outcome.\\n\\nRESULTS: Nineteen studies met criteria for review. These included studies of toddlers, children, and adolescents. Seventeen studies examined internalizing problems, and 11 studies examined externalizing problems. For both children and toddlers, recent cohorts did not exhibit worsening of mental health symptoms. In adolescents, the burden of externalizing problems appear to be stable. However, the majority of studies report an increase in internalizing problems in adolescent girls. The findings for internalizing problems in boys were mixed.\\n\\nCONCLUSIONS: These findings suggest that recent cohorts of adolescent girls are experiencing increases in internalizing symptoms compared to previous cohorts. Approaches for prevention and early intervention should be explored.", "author" : [ { "dropping-particle" : "", "family" : "Bor", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dean", "given" : "Angela J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Najman", "given" : "Jacob", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hayatbakhsh", "given" : "Reza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Australian and New Zealand journal of psychiatry", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "606-616", "title" : "Are child and adolescent mental health problems increasing in the 21st century? A systematic review.", "type" : "article-journal", "volume" : "48" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Bor, Dean, Najman, & Hayatbakhsh, 2014)", "plainTextFormattedCitation" : "(Bor, Dean, Najman, & Hayatbakhsh, 2014)", "previouslyFormattedCitation" : "(Bor, Dean, Najman, & Hayatbakhsh, 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Bor, Dean, Najman, & Hayatbakhsh, 2014). These disturbing trends are important as clinical depression or sub-threshold depression after concussion may set youth up for further episodes of depression throughout their lifespan ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kessler", "given" : "RC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Avenevoli", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Merikangas", "given" : "KR", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Biological Psychiatry", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "page" : "1002-1014", "title" : "Mood disorders in children and adolescents: an epidemiologic perspective", "type" : "article-journal", "volume" : "49" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1186/1471-244X-12-181", "ISBN" : "1471-244X", "ISSN" : "1471-244X", "PMID" : "23110575", "abstract" : "BACKGROUND: Subthreshold depressive disorders (minor and subthrehold depression) have been defined in a wide range of forms, varying on the number of symptoms and duration required. Disability associated with these conditions has also been reported. Our aim was to review the different definitions and to determine factors associated with these conditions in order to clarify the nosological implications of these disorders.\\n\\nMETHODS: A Medline search was conducted of the published literature between January 2001 and September 2011. Bibliographies of the retrieved papers were also analysed.\\n\\nRESULTS: There is a wide heterogeneity in the definition and diagnostic criteria of minor and subthreshold depression. Minor depression was defined according to DSM-IV criteria. Regarding subthreshold depression, also called subclinical depression or subsyndromal symptomatic depression, between 2 and 5 depressive symptoms were required for the diagnosis, and a minimum duration of 2 weeks. Significant impairment associated with subthreshold depressive conditions, as well as comorbidity with other mental disorders, has been described.\\n\\nCONCLUSIONS: Depression as a disorder is better explained as a spectrum rather than as a collection of discrete categories. Minor and subthreshold depression are common conditions and patients falling below the diagnostic threshold experience significant difficulties in functioning and a negative impact on their quality of life. Current diagnostic systems need to reexamine the thresholds for depressive disorders and distinguish them from ordinary feelings of sadness.", "author" : [ { "dropping-particle" : "", "family" : "Rivas Rodr\u00edguez", "given" : "Mar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nuevo", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chatterji", "given" : "Somnath", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ayuso-Mateos", "given" : "Jos\u00e9 Luis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "BMC Psychiatry", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "181", "title" : "Definitions and factors associated with subthreshold depressive conditions: a systematic review", "type" : "article-journal", "volume" : "12" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Kessler et al., 2001; Rivas Rodr\u00edguez, Nuevo, Chatterji, & Ayuso-Mateos, 2012)", "plainTextFormattedCitation" : "(Kessler et al., 2001; Rivas Rodr\u00edguez, Nuevo, Chatterji, & Ayuso-Mateos, 2012)", "previouslyFormattedCitation" : "(Kessler et al., 2001; Rivas Rodr\u00edguez, Nuevo, Chatterji, & Ayuso-Mateos, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Kessler et al., 2001; Rivas Rodríguez, Nuevo, Chatterji, & Ayuso-Mateos, 2012).SymptomsDepression presents quite differently in children than in adults. Developmental issues make the expression of symptoms different with younger children while adolescents and older children may experience symptoms similar to adults ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Children's Mental Health", "given" : "Ontario", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "number-of-pages" : "1 - 27", "title" : "Evidence based practices for depression in children and adolescents", "type" : "report" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1080/17518420701536095", "ISSN" : "1751-8423", "author" : [ { "dropping-particle" : "", "family" : "Carr", "given" : "Alan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental Neurorehabilitation", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "page" : "3-15", "title" : "Depression in young people: Description, assessment and evidence-based treatment", "type" : "article-journal", "volume" : "11" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Carr, 2008; Children\u2019s Mental Health, 2001)", "plainTextFormattedCitation" : "(Carr, 2008; Children\u2019s Mental Health, 2001)", "previouslyFormattedCitation" : "(Carr, 2008; Children\u2019s Mental Health, 2001)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Carr, 2008; Children’s Mental Health, 2001). Younger children are more likely to show:Separation anxietyIrritability, accompanying tantrums or behavioural problemsLack of co-operationSomatic complaints (headache, stomach ache)Withdrawal from friends and familyApathy and disinterest, loss of interest in playUnlike adolescents and adults, younger children are less likely to make serious suicide attempts. In adolescence, depression is experienced more with the following symptoms:Sleep and appetite disturbancesWeight loss or gainSchool refusal or decline in academic performanceSuicidal thoughts feelings and attemptsCauses of DepressionDepression commonly develops subsequent to life stresses and chronic health conditions ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.yebeh.2005.10.012", "ISSN" : "1525-5050", "PMID" : "16356779", "abstract" : "Depression is one of the most prevalent of the psychiatric disorders and is common among individuals with epilepsy. Depression often begins in adolescence. The present review focuses on adolescent depression. In particular, this review first summarizes the definition, description, and classification of adolescent depression. Next, potential causes of adolescent depression are reviewed from a vulnerability-stress perspective. This part of the review focuses on the role of stressors and how stressors interact with genetic, biological, cognitive, personality, and interpersonal vulnerabilities to predict adolescent depression. Last, clinical aspects of adolescent depression are reviewed, including treatment and prevention of depression and the relation to epileptic disorders in adolescence. In sum, a substantial percentage of youth with epilepsy and seizures exhibit depression, and many are not diagnosed or treated in a timely manner. The present review shows that there are valid, empirically based assessments, treatments, and preventions for depression in adolescence that hold promise for reducing the significant burden associated with depression.", "author" : [ { "dropping-particle" : "", "family" : "Hankin", "given" : "Benjamin L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Epilepsy & behavior : E&B", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2006", "2" ] ] }, "page" : "102-14", "title" : "Adolescent depression: description, causes, and interventions.", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Dejean", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giacomini", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vanstone", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brundisini", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issue" : "February", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "1-31", "title" : "Patient Experiences of Depression and Anxiety with Chronic Disease : A Systematic Review and Qualitative Meta-Synthesis \u2014 Pre-Edit Draft", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Dejean, Giacomini, Vanstone, & Brundisini, 2013; B. L. Hankin, 2006)", "manualFormatting" : "(Dejean, Giacomini, Vanstone, & Brundisini, 2013; Hankin, 2006)", "plainTextFormattedCitation" : "(Dejean, Giacomini, Vanstone, & Brundisini, 2013; B. L. Hankin, 2006)", "previouslyFormattedCitation" : "(Dejean, Giacomini, Vanstone, & Brundisini, 2013; B. L. Hankin, 2006)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Dejean, Giacomini, Vanstone, & Brundisini, 2013; Hankin, 2006). Not everyone who is exposed to stress will go on to develop depression. Development of depression is widely accepted as being influenced by genetic, environmental and neurobiological factors ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1038/nrn1925", "ISSN" : "1471-003X", "PMID" : "16791147", "abstract" : "Gene-environment interaction research in psychiatry is new, and is a natural ally of neuroscience. Mental disorders have known environmental causes, but there is heterogeneity in the response to each causal factor, which gene-environment findings attribute to genetic differences at the DNA sequence level. Such findings come from epidemiology, an ideal branch of science for showing that a gene-environment interactions exist in nature and affect a significant fraction of disease cases. The complementary discipline of epidemiology, experimental neuroscience, fuels gene-environment hypotheses and investigates underlying neural mechanisms. This article discusses opportunities and challenges in the collaboration between psychiatry, epidemiology and neuroscience in studying gene-environment interactions.", "author" : [ { "dropping-particle" : "", "family" : "Caspi", "given" : "Avshalom", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Moffitt", "given" : "Terrie E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Nature reviews. Neuroscience", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "2006", "7" ] ] }, "page" : "583-90", "title" : "Gene-environment interactions in psychiatry: joining forces with neuroscience.", "type" : "article-journal", "volume" : "7" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.yebeh.2005.10.012", "ISSN" : "1525-5050", "PMID" : "16356779", "abstract" : "Depression is one of the most prevalent of the psychiatric disorders and is common among individuals with epilepsy. Depression often begins in adolescence. The present review focuses on adolescent depression. In particular, this review first summarizes the definition, description, and classification of adolescent depression. Next, potential causes of adolescent depression are reviewed from a vulnerability-stress perspective. This part of the review focuses on the role of stressors and how stressors interact with genetic, biological, cognitive, personality, and interpersonal vulnerabilities to predict adolescent depression. Last, clinical aspects of adolescent depression are reviewed, including treatment and prevention of depression and the relation to epileptic disorders in adolescence. In sum, a substantial percentage of youth with epilepsy and seizures exhibit depression, and many are not diagnosed or treated in a timely manner. The present review shows that there are valid, empirically based assessments, treatments, and preventions for depression in adolescence that hold promise for reducing the significant burden associated with depression.", "author" : [ { "dropping-particle" : "", "family" : "Hankin", "given" : "Benjamin L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Epilepsy & behavior : E&B", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2006", "2" ] ] }, "page" : "102-14", "title" : "Adolescent depression: description, causes, and interventions.", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Caspi & Moffitt, 2006; B. L. Hankin, 2006)", "manualFormatting" : "(Caspi & Moffitt, 2006; Hankin, 2006)", "plainTextFormattedCitation" : "(Caspi & Moffitt, 2006; B. L. Hankin, 2006)", "previouslyFormattedCitation" : "(Caspi & Moffitt, 2006; B. L. Hankin, 2006)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Caspi & Moffitt, 2006; Hankin, 2006). This understanding is congruent with vulnerability-stress models that explain the development of psychopathology. Hypotheses based on these models have been researched with a variety of mental illnesses including depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Monroe", "given" : "Scott M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simons", "given" : "Anne D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychological Bulletin", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1991" ] ] }, "page" : "406-425", "title" : "Diathesis \u2014 Stress Theories in the Context of Life Stress Research Implications for the Depressive Disorders", "type" : "article-journal", "volume" : "110" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Monroe & Simons, 1991)", "plainTextFormattedCitation" : "(Monroe & Simons, 1991)", "previouslyFormattedCitation" : "(Monroe & Simons, 1991)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Monroe & Simons, 1991).In vulnerability-stress theory the vulnerability is a latent trait that only becomes relevant when it interacts with enough stress to bring about psychopathology ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "9781606233474", "author" : [ { "dropping-particle" : "", "family" : "Ingram", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "Second", "editor" : [ { "dropping-particle" : "", "family" : "Ingram", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Price", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New YOrk", "title" : "Vulnerability to Psychopathology: Risk across the lifespan", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ingram, 2010)", "plainTextFormattedCitation" : "(Ingram, 2010)", "previouslyFormattedCitation" : "(Ingram, 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Ingram, 2010). If significant life stressors are not experienced, there is no interaction and, thus, no trigger that would cause the vulnerability to produce depression. Conversely, stress alone is not able to induce the condition without the presence of the vulnerability. Vulnerabilities can be biological, social or cognitive in nature. An expansion of the vulnerability-stress model proposes that individuals who are more susceptible to adverse conditions are also more readily influenced by enriched developmentally enhancing environments ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1017/S0954579410000611", "ISBN" : "0954579410", "ISSN" : "1469-2198", "PMID" : "21262036", "abstract" : "Two extant evolutionary models, biological sensitivity to context theory (BSCT) and differential susceptibility theory (DST), converge on the hypothesis that some individuals are more susceptible than others to both negative (risk-promoting) and positive (development-enhancing) environmental conditions. These models contrast with the currently dominant perspective on personal vulnerability and environmental risk: diathesis stress/dual risk. We review challenges to this perspective based on emerging theory and data from the evolutionary, developmental, and health sciences. These challenges signify the need for a paradigm shift in conceptualizing Person x Environment interactions in development. In this context we advance an evolutionary--neurodevelopmental theory, based on DST and BSCT, of the role of neurobiological susceptibility to the environment in regulating environmental effects on adaptation, development, and health. We then outline current thinking about neurogenomic and endophenotypic mechanisms that may underpin neurobiological susceptibility, summarize extant empirical research on differential susceptibility, and evaluate the evolutionary bases and implications of BSCT and DST. Finally, we discuss applied issues including methodological and statistical considerations in conducting differential susceptibility research; issues of ecological, cultural, and racial--ethnic variation in neurobiological susceptibility; and implications of differential susceptibility for designing social programs. We conclude that the differential susceptibility paradigm has far-reaching implications for understanding whether and how much child and adult development responds, for better and for worse, to the gamut of species-typical environmental conditions.", "author" : [ { "dropping-particle" : "", "family" : "Ellis", "given" : "Bruce J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boyce", "given" : "W Thomas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Belsky", "given" : "Jay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bakermans-Kranenburg", "given" : "Marian J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ijzendoorn", "given" : "Marinus H", "non-dropping-particle" : "van", "parse-names" : false, "suffix" : "" } ], "container-title" : "Development and psychopathology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2011", "2" ] ] }, "page" : "7-28", "title" : "Differential susceptibility to the environment: an evolutionary--neurodevelopmental theory.", "type" : "article-journal", "volume" : "23" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Belsky", "given" : "Jay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "1997" ] ] }, "page" : "182-186", "title" : "Variation in susceptibility to Environmnetal Influence: An Evolutionary Argument", "type" : "chapter" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Belsky, 1997; Ellis, Boyce, Belsky, Bakermans-Kranenburg, & van Ijzendoorn, 2011)", "plainTextFormattedCitation" : "(Belsky, 1997; Ellis, Boyce, Belsky, Bakermans-Kranenburg, & van Ijzendoorn, 2011)", "previouslyFormattedCitation" : "(Belsky, 1997; Ellis, Boyce, Belsky, Bakermans-Kranenburg, & van Ijzendoorn, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Belsky, 1997; Ellis, Boyce, Belsky, Bakermans-Kranenburg, & van Ijzendoorn, 2011). This differential susceptibility to the environment ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "0954-5794", "PMID" : "16761546", "abstract" : "Biological reactivity to psychological stressors comprises a complex, integrated, and highly conserved repertoire of central neural and peripheral neuroendocrine responses designed to prepare the organism for challenge or threat. Developmental experience plays a role, along with heritable, polygenic variation, in calibrating the response dynamics of these systems, with early adversity biasing their combined effects toward a profile of heightened or prolonged reactivity. Conventional views of such high reactivity suggest that it is an atavistic and pathogenic legacy of an evolutionary past in which threats to survival were more prevalent and severe. Recent evidence, however, indicates that (a) stress reactivity is not a unitary process, but rather incorporates counterregulatory circuits serving to modify or temper physiological arousal, and (b) the effects of high reactivity phenotypes on psychiatric and biomedical outcomes are bivalent, rather than univalent, in character, exerting both risk-augmenting and risk-protective effects in a context-dependent manner. These observations suggest that heightened stress reactivity may reflect, not simply exaggerated arousal under challenge, but rather an increased biological sensitivity to context, with potential for negative health effects under conditions of adversity and positive effects under conditions of support and protection. From an evolutionary perspective, the developmental plasticity of the stress response systems, along with their structured, context-dependent effects, suggests that these systems may constitute conditional adaptations: evolved psychobiological mechanisms that monitor specific features of childhood environments as a basis for calibrating the development of stress response systems to adaptively match those environments. Taken together, these theoretical perspectives generate a novel hypothesis: that there is a curvilinear, U-shaped relation between early exposures to adversity and the development of stress-reactive profiles, with high reactivity phenotypes disproportionately emerging within both highly stressful and highly protected early social environments.", "author" : [ { "dropping-particle" : "", "family" : "Boyce", "given" : "W Thomas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ellis", "given" : "Bruce J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Development and psychopathology", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2005", "1" ] ] }, "page" : "271-301", "title" : "Biological sensitivity to context: I. An evolutionary-developmental theory of the origins and functions of stress reactivity.", "type" : "article-journal", "volume" : "17" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Boyce & Ellis, 2005)", "plainTextFormattedCitation" : "(Boyce & Ellis, 2005)", "previouslyFormattedCitation" : "(Boyce & Ellis, 2005)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Boyce & Ellis, 2005) may prove to be a very useful concept in explaining the onset of depression after concussion and some of the variable recovery patterns. There is a growing body of evidence that children who have had a concussion are at increased risk of being diagnosed with depression during the recovery period or up to 5 years post injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1076/jcen.24.3.270.982", "ISBN" : "1380-3395", "ISSN" : "1380-3395", "PMID" : "11992209", "abstract" : "Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children - IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Luis", "given" : "Cheryl a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mittenberg", "given" : "Wiley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical and experimental neuropsychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "270-279", "title" : "Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Max", "given" : "Jeffrey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keatley", "given" : "Eva", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilde", "given" : "Elisabeth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bigler", "given" : "Erin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schachar", "given" : "Russel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saunders", "given" : "Ann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ewing-Cobbs", "given" : "Linda", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chapman", "given" : "Sandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dennis", "given" : "Maureen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yang", "given" : "Tony", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levin", "given" : "Harvey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Int. J. Devl Neuroscience", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "239-245", "title" : "Depression in children and adolescents in the first 6 months after traumatic brain injury", "type" : "article-journal", "volume" : "30" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/j.jadohealth.2013.10.006", "ISBN" : "1879-1972", "ISSN" : "18791972", "PMID" : "24355628", "abstract" : "Purpose: Previous studies in adults have suggested concussion and other brain injury presents a risk factor for depression. The goal of our study was to analyze the association between previous concussion and current depression diagnosis in a large nationally representative adolescent data set. Methods: Retrospective cohort study using the National Survey of Children's Health 2007-2008, a nationally representative survey conducted via random digit dialing. Data were obtained by parental report. We included youth 12-17 years old without a current concussion (N = 36,060), and evaluated the association between previous concussion (binary) and current depression diagnosis (binary) using multiple logistic regression to control for age, sex, parental mental health, and socioeconomic status. Results: After controlling for age, sex, parental mental health, and socioeconomic status, history of concussion was associated with a 3.3-fold greater risk for depression diagnosis (95% CI: 2.0-5.5). Other factors significantly associated with depression diagnosis included poor or fair parental mental health (OR: 3.7, 95% CI: 2.8-4.9), and older age (15-17 years vs. 12-14 years, OR: 1.4, 95% CI: 1.1-1.8). Sex of the subject was not significantly related to depression diagnosis. Being above 200% of the poverty level was associated with approximately a 50% decreased risk of depression diagnosis (95% CI: 35%-70%). Conclusions: History of concussion was associated with a higher prevalence of diagnosed depression in a large nationally representative adolescent data set. Clinicians should screen for depression in their adolescent patients with concussion. Future studies should confirm this association using prospective methodology and examine potential treatment approaches. ?? 2014 Society for Adolescent Health and Medicine. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Chrisman", "given" : "Sara P D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Richardson", "given" : "Laura P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Adolescent Health", "id" : "ITEM-3", "issue" : "5", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "582-586", "publisher" : "Elsevier Ltd", "title" : "Prevalence of diagnosed depression in adolescents with history of concussion", "type" : "article-journal", "volume" : "54" }, "uris" : [ "" ] }, { "id" : "ITEM-4", "itemData" : { "DOI" : "10.1016/j.jpeds.2013.08.042", "ISBN" : "0022-3476 DO - ", "ISSN" : "1097-6833", "PMID" : "24112864", "abstract" : "OBJECTIVE: To delineate the relationship between traumatic brain injury (TBI) and mood disorders from population-based data in Taiwan.\\n\\nSTUDY DESIGN: This prospectively followed cohort study involved a subset of the National Health Insurance Research Database containing complete inpatient and outpatient data of 1 million randomly drawn beneficiaries. We included 10- to 24-year-old patients (n = 15,203) receiving the diagnosis of TBI in ambulatory visits or hospitalization from 2000-2004 and their age- and sex-matched comparison insureds using health service in the same year (n = 76,015). Diagnosis of mood disorders was recorded within 5 years after the traumatic event or index use of health service. Baseline demographics, clinical characteristics, and premorbid psychiatric conditions were compared using \u03c7(2) analysis. Increased risk during the 5-year follow-up period was represented by crude and adjusted hazard ratios with 95% CI using a Cox proportional hazard regression.\\n\\nRESULTS: A total of 451/15,203 patients with TBI (2.97%) received a diagnosis of mood disorders in the 5-year follow-up period compared with 1153/97,445 individuals (1.52%) without antecedent TBI. After adjusting for select premorbid comorbidities, TBI remained a significant predisposing factor with a 1.96-fold (95% CI 1.74-2.22) increase in risk of mood disorders.\\n\\nCONCLUSIONS: Our findings show a higher likelihood of manifesting mood disorders in adolescents and young adults who sustained a prior TBI. Health professionals should carefully monitor both the physical and psychological impacts of head trauma.", "author" : [ { "dropping-particle" : "", "family" : "Tsai", "given" : "Meng-Che", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tsai", "given" : "Kuen-Jer", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wang", "given" : "Hao-Kuang", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sung", "given" : "Pi-Shan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wu", "given" : "Ming-Hsiu", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hung", "given" : "Kuo-Wei", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lin", "given" : "Sheng-Hsiang", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-4", "issue" : "1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "136-141.e1", "publisher" : "Elsevier Ltd", "title" : "Mood disorders after traumatic brain injury in adolescents and young adults: a nationwide population-based cohort study.", "type" : "article-journal", "volume" : "164" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Chrisman & Richardson, 2014; Luis & Mittenberg, 2002; Max et al., 2012; Tsai et al., 2014)", "plainTextFormattedCitation" : "(Chrisman & Richardson, 2014; Luis & Mittenberg, 2002; Max et al., 2012; Tsai et al., 2014)", "previouslyFormattedCitation" : "(Chrisman & Richardson, 2014; Luis & Mittenberg, 2002; Max et al., 2012; Tsai et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Chrisman & Richardson, 2014; Luis & Mittenberg, 2002; Max et al., 2012; Tsai et al., 2014). Pre-injury stress, post-injury stress, social factors and neurobiological mechanisms have all been implicated as contributing to a depression outcome after concussion ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/HTR.0b013e3181e4622a", "ISSN" : "1550-509X", "PMID" : "20631632", "abstract" : "OBJECTIVE: To examine the influence of depression on postconcussion symptom reporting in patients following mild traumatic brain injury (MTBI).\n\nPARTICIPANTS: Sixty patients referred to a specialty clinic following MTBI, 58 outpatients with Structured Clinical Interview for DSM-diagnosed depression, and 72 healthy community control participants.\n\nPROCEDURE: Participants with MTBI were divided into 2 subgroups on the basis of self-reported symptoms of depression (23 MTBI-depressed, 37 MTBI-not depressed). All participants completed a postconcussion symptom questionnaire.\n\nMAIN OUTCOME MEASURE: British Columbia Post-concussion Symptom Inventory.\n\nRESULTS: There were significant differences in total reported postconcussion symptoms among all 4 groups (all P < .002; Cohen's d = 0.68-3.24, large to very large effect sizes; MTBI-depressed > depressed outpatients > MTBI-no depression > healthy controls). There were significant differences in the number of symptoms endorsed (P < .05), with the highest number of symptoms endorsed by the MTBI-depressed group, followed by depressed outpatients, MTBI-no depression, and healthy controls.\n\nCONCLUSIONS: Patients who experience MTBIs and who have a postinjury recovery course complicated by significant depression report more postconcussion symptoms, and more severe symptoms, than (a) outpatients with depression, and (b) patients with MTBIs who do not have significant symptoms of depression.", "author" : [ { "dropping-particle" : "", "family" : "Lange", "given" : "Rael T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Alice", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of head trauma rehabilitation", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "127-37", "title" : "Depression strongly influences postconcussion symptom reporting following mild traumatic brain injury.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1076/jcen.24.3.270.982", "ISBN" : "1380-3395", "ISSN" : "1380-3395", "PMID" : "11992209", "abstract" : "Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children - IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Luis", "given" : "Cheryl a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mittenberg", "given" : "Wiley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical and experimental neuropsychology", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "270-279", "title" : "Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kirkwood", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Janusz", "given" : "Jennifer", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yeates", "given" : "Keith", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "Gerry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wade", "given" : "Shari", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stancin", "given" : "Terry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Drotar", "given" : "Dennis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child Neuropsychology", "id" : "ITEM-3", "issue" : "3", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "195-208", "title" : "Prevalence and correlates of depressive symptoms following traumatic brain injuries in children", "type" : "article", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Kirkwood et al., 2000; Lange et al., 2011; Luis & Mittenberg, 2002)", "plainTextFormattedCitation" : "(Kirkwood et al., 2000; Lange et al., 2011; Luis & Mittenberg, 2002)", "previouslyFormattedCitation" : "(Kirkwood et al., 2000; Lange et al., 2011; Luis & Mittenberg, 2002)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Kirkwood et al., 2000; Lange et al., 2011; Luis & Mittenberg, 2002). Children with vulnerability traits plus concussion may have more susceptibilities making them more vulnerable to environmental influence after the injury. Diagnosis of DepressionDiagnosing depression can be complex as many options for diagnostic categories exist. Major depressive disorder, synonymous with clinical depression is rigorously defined by the DSM-V ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Association", "given" : "American Psychiatric", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "5th", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "publisher-place" : "Washington, DC", "title" : "Diagnostic and statistical manual of mental disorders", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Association, 2013)", "manualFormatting" : "(American Psychiatric Association, 2013)", "plainTextFormattedCitation" : "(Association, 2013)", "previouslyFormattedCitation" : "(Association, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(American Psychiatric Association, 2013) Mild or moderate depression is often referred to as sub-threshold depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1186/1471-244X-12-181", "ISBN" : "1471-244X", "ISSN" : "1471-244X", "PMID" : "23110575", "abstract" : "BACKGROUND: Subthreshold depressive disorders (minor and subthrehold depression) have been defined in a wide range of forms, varying on the number of symptoms and duration required. Disability associated with these conditions has also been reported. Our aim was to review the different definitions and to determine factors associated with these conditions in order to clarify the nosological implications of these disorders.\\n\\nMETHODS: A Medline search was conducted of the published literature between January 2001 and September 2011. Bibliographies of the retrieved papers were also analysed.\\n\\nRESULTS: There is a wide heterogeneity in the definition and diagnostic criteria of minor and subthreshold depression. Minor depression was defined according to DSM-IV criteria. Regarding subthreshold depression, also called subclinical depression or subsyndromal symptomatic depression, between 2 and 5 depressive symptoms were required for the diagnosis, and a minimum duration of 2 weeks. Significant impairment associated with subthreshold depressive conditions, as well as comorbidity with other mental disorders, has been described.\\n\\nCONCLUSIONS: Depression as a disorder is better explained as a spectrum rather than as a collection of discrete categories. Minor and subthreshold depression are common conditions and patients falling below the diagnostic threshold experience significant difficulties in functioning and a negative impact on their quality of life. Current diagnostic systems need to reexamine the thresholds for depressive disorders and distinguish them from ordinary feelings of sadness.", "author" : [ { "dropping-particle" : "", "family" : "Rivas Rodr\u00edguez", "given" : "Mar", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nuevo", "given" : "Roberto", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chatterji", "given" : "Somnath", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ayuso-Mateos", "given" : "Jos\u00e9 Luis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "BMC Psychiatry", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "181", "title" : "Definitions and factors associated with subthreshold depressive conditions: a systematic review", "type" : "article-journal", "volume" : "12" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Rivas Rodr\u00edguez et al., 2012)", "plainTextFormattedCitation" : "(Rivas Rodr\u00edguez et al., 2012)", "previouslyFormattedCitation" : "(Rivas Rodr\u00edguez et al., 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Rivas Rodríguez et al., 2012). Adjustment disorder is another diagnostic category found under Trauma and Stressor Related Disorders in the DSM-V: sometimes referred to as situational or reactive depression, it requires exposure to trauma or a stressful event ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Association", "given" : "American Psychiatric", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "5th", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "publisher-place" : "Washington, DC", "title" : "Diagnostic and statistical manual of mental disorders", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Association, 2013)", "manualFormatting" : "(American Psychiatric Association, 2013)", "plainTextFormattedCitation" : "(Association, 2013)", "previouslyFormattedCitation" : "(Association, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(American Psychiatric Association, 2013). Self-report measures of symptoms detect possible cases of depression, but cannot yield a diagnosis. The duration of symptoms, the type of symptoms and the functional deficits required for diagnosis require clinical judgment based on a variety of sources ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kovacs", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher" : "Multi-Health Systems", "title" : "Children's Depression Inventory-2", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Kovacs, 2011)", "plainTextFormattedCitation" : "(Kovacs, 2011)", "previouslyFormattedCitation" : "(Kovacs, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Kovacs, 2011). Diagnosis of depression is a complex decision-making process that uses information from a variety of sources and assessment procedures. An increasing focus and reliance on evidence-based systematic evaluation is being recommended in the practice of child and adolescent psychiatry ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.chc.2011.12.003", "author" : [ { "dropping-particle" : "", "family" : "D'Angelo", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Augenstein", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child and Adolescent Psychiatric Clinics of North America", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "279-298", "title" : "Developmentally informed evaluation of depression: Evidence-based instruments", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(D\u2019Angelo & Augenstein, 2012)", "plainTextFormattedCitation" : "(D\u2019Angelo & Augenstein, 2012)", "previouslyFormattedCitation" : "(D\u2019Angelo & Augenstein, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(D’Angelo & Augenstein, 2012). The early detection of depression in childhood is vital to provide timely intervention and prevent the accompanying negative outcomes, recurrence, chronicity and comorbid mental disorders ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s10578-011-0254-1", "author" : [ { "dropping-particle" : "", "family" : "Fruhe", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Allgaier", "given" : "Antje-Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pietsch", "given" : "Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baethmann", "given" : "Martina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Peters", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kellnar", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Heep", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burdach", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schweinitz", "given" : "D", "non-dropping-particle" : "von", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schulte-Korne", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child Psychiatry and Human Development", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "137-151", "title" : "Children's depression screener (ChilD-S): Development and Validation of a depression screening instrument for children in pediatric care", "type" : "article-journal", "volume" : "43" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Fruhe et al., 2011)", "plainTextFormattedCitation" : "(Fruhe et al., 2011)", "previouslyFormattedCitation" : "(Fruhe et al., 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Fruhe et al., 2011). Nevertheless, depressive disorders often remain undiagnosed. A study of pediatric clinics showed that only 22% of 51 adolescents who actually had mood disorders were detected ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.acap.2009.09.011", "ISSN" : "18762859", "PMID" : "20129479", "abstract" : "Objective: Anxiety and depression are common among youth and are associated with significant morbidity. Few youth with depression are diagnosed and receive treatment for these disorders. The purpose of this study was to examine the rate of recognition and management among an insured population and the factors associated with evidence of detection among youth. Methods: Structured mental health interviews assessing depression and anxiety diagnoses were completed with a random sample of 581 youth (age range 11-17 years) from an integrated health care system. Administrative data on medical and pharmacy services were used to examine any evidence of detection by the medical system in the prior 12 months. Results: Fifty-one youth met criteria for an anxiety or depressive disorder. Twenty-two percent of these youth with an anxiety or depressive disorder as defined in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition had evidence of detection or treatment. Factors associated with detection and treatment included having diagnosis of a depressive disorder (with or without an anxiety disorder), more depressive symptoms, greater functional impairment, a higher number of primary care visits in the prior year, and higher parent-reported externalizing symptoms. On multivariate analysis, having more depressive symptoms and a higher number of primary care visits were significant predictors of detection and receipt of treatment. Conclusions: The rate of detection and treatment of anxiety and depressive disorders is very low in this age group and suggests a need for increased focus on detection, particularly in light of recent evidence suggesting decreases in diagnosis and treatment among youth following the black box warning regarding antidepressant medications. ?? 2010 Academic Pediatric Association.", "author" : [ { "dropping-particle" : "", "family" : "Richardson", "given" : "Laura P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Russo", "given" : "Joan E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lozano", "given" : "Paula", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCauley", "given" : "Elizabeth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Katon", "given" : "Wayne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Academic Pediatrics", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "36-40", "publisher" : "Elsevier Ltd", "title" : "Factors Associated with Detection and Receipt of Treatment for Youth with Depression and Anxiety Disorders", "type" : "article-journal", "volume" : "10" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Richardson, Russo, Lozano, McCauley, & Katon, 2010)", "plainTextFormattedCitation" : "(Richardson, Russo, Lozano, McCauley, & Katon, 2010)", "previouslyFormattedCitation" : "(Richardson, Russo, Lozano, McCauley, & Katon, 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Richardson, Russo, Lozano, McCauley, & Katon, 2010). One of the major barriers to screening for depression in clinical populations is the overlap of physical symptoms of disease processes with depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Dejean", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giacomini", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vanstone", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brundisini", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issue" : "February", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "1-31", "title" : "Patient Experiences of Depression and Anxiety with Chronic Disease : A Systematic Review and Qualitative Meta-Synthesis \u2014 Pre-Edit Draft", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Dejean et al., 2013)", "plainTextFormattedCitation" : "(Dejean et al., 2013)", "previouslyFormattedCitation" : "(Dejean et al., 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Dejean et al., 2013). Clinicians often attribute depressive symptoms to part of the chronic disease process and, therefore, depression as a distinct condition is not always recognized by patients or health care professionals ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Dejean", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giacomini", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vanstone", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brundisini", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issue" : "February", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "1-31", "title" : "Patient Experiences of Depression and Anxiety with Chronic Disease : A Systematic Review and Qualitative Meta-Synthesis \u2014 Pre-Edit Draft", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Dejean et al., 2013)", "plainTextFormattedCitation" : "(Dejean et al., 2013)", "previouslyFormattedCitation" : "(Dejean et al., 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Dejean et al., 2013). Primary care physicians also often rely on a clinical unstructured interview, which has low levels of agreement between clinicians ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.chc.2011.12.003", "author" : [ { "dropping-particle" : "", "family" : "D'Angelo", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Augenstein", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child and Adolescent Psychiatric Clinics of North America", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "279-298", "title" : "Developmentally informed evaluation of depression: Evidence-based instruments", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(D\u2019Angelo & Augenstein, 2012)", "plainTextFormattedCitation" : "(D\u2019Angelo & Augenstein, 2012)", "previouslyFormattedCitation" : "(D\u2019Angelo & Augenstein, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(D’Angelo & Augenstein, 2012). Structured interviews have been perceived as the gold standard; however, these are extensive and time consuming and not usually practiced outside of research settings. Semi-structured interviews and rating scales, when used together, can enhance the diagnosis of depression and provide more evidence-based evaluation ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.chc.2011.12.003", "author" : [ { "dropping-particle" : "", "family" : "D'Angelo", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Augenstein", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child and Adolescent Psychiatric Clinics of North America", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "279-298", "title" : "Developmentally informed evaluation of depression: Evidence-based instruments", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(D\u2019Angelo & Augenstein, 2012)", "plainTextFormattedCitation" : "(D\u2019Angelo & Augenstein, 2012)", "previouslyFormattedCitation" : "(D\u2019Angelo & Augenstein, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(D’Angelo & Augenstein, 2012). Typically, child self-report measures are considered to have greater sensitivity than parent-rating forms, although having a variety of sources and assessment procedures increases confidence in the diagnosis ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.chc.2011.12.003", "author" : [ { "dropping-particle" : "", "family" : "D'Angelo", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Augenstein", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child and Adolescent Psychiatric Clinics of North America", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "279-298", "title" : "Developmentally informed evaluation of depression: Evidence-based instruments", "type" : "article-journal", "volume" : "21" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(D\u2019Angelo & Augenstein, 2012)", "plainTextFormattedCitation" : "(D\u2019Angelo & Augenstein, 2012)", "previouslyFormattedCitation" : "(D\u2019Angelo & Augenstein, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(D’Angelo & Augenstein, 2012). An example of a self-report child measure is the Childhood Depression Inventory (CDI; ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kovacs", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher" : "Multi-Health Systems", "title" : "Children's Depression Inventory-2", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Kovacs, 2011)", "manualFormatting" : "Kovacs, 2011)", "plainTextFormattedCitation" : "(Kovacs, 2011)", "previouslyFormattedCitation" : "(Kovacs, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }Kovacs, 2011) which a well-researched measure of depression. It has been shown to have a moderate relationship to independent psychiatric ratings ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1037//0021-843X.111.4.578", "ISBN" : "0021-843X", "ISSN" : "0021-843X", "PMID" : "12428771", "abstract" : "A within-scale meta-analysis was performed on 310 samples of children (ages 8-16; N = 61,424) responding to the Children's Depression Inventory (CDI). Girls' depression scores stayed steady from ages 8 to 11 and then increased between ages 12 and 16. Boys' CDI scores were stable from ages 8 to 16 except for a high CDI score at age 12. Girls' scores were slightly lower than boys' during childhood, but girls scored higher beginning at age 13. There were no socioeconomic status effects and no differences between White and Black samples. However, Hispanic samples scored significantly higher on the CDI. Analyses for birth cohort showed a slight decrease in boys' CDI scores over time and no change for girls. Longitudinal studies demonstrated a marked testing effect.", "author" : [ { "dropping-particle" : "", "family" : "Twenge", "given" : "Jean M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nolen-Hoeksema", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of abnormal psychology", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "578-588", "title" : "Age, gender, race, socioeconomic status, and birth cohort differences on the children's depression inventory: a meta-analysis.", "type" : "article-journal", "volume" : "111" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)", "plainTextFormattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)", "previouslyFormattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Twenge & Nolen-Hoeksema, 2002). The CDI is a measure of psychosocial distress rather than depression alone because it measures a subclinical level of depressive symptomatology and it does not discriminate well between depression and anxiety ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1037//0021-843X.111.4.578", "ISBN" : "0021-843X", "ISSN" : "0021-843X", "PMID" : "12428771", "abstract" : "A within-scale meta-analysis was performed on 310 samples of children (ages 8-16; N = 61,424) responding to the Children's Depression Inventory (CDI). Girls' depression scores stayed steady from ages 8 to 11 and then increased between ages 12 and 16. Boys' CDI scores were stable from ages 8 to 16 except for a high CDI score at age 12. Girls' scores were slightly lower than boys' during childhood, but girls scored higher beginning at age 13. There were no socioeconomic status effects and no differences between White and Black samples. However, Hispanic samples scored significantly higher on the CDI. Analyses for birth cohort showed a slight decrease in boys' CDI scores over time and no change for girls. Longitudinal studies demonstrated a marked testing effect.", "author" : [ { "dropping-particle" : "", "family" : "Twenge", "given" : "Jean M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nolen-Hoeksema", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of abnormal psychology", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "578-588", "title" : "Age, gender, race, socioeconomic status, and birth cohort differences on the children's depression inventory: a meta-analysis.", "type" : "article-journal", "volume" : "111" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)", "plainTextFormattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)", "previouslyFormattedCitation" : "(Twenge & Nolen-Hoeksema, 2002)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Twenge & Nolen-Hoeksema, 2002). This screening tool takes only a few minutes to complete and has been validated for use with medically ill children ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpsychores.2012.08.016", "ISSN" : "1879-1360", "PMID" : "23062811", "abstract" : "OBJECTIVE: This is the first study to validate and to compare the Children's Depression Inventory (CDI) and its short version (CDI:S) as screening tools for medically ill children.\n\nMETHODS: A sample of 406 pediatric hospital patients, aged 9 to 12 years (56.2% male, 77.1% inpatients), completed the German CDI. Criterion validity of the 26-item CDI and the 10-item CDI:S was calculated by receiver operating characteristic (ROC) curves. DSM-IV diagnoses of depression based on the structured diagnostic interview for mental disorders in children and adolescents (Kinder-DIPS) served as the reference standard. Areas under the ROC curves as well as sensitivities and specificities for the optimal cutoffs were compared for both versions.\n\nRESULTS: Diagnoses of major or minor depression were established for 7.4% of the children. Areas under the curve for the 26-item CDI (87.7%) and the 10-item CDI:S (88.2%) were comparable. For the CDI, the cutoff\u226512 yielded the best balance between sensitivity (83.3%) and specificity (82.7%). At the optimal cutoff\u22653, the CDI:S resulted in a high sensitivity of 93.3% and a specificity of 70.7%. Thus, the CDI:S proved to be as sensitive as the CDI, but was less specific than the full-length version.\n\nCONCLUSION: Both the CDI and the CDI:S are valid screening instruments for depression in medically ill children. The sensitive and brief CDI:S is a promising tool in time-pressed settings such as pediatric care, but has to be followed by a thorough diagnostic assessment to rule out false positive cases.", "author" : [ { "dropping-particle" : "", "family" : "Allgaier", "given" : "Antje-Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fr\u00fche", "given" : "Barbara", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pietsch", "given" : "Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saravo", "given" : "Barbara", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baethmann", "given" : "Martina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schulte-K\u00f6rne", "given" : "Gerd", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of psychosomatic research", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2012", "11" ] ] }, "page" : "369-74", "publisher" : "Elsevier Inc.", "title" : "Is the Children's Depression Inventory Short version a valid screening tool in pediatric care? A comparison to its full-length version.", "type" : "article-journal", "volume" : "73" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Allgaier et al., 2012)", "plainTextFormattedCitation" : "(Allgaier et al., 2012)", "previouslyFormattedCitation" : "(Allgaier et al., 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Allgaier et al., 2012). For screening tools to be used in busy clinical settings, the brevity of the instrument and high criterion validity are important ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1007/s10578-011-0254-1", "author" : [ { "dropping-particle" : "", "family" : "Fruhe", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Allgaier", "given" : "Antje-Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pietsch", "given" : "Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baethmann", "given" : "Martina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Peters", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kellnar", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Heep", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Burdach", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schweinitz", "given" : "D", "non-dropping-particle" : "von", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schulte-Korne", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child Psychiatry and Human Development", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "137-151", "title" : "Children's depression screener (ChilD-S): Development and Validation of a depression screening instrument for children in pediatric care", "type" : "article-journal", "volume" : "43" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Fruhe et al., 2011)", "plainTextFormattedCitation" : "(Fruhe et al., 2011)", "previouslyFormattedCitation" : "(Fruhe et al., 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Fruhe et al., 2011). Depression and Brain InjuryEmotional symptoms, irritability and depressed mood are common in recovering from a brain injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2014-0158", "author" : [ { "dropping-particle" : "", "family" : "Eisenberg", "given" : "Matthew A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meehan", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mannix", "given" : "Rebekah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "title" : "Duration and Course of Post-Concussive Symptoms", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.jpeds.2014.08.034", "ISSN" : "1097-6833", "PMID" : "25262302", "abstract" : "OBJECTIVE: To identify pre-existing characteristics associated with prolonged recovery from concussion in a sample of patients referred to a pediatric sports medicine clinic.\n\nSTUDY DESIGN: This was a retrospective, exploratory cohort study of 247 patients age 5-18\u00a0years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010, through December 31, 2011. A random sample of all eligible patient visits (3740) was chosen for further review and abstraction. Statistical comparisons between subsets of patients were conducted using exact \u03c7(2) tests, logistic regression, quantile regression, and Kaplan-Meier survival curves.\n\nRESULTS: The median time until returning to school part-time was 12\u00a0days (IQR 6-21); until returning to school full-time without accommodations was 35\u00a0days (IQR 11-105); until becoming symptom-free was 64\u00a0days (IQR 18-119); and until being fully cleared to return to sports was 75\u00a0days (IQR 30-153). Furthermore, 73% of all patients were symptomatic for >4\u00a0weeks, 73% were prescribed some form of school accommodation, and 61% reported a decline in grades. Characteristics associated with a prolonged recovery included a history of depression or anxiety; an initial complaint of dizziness; abnormal convergence or symptom provocation following oculomotor examination on physical examination; and history of prior concussion.\n\nCONCLUSIONS: Pediatric and adolescent patients with concussion may experience cognitive and emotional morbidity that can last for several months following injury. Clinicians should consider specific pre-existing characteristics and presenting symptoms that may be associated with a more complicated recovery for concussion patients.", "author" : [ { "dropping-particle" : "", "family" : "Corwin", "given" : "Daniel J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zonfrillo", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Master", "given" : "Christina L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Arbogast", "given" : "Kristy B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grady", "given" : "Matthew F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "Roni L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goodman", "given" : "Arlene M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wiebe", "given" : "Douglas J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2014", "9", "25" ] ] }, "page" : "1-9", "publisher" : "Elsevier\u00a0Inc", "title" : "Characteristics of Prolonged Concussion Recovery in a Pediatric Subspecialty Referral Population.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Corwin et al., 2014b; Eisenberg, Meehan, et al., 2014)", "plainTextFormattedCitation" : "(Corwin et al., 2014b; Eisenberg, Meehan, et al., 2014)", "previouslyFormattedCitation" : "(Corwin et al., 2014b; Eisenberg, Meehan, et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Corwin et al., 2014b; Eisenberg, Meehan, et al., 2014). Sixty percent of children have been reported to be more emotional and 58% to be more irritable one month following the injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2009-0925", "ISSN" : "1098-4275", "PMID" : "20660554", "abstract" : "Much disagreement exists as to whether postconcussion syndrome (PCS) is attributable to brain injury or to other factors such as trauma alone, preexisting psychosocial problems, or medicolegal issues. We investigated the epidemiology and natural history of PCS symptoms in a large cohort of children with a mild traumatic brain injury (mTBI) and compared them with children with an extracranial injury (ECI).", "author" : [ { "dropping-particle" : "", "family" : "Barlow", "given" : "Karen Maria", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crawford", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stevenson", "given" : "Andrea", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Sandeep Sona", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Belanger", "given" : "Fran\u00e7ois", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dewey", "given" : "Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2010", "8" ] ] }, "page" : "e374-81", "title" : "Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury.", "type" : "article-journal", "volume" : "126" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Barlow et al., 2010)", "plainTextFormattedCitation" : "(Barlow et al., 2010)", "previouslyFormattedCitation" : "(Barlow et al., 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Barlow et al., 2010). ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.apmr.2012.03.032", "ISSN" : "1532-821X", "PMID" : "22503738", "abstract" : "To prospectively examine the relationship of sport-related concussion with depression and neurocognitive performance and symptoms among male and female high school and college athletes. A secondary objective was to explore age and sex differences.", "author" : [ { "dropping-particle" : "", "family" : "Kontos", "given" : "Anthony P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Covassin", "given" : "Tracey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Elbin", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Parker", "given" : "Tonya", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of physical medicine and rehabilitation", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2012", "10" ] ] }, "page" : "1751-6", "publisher" : "Elsevier Inc.", "title" : "Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes.", "type" : "article-journal", "volume" : "93" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Kontos, Covassin, Elbin, & Parker, 2012)", "manualFormatting" : "Kontos and collegues (2012)", "plainTextFormattedCitation" : "(Kontos, Covassin, Elbin, & Parker, 2012)", "previouslyFormattedCitation" : "(Kontos, Covassin, Elbin, & Parker, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }Kontos and collegues (2012) investigated depressive and neurocognitive symptoms in 129 high school and collegiate athletes following concussion and found that, in comparison with baseline scores obtained at two days post-injury, increased depression scores were experienced up to 14 days after injury. Eisenberg (2014) recently found that emotional symptoms, which developed in the follow up period during recovery from concussion, lasted the longest from 7 – 23 days on average. If these symptoms are a typical part of brain injury recovery, a question still remains about how does one distinguish when children’s emotional health is most at risk?Contributions from Adult Studies A review of the literature indicates that evidence from adult studies, which are more abundant, may provide a basis for further exploration of depression in children. A recent Canadian national population health study of neurological conditions in all ages found that 38.3% of those with TBI reported mood and anxiety disorders compared to 8.6% without a neurological condition ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Canada)", "given" : "(Public Health Agency of", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "publisher-place" : "Ottawa, Ontario", "title" : "Mapping connections: An understanding of neurological conditions in canada", "type" : "report" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Canada), 2014)", "manualFormatting" : "(Ministry of Health,Canada, 2014)", "plainTextFormattedCitation" : "(Canada), 2014)", "previouslyFormattedCitation" : "(Canada), 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Ministry of Health,Canada, 2014). Other studies in adult populations with acquired brain injury report incidences up to 77% ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1053/apmr.2003.50106", "ISSN" : "0003-9993", "PMID" : "12601647", "abstract" : "OBJECTIVE: To identify the frequency and manifestations of depression after traumatic brain injury (TBI) and the factors that contribute to developing this mood disorder.\n\nDESIGN: A prospective, nationwide, multicenter study; 17 centers supplied data from medical records and patient responses on a standardized criterion instrument.\n\nSETTING: Traumatic Brain Injury Model Systems programs.\n\nPARTICIPANTS: A demographically diverse sample of 666 outpatients with TBI was evaluated 10 to 126 months after injury.\n\nINTERVENTIONS: Not applicable.\n\nMAIN OUTCOME MEASURES: Depressive symptoms were characterized with the Neurobehavioral Functioning Inventory by using the Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV) diagnostic framework. Analysis of variance and Pearson correlations were used to identify factors that were significantly related to depression.\n\nRESULTS: Fatigue (29%), distractibility (28%), anger or irritability (28%), and rumination (25%) were the most commonly cited depressive symptoms in the sample. Twenty-seven percent of patients with TBI met the prerequisite number (>/=5) of criterion A symptoms for a DSM-IV diagnosis of major depressive disorder. Feeling hopeless, feeling worthless, and difficulty enjoying activities were the 3 symptoms that most differentiated depressed from nondepressed patients. Patients who were unemployed at the time of injury and who were impoverished were significantly more likely to report DSM-IV criterion A symptoms than patients who were employed, were students, or were retired due to age. Time after injury, injury severity, and postinjury marital status were not significantly related to depression.\n\nCONCLUSIONS: Patients with TBI are at great risk for developing depressive symptoms. Findings provide empirical support for the inclusion of depression evaluation and treatment protocols in brain injury programs. Unemployment and poverty may be substantial risk factors for the development of depressive symptoms. Future research should develop biopsychosocial predictive models to identify high-risk patients and examine the efficacy of treatment interventions.", "author" : [ { "dropping-particle" : "", "family" : "Seel", "given" : "Ronald T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kreutzer", "given" : "Jeffrey S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rosenthal", "given" : "Mitchell", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hammond", "given" : "Flora M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Corrigan", "given" : "John D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Black", "given" : "Kertia", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of physical medicine and rehabilitation", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2003", "3" ] ] }, "page" : "177-84", "title" : "Depression after traumatic brain injury: a National Institute on Disability and Rehabilitation Research Model Systems multicenter investigation.", "type" : "article-journal", "volume" : "84" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Seel et al., 2003)", "plainTextFormattedCitation" : "(Seel et al., 2003)", "previouslyFormattedCitation" : "(Seel et al., 2003)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Seel et al., 2003). Some of these studies have been criticized for using self-report measures of depression, having different definitions of depression, using retrospective methodologies and for the variation in follow up time, sometimes up to ten years after injury. Even fewer studies have been conducted with the population of individuals who have had a concussion or mTBI. ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1176/appi.psy.44.1.31", "ISSN" : "0033-3182", "PMID" : "12515835", "abstract" : "The authors assessed the association of major depression with behavioral outcome following mild traumatic brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Rapoport", "given" : "Mark J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCullagh", "given" : "Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Streiner", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feinstein", "given" : "Anthony", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychosomatics", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "31-7", "title" : "The clinical significance of major depression following mild traumatic brain injury.", "type" : "article-journal", "volume" : "44" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Rapoport, McCullagh, Streiner, & Feinstein, 2003)", "manualFormatting" : "Rapoport,et al. (2003)", "plainTextFormattedCitation" : "(Rapoport, McCullagh, Streiner, & Feinstein, 2003)", "previouslyFormattedCitation" : "(Rapoport, McCullagh, Streiner, & Feinstein, 2003)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }Rapoport,et al. (2003) specifically examined depression after concussion in a cross-sectional study of 170 adults and found that 15.3% met criteria for major depression after a mean of 48 days post-injury. Depression was associated with increased post concussive symptoms and greater psychological and psychosocial distress. Another prospective study that followed a cohort of 43 adults with concussion found depression in 18% of patients up to a year after injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1176/appi.neuropsych.22.1.100.Predictors", "author" : [ { "dropping-particle" : "", "family" : "Rao", "given" : "Vani", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bertrand", "given" : "Melaine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rosenberg", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Makley", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schretlen", "given" : "David J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brandt", "given" : "Jason", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mielke", "given" : "Michelle M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J. Neuropsychiatry Clin Neurosci.", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "100-104", "title" : "Predictors of new-onset depression after mild traumatic brain injury", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Rao et al., 2010)", "plainTextFormattedCitation" : "(Rao et al., 2010)", "previouslyFormattedCitation" : "(Rao et al., 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Rao et al., 2010). These studies addressed the problem of inconsistent diagnosis and definition of depression by using the Structured Clinical Interview for DSM-IV disorders ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "First", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Spitzer", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gibbon", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Williams", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2002" ] ] }, "publisher" : "Biometric Research", "publisher-place" : "New York", "title" : "Structured Clinical Interview for DSM IV-TR Axis I Disorders, Research Version, Patient Edition", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(First, Spitzer, Gibbon, & Williams, 2002)", "plainTextFormattedCitation" : "(First, Spitzer, Gibbon, & Williams, 2002)", "previouslyFormattedCitation" : "(First, Spitzer, Gibbon, & Williams, 2002)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(First, Spitzer, Gibbon, & Williams, 2002) which is considered to be the gold standard for diagnosis of depression. Both investigators excluded those individuals with histories of psychiatric or mood disorder to focus on new-onset depression. Rao and colleagues (2010) also excluded those with prior concussion. This may be an important omission, as there is evidence that multiple concussions are associated with the likelihood of being diagnosed with depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1249/mss.0b013e3180383da5", "ISSN" : "0195-9131", "PMID" : "17545878", "abstract" : "PURPOSE: The purpose of our study was to investigate the association between prior head injury and the likelihood of being diagnosed with clinical depression among retired professional football players with prior head injury exposure.\n\nMETHODS: A general health questionnaire, including information about prior injuries, the SF-36 (Short Form 36), and other markers for depression, was completed by 2552 retired professional football players with an average age of 53.8 (+/-13.4) yr and an average professional football-playing career of 6.6 (+/-3.6) yr. A second questionnaire focusing on mild cognitive impairment (MCI)-related issues was completed by a subset of 758 retired professional football players (50 yr and older).\n\nRESULTS: Two hundred sixty-nine (11.1%) of all respondents reported having prior or current diagnosis of clinical depression. There was an association between recurrent concussion and diagnosis of lifetime depression (chi2=71.21, df=2, P<0.005), suggesting that the prevalence increases with increasing concussion history. Compared with retired players with no history of concussion, retired players reporting three or more previous concussions (24.4%) were three times more likely to be diagnosed with depression; those with a history of one or two previous concussions (36.3%) were 1.5 times more likely to be diagnosed with depression. The analyses controlled for age, number of years since retirement, number of years played, physical component score on the SF-36, and diagnosed comorbidities such as osteoarthritis, coronary heart disease, stroke, cancer, and diabetes.\n\nCONCLUSION: Our findings suggest a possible link between recurrent sport-related concussion and increased risk of clinical depression. The findings emphasize the importance of understanding potential neurological consequences of recurrent concussion.", "author" : [ { "dropping-particle" : "", "family" : "Guskiewicz", "given" : "Kevin M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marshall", "given" : "Stephen W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bailes", "given" : "Julian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCrea", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harding", "given" : "Herndon P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Matthews", "given" : "Amy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mihalik", "given" : "Johna Register", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Medicine and science in sports and exercise", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2007", "6" ] ] }, "page" : "903-9", "title" : "Recurrent concussion and risk of depression in retired professional football players.", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Guskiewicz et al., 2007)", "plainTextFormattedCitation" : "(Guskiewicz et al., 2007)", "previouslyFormattedCitation" : "(Guskiewicz et al., 2007)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Guskiewicz et al., 2007). A dose-response relationship was found between the number of concussions and the odds of depression in retired NFL football players: those with a history of three or more concussions were three times more likely to have a diagnosis of depression and those with one to two concussions were 1.5 times more likely than those with no history of concussion to have a clinical diagnosis of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1249/mss.0b013e3180383da5", "ISSN" : "0195-9131", "PMID" : "17545878", "abstract" : "PURPOSE: The purpose of our study was to investigate the association between prior head injury and the likelihood of being diagnosed with clinical depression among retired professional football players with prior head injury exposure.\n\nMETHODS: A general health questionnaire, including information about prior injuries, the SF-36 (Short Form 36), and other markers for depression, was completed by 2552 retired professional football players with an average age of 53.8 (+/-13.4) yr and an average professional football-playing career of 6.6 (+/-3.6) yr. A second questionnaire focusing on mild cognitive impairment (MCI)-related issues was completed by a subset of 758 retired professional football players (50 yr and older).\n\nRESULTS: Two hundred sixty-nine (11.1%) of all respondents reported having prior or current diagnosis of clinical depression. There was an association between recurrent concussion and diagnosis of lifetime depression (chi2=71.21, df=2, P<0.005), suggesting that the prevalence increases with increasing concussion history. Compared with retired players with no history of concussion, retired players reporting three or more previous concussions (24.4%) were three times more likely to be diagnosed with depression; those with a history of one or two previous concussions (36.3%) were 1.5 times more likely to be diagnosed with depression. The analyses controlled for age, number of years since retirement, number of years played, physical component score on the SF-36, and diagnosed comorbidities such as osteoarthritis, coronary heart disease, stroke, cancer, and diabetes.\n\nCONCLUSION: Our findings suggest a possible link between recurrent sport-related concussion and increased risk of clinical depression. The findings emphasize the importance of understanding potential neurological consequences of recurrent concussion.", "author" : [ { "dropping-particle" : "", "family" : "Guskiewicz", "given" : "Kevin M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marshall", "given" : "Stephen W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bailes", "given" : "Julian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCrea", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harding", "given" : "Herndon P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Matthews", "given" : "Amy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mihalik", "given" : "Johna Register", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Medicine and science in sports and exercise", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2007", "6" ] ] }, "page" : "903-9", "title" : "Recurrent concussion and risk of depression in retired professional football players.", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Guskiewicz et al., 2007)", "plainTextFormattedCitation" : "(Guskiewicz et al., 2007)", "previouslyFormattedCitation" : "(Guskiewicz et al., 2007)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Guskiewicz et al., 2007).Contributions from Pediatric StudiesResearch specific to the pediatric population addressing questions of psychiatric sequelae after TBI is sparse. ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kirkwood", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Janusz", "given" : "Jennifer", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yeates", "given" : "Keith", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "Gerry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wade", "given" : "Shari", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stancin", "given" : "Terry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Drotar", "given" : "Dennis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child Neuropsychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "195-208", "title" : "Prevalence and correlates of depressive symptoms following traumatic brain injuries in children", "type" : "article", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Kirkwood et al., 2000)", "manualFormatting" : "Kirkwood et al. (2000)", "plainTextFormattedCitation" : "(Kirkwood et al., 2000)", "previouslyFormattedCitation" : "(Kirkwood et al., 2000)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }Kirkwood et al. (2000) prospectively studied 189 children with moderate to severe TBI (6 – 12 years of age) and examined the prevalence and clinical correlates of depression. Baseline testing was completed using, self-report measures of depression, family environment and neurocognitive testing. These measures were repeated at 6 and 12 months. A slightly elevated prevalence of depressive symptoms was found. Fifteen percent of the sample had a T score on the Children’s Depression Inventory (CDI) of 60 six months after their injury and nine percent at 12 months post injury. A T score of 65 on the CDI is suggested to be indicative of clinical depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kovacs", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher" : "Multi-Health Systems", "title" : "Children's Depression Inventory-2", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Kovacs, 2011)", "plainTextFormattedCitation" : "(Kovacs, 2011)", "previouslyFormattedCitation" : "(Kovacs, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Kovacs, 2011); therefore, the children who had a T score of >60 in Kirkwood’s (2000) study may have had a sub-threshold depressive disorder. Depressive symptoms were associated with socioeconomic status in children with brain injuries as well as in a control group of those with orthopedic injury. Missing data may affect the results of both prevalence and any associated relationships. Similar findings regarding incidence were reported in a well conducted longitudinal prospective cohort study of 177 children 5 – 14 years of age and controls ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Max", "given" : "Jeffrey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keatley", "given" : "Eva", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilde", "given" : "Elisabeth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bigler", "given" : "Erin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schachar", "given" : "Russel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saunders", "given" : "Ann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ewing-Cobbs", "given" : "Linda", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chapman", "given" : "Sandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dennis", "given" : "Maureen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yang", "given" : "Tony", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levin", "given" : "Harvey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Int. J. Devl Neuroscience", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "239-245", "title" : "Depression in children and adolescents in the first 6 months after traumatic brain injury", "type" : "article-journal", "volume" : "30" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Max et al., 2012)", "plainTextFormattedCitation" : "(Max et al., 2012)", "previouslyFormattedCitation" : "(Max et al., 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Max et al., 2012). Participants were children hospitalized after TBI with 50% of the sample having had a mild injury. Results indicate that 11% were subsequently diagnosed with a new depressive disorder. Predictors of depression in this cohort were older age, traumatic lesions in left parietal and left inferior gyrus, as well as a family history of anxiety. Children 12 years of age and older had a five-fold increased risk of having depression in comparison with younger children. In contrast, Luis & Mittenberg (2002) in another prospective cohort found, a 38% rate of mood and anxiety disorders in a group of 6-15 year olds admitted to hospital with mild (N=42) and moderate/severe (N=19) brain injury six months post injury compared to 14%t in the orthopedic controls; 26% of the mood disorders were depression related. The significant predictors in this study were post-injury stress and severity of TBI. Finally in a weaker cross-sectional design study of children with concussion (only 5% of whom were admitted to hospital) demonstrated a much lower rate of 3% with depression 1 – 3 years after injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/dmcn.12263", "ISSN" : "1469-8749", "PMID" : "23992222", "abstract" : "AIM: To determine whether post-injury depressive symptoms, and pre-injury major life stressors and genetic factors (HTR1A C(-1019)G alleles; rs6295) are more common in children with mild traumatic brain injury (mTBI) who develop postconcussion syndrome (PCS) symptoms compared with children with asymptomatic mTBI.\n\nMETHOD: This was a cross-sectional study of 47 symptomatic children (32 males, 15 females; mean age 14y [SD 3y 3mo]) who experienced post-concussive symptoms for 7 or more days and 42 asymptomatic children (26 males 16 females; mean age 13y 6mo [SD 3y 1mo]) after mTBI. Outcome measures were the Postconcussion Symptoms Inventory (PCSI), the Children's Depression Inventory (CDI), standard questionnaire of previous life events, and buccal DNA analysis to determine genotype and allele frequencies for the HTR1A C(-1019)G polymorphism.\n\nRESULTS: Depressive symptoms were uncommon. CDI scores did not differ between groups. Allelic and genotypic frequencies for HTR1A C(-1019)G were similar in both groups. Symptomatic children continued to have elevated PCS scores compared with asymptomatic children 1.72 (SD 0.69) years later and had experienced significantly more life stressors (Wald (1)=8.51, p=0.004).\n\nINTERPRETATION: HTR1A polymorphisms do not differ in children with PCS. Children who have experienced more significant life stresses are more likely to develop PCS symptoms after mTBI.", "author" : [ { "dropping-particle" : "", "family" : "Smyth", "given" : "Kim", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Sandeep S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crawford", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dewey", "given" : "Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Parboosingh", "given" : "Jillian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barlow", "given" : "Karen M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental medicine and child neurology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "73-7", "title" : "The role of serotonin receptor alleles and environmental stressors in the development of post-concussive symptoms after pediatric mild traumatic brain injury.", "type" : "article-journal", "volume" : "56" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Smyth et al., 2014)", "plainTextFormattedCitation" : "(Smyth et al., 2014)", "previouslyFormattedCitation" : "(Smyth et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Smyth et al., 2014).These studies highlight the need for continued research in this area as differing populations (hospitalized versus non-hospitalized), varying length of follow up times (6 months – 3 years), different measures for outcome and divergent ages (younger children only or adolescents included) make it difficult to compare the clinical populations who served as participants. Studies to date have been more focused on the prevalence and prediction of post-concussive syndrome rather than on the psychosocial outcomes. No prospective long-term studies of depression specific to concussion in children have been conducted; however, the literature suggests an increased prevalence of depression after concussion that is greater than that reported in the general community and that occurs relatively early after injury. Depression after childhood concussion requires more empirical study to determine the extent of the problem and to answer questions about who may be vulnerable to this outcome. The Relationship Between Post-Concussion Syndrome and DepressionAssociations between prolonged recovery and depression have not been systematically studied. Investigators have reported that differential diagnosis of PCS and depression is not straightforward ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1155/2012/705309", "ISSN" : "2090-2875", "PMID" : "22292122", "abstract" : "Exercise assessment and aerobic exercise training for postconcussion syndrome (PCS) may reduce concussion-related physiological dysfunction and symptoms by restoring autonomic balance and improving cerebral blood flow autoregulation. In a descriptive pilot study of 91 patients referred to a university clinic for treatment of PCS, a subset of 63 patients were contacted by telephone for assessment of symptoms and return to full daily functioning. Those who experienced symptoms during a graded exercise treadmill test (physiologic PCS, n = 40) were compared to those who could exercise to capacity (PCS, n = 23). Both groups had been offered progressive exercise rehabilitation. Overall 41 of 57 (72%) who participated in the exercise rehabilitation program returned to full daily functioning. This included 27 of 35 (77%) from the physiologic PCS group, and 14 of 22 (64%) from the PCS group. Only 1 of the 6 patients who declined exercise rehabilitation returned to full functioning. Interpretation of these results is limited by the descriptive nature of the study, the small sample size, and the relatively few patients who declined exercise treatment. Nonetheless, exercise assessment indicates that approximately one third of those examined did not have physiologic PCS.", "author" : [ { "dropping-particle" : "", "family" : "Baker", "given" : "John G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Freitas", "given" : "Michael S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Leddy", "given" : "John J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kozlowski", "given" : "Karl F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Willer", "given" : "Barry S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Rehabilitation research and practice", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012", "1" ] ] }, "page" : "705309", "title" : "Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome.", "type" : "article-journal", "volume" : "2012" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "PMID" : "16901381", "abstract" : "Concussion and mild traumatic brain injury (mTBI) are common clinical problems. However, the literature is not consistent in defining how concussion and mTBI are related. Although most patients with concussion recover within days to weeks, approximately 10% develop persistent signs and symptoms of post-concussion syndrome (PCS). There are no scientifically established treatments for concussion or PCS and thus rest and cognitive rehabilitation are traditionally applied, with limited effectiveness. This article presents a clinical model to suggest that concussion evolves to become mTBI after PCS has developed, representing a more severe form of brain injury. The basic pathophysiology of concussion is presented, followed by a recommended approach to the clinical evaluation of concussion in the emergency department and the physician's office. We evaluate the limited evidence-based pharmacologic treatment of acute concussion symptoms and PCS symptoms and also discuss return to activity recommendations, with an emphasis on athletes. Lastly, we suggest a promising new direction for helping patients recover from PCS", "author" : [ { "dropping-particle" : "", "family" : "Willer", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Leddy", "given" : "J J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Current Treatment Options in Neurology", "id" : "ITEM-2", "issue" : "1092-8480 (Print)", "issued" : { "date-parts" : [ [ "2006" ] ] }, "language" : "eng PT - Journal Article", "note" : "DA - 20060811", "page" : "415-426", "publisher-place" : "University at Buffalo, G 96 Farber Hall, 3435 Main Street, Buffalo, NY 14214, USA. willer@", "title" : "Management of concussion and post-concussion syndrome", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Baker, Freitas, Leddy, Kozlowski, & Willer, 2012; Willer & Leddy, 2006)", "plainTextFormattedCitation" : "(Baker, Freitas, Leddy, Kozlowski, & Willer, 2012; Willer & Leddy, 2006)", "previouslyFormattedCitation" : "(Baker, Freitas, Leddy, Kozlowski, & Willer, 2012; Willer & Leddy, 2006)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Baker, Freitas, Leddy, Kozlowski, & Willer, 2012; Willer & Leddy, 2006). Increased symptom reporting, however, has been found to predict the development of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1176/appi.psy.44.1.31", "ISSN" : "0033-3182", "PMID" : "12515835", "abstract" : "The authors assessed the association of major depression with behavioral outcome following mild traumatic brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Rapoport", "given" : "Mark J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCullagh", "given" : "Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Streiner", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feinstein", "given" : "Anthony", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychosomatics", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "31-7", "title" : "The clinical significance of major depression following mild traumatic brain injury.", "type" : "article-journal", "volume" : "44" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Rapoport et al., 2003)", "plainTextFormattedCitation" : "(Rapoport et al., 2003)", "previouslyFormattedCitation" : "(Rapoport et al., 2003)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Rapoport et al., 2003) and those who are diagnosed with depression after mTBI endorse more post concussive symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/HTR.0b013e3181e4622a", "ISSN" : "1550-509X", "PMID" : "20631632", "abstract" : "OBJECTIVE: To examine the influence of depression on postconcussion symptom reporting in patients following mild traumatic brain injury (MTBI).\n\nPARTICIPANTS: Sixty patients referred to a specialty clinic following MTBI, 58 outpatients with Structured Clinical Interview for DSM-diagnosed depression, and 72 healthy community control participants.\n\nPROCEDURE: Participants with MTBI were divided into 2 subgroups on the basis of self-reported symptoms of depression (23 MTBI-depressed, 37 MTBI-not depressed). All participants completed a postconcussion symptom questionnaire.\n\nMAIN OUTCOME MEASURE: British Columbia Post-concussion Symptom Inventory.\n\nRESULTS: There were significant differences in total reported postconcussion symptoms among all 4 groups (all P < .002; Cohen's d = 0.68-3.24, large to very large effect sizes; MTBI-depressed > depressed outpatients > MTBI-no depression > healthy controls). There were significant differences in the number of symptoms endorsed (P < .05), with the highest number of symptoms endorsed by the MTBI-depressed group, followed by depressed outpatients, MTBI-no depression, and healthy controls.\n\nCONCLUSIONS: Patients who experience MTBIs and who have a postinjury recovery course complicated by significant depression report more postconcussion symptoms, and more severe symptoms, than (a) outpatients with depression, and (b) patients with MTBIs who do not have significant symptoms of depression.", "author" : [ { "dropping-particle" : "", "family" : "Lange", "given" : "Rael T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Alice", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of head trauma rehabilitation", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "127-37", "title" : "Depression strongly influences postconcussion symptom reporting following mild traumatic brain injury.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Lange et al., 2011)", "plainTextFormattedCitation" : "(Lange et al., 2011)", "previouslyFormattedCitation" : "(Lange et al., 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Lange et al., 2011). PCS is known also to exacerbate pre-existing depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.009", "ISSN" : "1558-1381", "PMID" : "22050943", "abstract" : "Each year in the United States, approximately 1.7 million people are diagnosed with a traumatic brain injury (TBI), about 75% of which are classified as mild TBIs or concussions. Although symptoms typically resolve in a matter of weeks, both children and adults may suffer from postconcussion syndrome for months or longer. A progressive tauopathy, chronic traumatic encephalopathy, is believed to stem from repeated brain trauma. Alzheimer-like dementia, Parkinsonism, and motor neuron disease are also associated with repetitive brain trauma. Effective diagnoses, treatments, and education plans are required to reduce the future burden and incidence of long-term effects of head injuries.", "author" : [ { "dropping-particle" : "", "family" : "Daneshvar", "given" : "Daniel H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Riley", "given" : "David O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nowinski", "given" : "Christopher J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McKee", "given" : "Ann C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stern", "given" : "Robert a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Physical medicine and rehabilitation clinics of North America", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2011", "11" ] ] }, "page" : "683-700, ix", "title" : "Long-term consequences: effects on normal development profile after concussion.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Daneshvar et al., 2011)", "plainTextFormattedCitation" : "(Daneshvar et al., 2011)", "previouslyFormattedCitation" : "(Daneshvar et al., 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Daneshvar et al., 2011). There continue to be many unanswered questions about the underlying causes of either of these outcomes. ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1001/archgenpsychiatry.2007.8", "ISSN" : "1538-3636", "PMID" : "18180432", "abstract" : "Depressed mood is frequently reported by individuals who have sustained cerebral concussion but little is known about the nature of this alteration in mood state.", "author" : [ { "dropping-particle" : "", "family" : "Chen", "given" : "Jen-Kai", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Johnston", "given" : "Karen M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Petrides", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ptito", "given" : "Alain", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of general psychiatry", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2008", "1" ] ] }, "page" : "81-9", "title" : "Neural substrates of symptoms of depression following concussion in male athletes with persisting postconcussion symptoms.", "type" : "article-journal", "volume" : "65" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Chen, Johnston, Petrides, & Ptito, 2008)", "manualFormatting" : "Chen,and collegues (2008)", "plainTextFormattedCitation" : "(Chen, Johnston, Petrides, & Ptito, 2008)", "previouslyFormattedCitation" : "(Chen, Johnston, Petrides, & Ptito, 2008)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }Chen,and collegues (2008) investigated the neural substrates of depression and prolonged symptoms after concussion with 56 young adult male athletes who had a concussion in the previous year. Functional magnetic resonance imaging (fMRI) has demonstrated differences between those experiencing depression versus those experiencing persistent negative symptoms and concluded that there is an organic basis to PCS that is different from that seen in depression. Depression and prolonged symptoms of concussion are similar with some overlapping symptoms particularly sleep disturbance, concentration and memory difficulties, fatigue and emotional symptoms such as irritability and sadness. Research is needed to advance our understanding about both of these outcomes and led to the research questions that form the basis of this thesis. Research ObjectivesThe purpose of this research is to examine depression in children who have experienced a concussive injury and to identify the factors associated with the development of depression. The research questions guiding this study are:Do children being followed for concussion at a local Children’s Hospital Acquired Brain Injury clinic develop depression during recovery, and at what point?What factors contribute to depression after concussion in the pediatric population?To what extent do injury-related factors: a) recovery time; b) mechanism of injury; c) number of injuries; and d) number and type of symptoms predict the presence of depressive symptoms 3 – 12 months after concussion in children 8 – 18 years of age?To what extent do non-injury related factors: a) age; b) sex; and c) premorbid diagnosis, learning and behavioural difficulties; predict the presence of depressive symptoms 3 – 12 months after concussion?What are the experiences of families living with their child’s prolonged recovery and depressive symptoms after concussion? Two different research methodologies are needed to answer these questions. A quantitative approach analyzing data collected from the Acquired Brain Injury database of the McMaster Children’s Hospital was utilized to address Questions 1 and 2 regarding any association between injury and non-injury variables and the development of depression in a child after concussion. Incidence and predictors of self-reported depression were also examined. These results are presented in Chapter Two. In order to address Question 3, a qualitative phenomenological study was conducted using face-to-face in-depth interviews of six children and their families in order to explore their lived experience of prolonged recovery from concussion when the child had significant depressive symptoms. The results of this study are presented in Chapter Three. The ultimate aim is to provide a more systematic approach to identifying children who may be experiencing depression during recovery from concussion. The results of the two studies are integrated and discussed in Chapter Four and clinical implications are described. It is anticipated that this study will lead to improved early identification and health care delivery for families and for the silent minority of children experiencing post-concussive depression.ReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY Abela, J., & Hankin, B. (2008). Handbook of Depression in Children and Adolescents. (J. Abela & B. Hankin, Eds.). New York: Guilford Press.Ahmoi, C., & Petermann, F. (Eds.). (1999). Depressive Disorders in Children and Adolescents: Epidemiology, Risk Facors and Treatment. New Jersey, NJ: Library of Congress.Allgaier, A.-K., Frühe, B., Pietsch, K., Saravo, B., Baethmann, M., & Schulte-K?rne, G. (2012). Is the Children’s Depression Inventory Short version a valid screening tool in pediatric care? A comparison to its full-length version. Journal of Psychosomatic Research, 73(5), 369–74. doi:10.1016/j.jpsychores.2012.08.016Association, A. P. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC.Association, A. P. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.Babcock, L., Byczkowski, T., Wade, S. L., Ho, M., Mookerjee, S., & Bazarian, J. J. (2013). Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department. JAMA Pediatrics, 167(2), 156–61. doi:10.1001/jamapediatrics.2013.434Baker, J. G., Freitas, M. S., Leddy, J. J., Kozlowski, K. F., & Willer, B. S. (2012). Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussion syndrome. Rehabilitation Research and Practice, 2012, 705309. doi:10.1155/2012/705309Barlow, K. M., Crawford, S., Stevenson, A., Sandhu, S. S., Belanger, F., & Dewey, D. (2010). 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OT Reg (Ont), Carol DeMatteo MSc., Dip P & OT, OT Reg (Ont), Sandra Moll Ph.D, OT Reg (Ont), Cheryl Missiuna Ph.D, OT Reg (Ont)To be submitted to: Brain InjuryAbstractObjectives: Although depression can be a serious consequence of concussion, little is known about the factors that predict depression and concussion recovery outcomes in children. The purpose of this study was to explore the risk and possible predictors of developing significant depressive symptoms in children recovering from concussion. Methods: A prospective cohort study was conducted in a pediatric tertiary care clinic. Depression data was collected on 92 children using the Children’s Depression Inventory-2 (CDI-2) screening tool. Correlations, t-tests and logistic regression were used to examine the associations between depression scores and demographic as well as injury-related factors. Results: Depressive symptoms were found in 22% of the children (T score on CDI-2 > 65). Children with evidence of depressive symptomatology had significantly higher mean post- concussive symptom inventory (PCSI) scores in recovery (p=0.004) than children who were not depressed. i) Sex; ii) hospital admission; iii) number of head injuries; iv) post-concussion symptom score and v) experience of prolonged symptoms were predictive of clinically significant CDI T scores, explaining 36% of the variation in the binary logistic model. Conclusion: Depression is commonly reported in this subset of children. High post-concussive symptom scores and hospital admission were strong predictors of depression. Screening for depression should be standard practice in concussion management in children and youth.In the United States, the incidence of concussion is reported to be between 1.7 and 3.8 million individuals per year; more than half are children ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.pmrj.2011.07.015", "ISSN" : "1934-1563", "PMID" : "22035679", "abstract" : "ABSTRACTS: Sports-related concussions are common among pediatric and adolescent athletes, yet a scarcity of age-specific research often has meant that practitioners use guidelines developed for collegiate or adult populations. This situation is changing, as more studies are being published about this population that bears special attention because of the immaturity of the developing brain. 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Recent figures from sports injuries alone show that the prevalence of concussions doubled in the 8-19 year old age group from 1997 to 2007 ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2009-3101", "ISBN" : "1098-4275 (Electronic) 0031-4005 (Linking)", "ISSN" : "0031-4005", "PMID" : "20805145", "abstract" : "OBJECTIVES: The objective of this study was to characterize emergency department (ED) visits for pediatric sport-related concussion (SRC) in pre-high school- versus high school-aged athletes. METHODS: A stratified probability sample of US hospitals that provide emergency services in the National Electronic Injury Surveillance System (1997-2007) and All Injury Program (2001-2005) was used. Concussion-related ED visits were analyzed for 8- to 13- and 14- to 19-year-old patients. Population data were obtained from the US Census Bureau; sport participation data were obtained from National Sporting Goods Association. RESULTS: From 2001 to 2005, US children who were aged 8 to 19 years had an estimated 502 000 ED visits for concussion. The 8- to 13-year-old group accounted for approximately 35% of these visits. Approximately half of all ED visits for concussion were SRC. The 8- to 13-year-old group sustained 40% of these, which represents 58% of all concussions in this group. Approximately 25% of all SRC visits in the 8- to 13-year-old group occurred during organized team sport (OTS). During the study period, approximately 4 in 1000 children aged 8 to 13 years and 6 in 1000 children aged 14 to 19 years had an ED visit for SRC, and 1 in 1000 children aged 8 to 13 years and 3 in 1000 children aged 14 to 19 years had an ED visit for concussion sustained during OTS. From 1997 to 2007, although participation had declined, ED visits for concussions in OTS in 8- to 13-year-old children had doubled and had increased by >200% in the 14- to 19-year-old group. CONCLUSIONS: The number of SRCs in young athletes is noteworthy. Additional research is required.", "author" : [ { "dropping-particle" : "", "family" : "Bakhos", "given" : "Lisa L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lockhart", "given" : "Gregory R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Myers", "given" : "Richard", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Linakis", "given" : "James G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "e550-e556", "title" : "Emergency department visits for concussion in young child athletes.", "type" : "article-journal", "volume" : "126" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[2]", "plainTextFormattedCitation" : "[2]", "previouslyFormattedCitation" : "[2]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[2]. Children are a vulnerable group and have the potential for many injuries over their lifespan especially given that concussion is a predictor of future concussions ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2006-1186", "ISSN" : "1098-4275", "PMID" : "17403846", "abstract" : "OBJECTIVE: The objective of this study was to determine whether children who sought care for a head injury were at greater risk of having a subsequent head injury within the following 6 and 12 months compared with children who sought care for an injury other than to the head. DESIGN/SETTING: This was a longitudinal cohort study conducted in the emergency departments of 2 Montreal (Quebec, Canada) pediatric hospitals. PARTICIPANTS: The parents of 11,867 injured children aged 1 to 18 years were interviewed by telephone at 6 (n = 10,315) and 12 (n = 9486) months after their child's injury to ascertain outcome (ie, subsequent head injury) and to provide information on potential risk factors (age, gender, chronic medical condition, activity level, and socioeconomic status). MAIN OUTCOME MEASURE: The outcome of interest was a head injury requiring medical attention within the following year ascertained by parental recall or physician claims data. RESULTS: A total of 245 and 386 previously head-injured children sustained a subsequent head injury within 6 and 12 months, respectively. Children who sought care for an initial head injury (n = 3599) were at higher risk of having a subsequent head injury within 6 months than children who sought care for an injury not to the head (n = 6716). The adjusted odds ratio suggested weak confounding by age, gender, and history of previous head injury. Results were consistent on the basis of physician claims data and 12-month follow-up interview data. CONCLUSIONS: These results provide evidence that having a head injury increases a child's risk of having a subsequent head injury. Although age, gender, and history of previous head injury confound the relationship, the effect remains substantial.", "author" : [ { "dropping-particle" : "", "family" : "Swaine", "given" : "Bonnie R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Tremblay", "given" : "Camille", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Platt", "given" : "Robert W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grimard", "given" : "Guy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zhang", "given" : "Xun", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pless", "given" : "I Barry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2007" ] ] }, "page" : "749-758", "title" : "Previous head injury is a risk factor for subsequent head injury in children: a longitudinal cohort study.", "type" : "article-journal", "volume" : "119" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1002/acn3.70", "ISSN" : "2328-9503", "PMID" : "25356413", "abstract" : "OBJECTIVES: The purpose of this study was to evaluate the association of prior concussion on baseline computerized neurocognitive testing in a large cohort of high school athletes.\n\nMETHODS: This is a retrospective cohort study of student athletes from 49 Maine High Schools in 2010 who underwent baseline computerized neurocognitive evaluation with Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT\u00ae). As part of the ImPACT\u00ae, subjects reported a prior history of concussion as well as demographic information and a symptom questionnaire. We used linear regression to evaluate the association of prior concussion with baseline: (1) ImPACT\u00ae composite scores; and (2) symptom scores.\n\nRESULTS: Six thousand seventy-five subjects were included in the study, of whom 57% were boys. The majority of student athletes (85.3%) reported no prior history of concussion while 4.6% reported having sustained two or more prior concussions. On simple linear regression, increasing number of concussions was related to worse performance in verbal memory (P = 0.039) and greater symptoms scores (P < 0.001). On multivariate modeling, only the association with baseline symptoms remained (P < 0.001). Other factors associated with baseline symptom reporting in the multivariate model included mental health history, headache/migraine history, gender, developmental and/or learning problems, and number of prior concussions.\n\nINTERPRETATION: In this large-scale, retrospective survey study, history of multiple prior concussions was associated with higher symptom burden but not baseline computerized neurocognitive testing. The association between baseline symptom reporting and clinical and demographic factors was greater than the association with a history of multiple concussions.", "author" : [ { "dropping-particle" : "", "family" : "Mannix", "given" : "Rebekah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Maxwell", "given" : "Bruce", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Atkins", "given" : "Joseph E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zafonte", "given" : "Ross", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Berkner", "given" : "Paul D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Annals of clinical and translational neurology", "id" : "ITEM-2", "issue" : "6", "issued" : { "date-parts" : [ [ "2014", "6" ] ] }, "page" : "433-8", "title" : "Multiple prior concussions are associated with symptoms in high school athletes.", "type" : "article-journal", "volume" : "1" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[3], [4]", "manualFormatting" : "[3, 4]", "plainTextFormattedCitation" : "[3], [4]", "previouslyFormattedCitation" : "[3], [4]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[3, 4]. Recovery trajectories for children post-concussion are varied ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpeds.2014.08.034", "ISSN" : "1097-6833", "PMID" : "25262302", "abstract" : "OBJECTIVE: To identify pre-existing characteristics associated with prolonged recovery from concussion in a sample of patients referred to a pediatric sports medicine clinic.\n\nSTUDY DESIGN: This was a retrospective, exploratory cohort study of 247 patients age 5-18\u00a0years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010, through December 31, 2011. A random sample of all eligible patient visits (3740) was chosen for further review and abstraction. Statistical comparisons between subsets of patients were conducted using exact \u03c7(2) tests, logistic regression, quantile regression, and Kaplan-Meier survival curves.\n\nRESULTS: The median time until returning to school part-time was 12\u00a0days (IQR 6-21); until returning to school full-time without accommodations was 35\u00a0days (IQR 11-105); until becoming symptom-free was 64\u00a0days (IQR 18-119); and until being fully cleared to return to sports was 75\u00a0days (IQR 30-153). Furthermore, 73% of all patients were symptomatic for >4\u00a0weeks, 73% were prescribed some form of school accommodation, and 61% reported a decline in grades. Characteristics associated with a prolonged recovery included a history of depression or anxiety; an initial complaint of dizziness; abnormal convergence or symptom provocation following oculomotor examination on physical examination; and history of prior concussion.\n\nCONCLUSIONS: Pediatric and adolescent patients with concussion may experience cognitive and emotional morbidity that can last for several months following injury. Clinicians should consider specific pre-existing characteristics and presenting symptoms that may be associated with a more complicated recovery for concussion patients.", "author" : [ { "dropping-particle" : "", "family" : "Corwin", "given" : "Daniel J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zonfrillo", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Master", "given" : "Christina L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Arbogast", "given" : "Kristy B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grady", "given" : "Matthew F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "Roni L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goodman", "given" : "Arlene M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wiebe", "given" : "Douglas J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014", "9", "25" ] ] }, "page" : "1-9", "publisher" : "Elsevier\u00a0Inc", "title" : "Characteristics of Prolonged Concussion Recovery in a Pediatric Subspecialty Referral Population.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1177/0009922814558256", "ISBN" : "0009922814", "ISSN" : "0009-9228", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stazyk", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Singh", "given" : "S. K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giglia", "given" : "L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hollenberg", "given" : "R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Malcolmson", "given" : "C. H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mahoney", "given" : "W.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harper", "given" : "J. a.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Missiuna", "given" : "C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Law", "given" : "M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCauley", "given" : "D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical Pediatrics", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "152-163", "title" : "Development of a Conservative Protocol to Return Children and Youth to Activity Following Concussive Injury", "type" : "article-journal", "volume" : "54" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[5], [6]", "manualFormatting" : "[5, 6]", "plainTextFormattedCitation" : "[5], [6]", "previouslyFormattedCitation" : "[5], [6]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[5, 6] and are currently described on the basis of the length of symptom presentation; under one month, between 1 – 3 months and over 3 months. Symptoms of concussion are categorized as somatic (e.g., headache and balance issues), emotional (e.g., irritability and anxiety), cognitive (e.g., difficulty concentrating and remembering) and sleep symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Gioia", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "MW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "publisher-place" : "USA", "title" : "Acute Concussion Evaluation", "type" : "patent" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[7]", "plainTextFormattedCitation" : "[7]", "previouslyFormattedCitation" : "[7]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[7]. Childhood concussive injuries typically resolve in days or weeks but some of these “mild” injuries can have serious and prolonged health consequences ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1148/radiol.13122542", "abstract" : "Purpose: To investigate longitudinal changes in global and regional brain volume in patients 1 year after mild traumatic brain injury (MTBI) and to correlate such changes with clinical and neurocognitive metrics.Materials and Methods: This institutional review board\u2013approved study was HIPAA compliant. Twenty-eight patients with MTBI (with 19 followed up at 1 year) with posttraumatic symptoms after injury and 22 matched control subjects (with 12 followed up at 1 year) were enrolled. Automated segmentation of brain regions to compute regional gray matter (GM) and white matter (WM) volumes was performed by using three-dimensional T1-weighted 3.0-T magnetic resonance imaging, and results were correlated with clinical metrics. Pearson and Spearman rank correlation coefficients were computed between longitudinal brain volume and neurocognitive scores, as well as clinical metrics, over the course of the follow-up period.Results: One year after MTBI, there was measurable global brain atrophy, larger than that in control subjects. The anterior cingulate WM bilaterally and the left cingulate gyrus isthmus WM, as well as the right precuneal GM, showed significant decreases in regional volume in patients with MTBI over the 1st year after injury (corrected P < .05); this was confirmed by means of cross-sectional comparison with data in control subjects (corrected P < .05). Left and right rostral anterior cingulum WM volume loss correlated with changes in neurocognitive measures of memory (r = 0.65, P = .005) and attention (r = 0.60, P = .01). At 1-year follow-up, WM volume in the left cingulate gyrus isthmus correlated with clinical scores of anxiety (Spearman rank correlation r = \u22120.68, P = .007) and postconcussive symptoms (Spearman rank correlation r = \u22120.65, P = .01).Conclusion: These observations demonstrate structural changes to the brain 1 year after injury after a single concussive episode. Regional brain atrophy is not exclusive to moderate and severe traumatic brain injury but may be seen after mild injury. In particular, the anterior part of the cingulum and the cingulate gyrus isthmus, as well as the precuneal GM, may be distinctively vulnerable 1 year after MTBI.\u00a9 RSNA, 2013 ", "author" : [ { "dropping-particle" : "", "family" : "Zhou", "given" : "Yongxia", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kierans", "given" : "Andrea", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kenul", "given" : "Damon", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ge", "given" : "Yulin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rath", "given" : "Joseph", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reaume", "given" : "Joseph", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grossman", "given" : "Robert I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lui", "given" : "Yvonne W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Radiology ", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013", "3", "12" ] ] }, "note" : "10.1148/radiol.13122542", "title" : "Mild Traumatic Brain Injury: Longitudinal Regional Brain Volume Changes", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1001/archpediatrics.2011.1082", "ISSN" : "1538-3628", "PMID" : "22393171", "abstract" : "OBJECTIVE: To examine reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury (TBI) over the first year postinjury as compared with children with orthopedic injuries. DESIGN: Prospective, longitudinal cohort. SETTING: Emergency departments at 2 children's hospitals. PARTICIPANTS: Eight- to 15-year-old children with mild TBI (n\u00a0=\u00a0186) or orthopedic injuries (n\u00a0=\u00a099). Main Exposure\u00a0 Closed-head or orthopedic trauma. MAIN OUTCOME MEASURES: Parents rated preinjury symptoms retrospectively shortly after injury and postconcussive symptoms at 2 weeks and 3 and 12 months postinjury. A regression-based approach was used to determine whether each child displayed reliable increases in postconcussive symptoms at each postinjury occasion. Health-related quality of life was assessed at 3 and 12 months postinjury. Information regarding children's educational programming was collected at the initial and 12-month assessments. RESULTS: Children with mild TBI were significantly more likely than those with orthopedic injuries to show reliable increases in both cognitive and somatic symptoms. Group differences in the likelihood of reliable increases became less common with time for somatic symptoms but persisted to 12 months postinjury for cognitive symptoms. Among children with mild TBI, reliable increases in symptoms were more common among children with loss of consciousness or abnormalities on neuroimaging. Reliable increases in symptoms were associated with significant declines in health-related quality of life and an increased likelihood of educational intervention. CONCLUSION: Many children with mild TBI show reliable increases in postconcussive symptoms that are associated with significant functional impairment in their daily lives.", "author" : [ { "dropping-particle" : "", "family" : "Yeates", "given" : "Keith Owen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kaizar", "given" : "Eloise", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rusin", "given" : "Jerome", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bangert", "given" : "Barbara", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dietrich", "given" : "Ann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nuss", "given" : "Kathryn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wright", "given" : "Martha", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "H Gerry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of pediatrics & adolescent medicine", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2012", "3", "5" ] ] }, "page" : "1-8", "title" : "Reliable Change in Postconcussive Symptoms and Its Functional Consequences Among Children With Mild Traumatic Brain Injury.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[8], [9]", "manualFormatting" : "[8,9]", "plainTextFormattedCitation" : "[8], [9]", "previouslyFormattedCitation" : "[8], [9]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[8,9]. When symptoms last more than 3 months they can significantly affect the child’s everyday life and may intensify emotional or depressive symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Duffy A", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012", "9", "26" ] ] }, "publisher-place" : "Ottawa", "title" : "Concussions ruin quality of life for young athletes", "type" : "article-newspaper" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[10]", "plainTextFormattedCitation" : "[10]", "previouslyFormattedCitation" : "[10]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[10]. Children and adolescents are at higher risk for prolonged symptoms after concussion with 11- 30% of children report ongoing symptoms at 3 months post injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2009-0925", "ISSN" : "1098-4275", "PMID" : "20660554", "abstract" : "Much disagreement exists as to whether postconcussion syndrome (PCS) is attributable to brain injury or to other factors such as trauma alone, preexisting psychosocial problems, or medicolegal issues. We investigated the epidemiology and natural history of PCS symptoms in a large cohort of children with a mild traumatic brain injury (mTBI) and compared them with children with an extracranial injury (ECI).", "author" : [ { "dropping-particle" : "", "family" : "Barlow", "given" : "Karen Maria", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crawford", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stevenson", "given" : "Andrea", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Sandeep Sona", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Belanger", "given" : "Fran\u00e7ois", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dewey", "given" : "Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2010", "8" ] ] }, "page" : "e374-81", "title" : "Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury.", "type" : "article-journal", "volume" : "126" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1001/jamapediatrics.2013.434", "ISSN" : "2168-6211", "PMID" : "23247384", "abstract" : "To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Babcock", "given" : "Lynn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Byczkowski", "given" : "Terri", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wade", "given" : "Shari L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ho", "given" : "Mona", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mookerjee", "given" : "Sohug", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bazarian", "given" : "Jeffrey J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "JAMA pediatrics", "id" : "ITEM-2", "issue" : "2", "issued" : { "date-parts" : [ [ "2013", "2" ] ] }, "page" : "156-61", "title" : "Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department.", "type" : "article-journal", "volume" : "167" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[11], [12]", "manualFormatting" : "[11,12]", "plainTextFormattedCitation" : "[11], [12]", "previouslyFormattedCitation" : "[11], [12]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[11,12].While there are frequent references to the risk of developing depression after mild traumatic brain injury (mTBI) otherwise known as concussion, there is little evidence specifically about this result in children. Psychosocial outcomes after childhood concussion are beginning to receive more attention, as depression in young people profoundly affects their participation in school, social and physical activities as well as putting youth at risk for suicidal behavior, substance abuse and negative life trajectories ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Garland", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Solomons", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "BC Medical Journal", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "469-472", "title" : "Early detection of depression in young and elderly people", "type" : "article-journal", "volume" : "44" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Children's Mental Health", "given" : "Ontario", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2001" ] ] }, "number-of-pages" : "1 - 27", "title" : "Evidence based practices for depression in children and adolescents", "type" : "report" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[13], [14]", "manualFormatting" : "[13,14]", "plainTextFormattedCitation" : "[13], [14]", "previouslyFormattedCitation" : "[13], [14]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[13,14]. The prevalence for depression in the general population is reported to be 1- 2% in children and 4-8% in adolescents ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Children's Mental Health", "given" : "Ontario", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2001" ] ] }, "number-of-pages" : "1 - 27", "title" : "Evidence based practices for depression in children and adolescents", "type" : "report" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "editor" : [ { "dropping-particle" : "", "family" : "Ahmoi", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Petermann", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "1999" ] ] }, "publisher" : "Library of Congress", "publisher-place" : "New Jersey, NJ", "title" : "Depressive Disorders in Children and Adolescents: Epidemiology, Risk Facors and Treatment", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[14], [15]", "manualFormatting" : "[14,15]", "plainTextFormattedCitation" : "[14], [15]", "previouslyFormattedCitation" : "[14], [15]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[14,15]. Girls report depression more than boys beginning at 12 years of age and increasing to a 2:1 ratio in later adolescence and adulthood ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Canada", "given" : "Public Health Agency of", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher-place" : "Ottawa", "title" : "The chief public health officer's report on the state of public health in Canada 2011", "type" : "report" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[16]", "plainTextFormattedCitation" : "[16]", "previouslyFormattedCitation" : "[16]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[16]. Injury or illness increases the susceptibility to depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/HTR.0b013e31825ad658", "author" : [ { "dropping-particle" : "", "family" : "Silverberg", "given" : "Noah D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J Head Trauma Rehabil", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "250-259", "title" : "Is Rest After Concussion \u201c The Best Medicine ?\u201d: Recommendations for Activity Resumption Following Concussion in Athletes , Civilians , and Military Service Members", "type" : "article-journal", "volume" : "28" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.yebeh.2005.10.012", "ISSN" : "1525-5050", "PMID" : "16356779", "abstract" : "Depression is one of the most prevalent of the psychiatric disorders and is common among individuals with epilepsy. Depression often begins in adolescence. The present review focuses on adolescent depression. In particular, this review first summarizes the definition, description, and classification of adolescent depression. Next, potential causes of adolescent depression are reviewed from a vulnerability-stress perspective. This part of the review focuses on the role of stressors and how stressors interact with genetic, biological, cognitive, personality, and interpersonal vulnerabilities to predict adolescent depression. Last, clinical aspects of adolescent depression are reviewed, including treatment and prevention of depression and the relation to epileptic disorders in adolescence. In sum, a substantial percentage of youth with epilepsy and seizures exhibit depression, and many are not diagnosed or treated in a timely manner. The present review shows that there are valid, empirically based assessments, treatments, and preventions for depression in adolescence that hold promise for reducing the significant burden associated with depression.", "author" : [ { "dropping-particle" : "", "family" : "Hankin", "given" : "Benjamin L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Epilepsy & behavior : E&B", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2006", "2" ] ] }, "page" : "102-14", "title" : "Adolescent depression: description, causes, and interventions.", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[17], [18]", "manualFormatting" : "[17,18]", "plainTextFormattedCitation" : "[17], [18]", "previouslyFormattedCitation" : "[17], [18]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[17,18]. Within the first year after concussion adults demonstrate rates of 15 – 18% of new onset depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1176/appi.neuropsych.22.1.100.Predictors", "author" : [ { "dropping-particle" : "", "family" : "Rao", "given" : "Vani", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bertrand", "given" : "Melaine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rosenberg", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Makley", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schretlen", "given" : "David J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brandt", "given" : "Jason", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mielke", "given" : "Michelle M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J. Neuropsychiatry Clin Neurosci.", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "100-104", "title" : "Predictors of new-onset depression after mild traumatic brain injury", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1176/appi.psy.44.1.31", "ISSN" : "0033-3182", "PMID" : "12515835", "abstract" : "The authors assessed the association of major depression with behavioral outcome following mild traumatic brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Rapoport", "given" : "Mark J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCullagh", "given" : "Scott", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Streiner", "given" : "David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feinstein", "given" : "Anthony", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychosomatics", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "31-7", "title" : "The clinical significance of major depression following mild traumatic brain injury.", "type" : "article-journal", "volume" : "44" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[19], [20]", "manualFormatting" : "[19, 20]", "plainTextFormattedCitation" : "[19], [20]", "previouslyFormattedCitation" : "[19], [20]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[19, 20]. Recent studies investigating depression after concussion in children fall into two categories: 1) those investigating the risk of depression based on exposure to concussion and 2) those that are investigating depression that occurs shortly after injury, complicating the recovery from concussion. Consistent results from the former studies show an increased likelihood of becoming depressed when there is a history of concussion or traumatic brain injury (TBI) ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jadohealth.2013.10.006", "ISBN" : "1879-1972", "ISSN" : "18791972", "PMID" : "24355628", "abstract" : "Purpose: Previous studies in adults have suggested concussion and other brain injury presents a risk factor for depression. The goal of our study was to analyze the association between previous concussion and current depression diagnosis in a large nationally representative adolescent data set. Methods: Retrospective cohort study using the National Survey of Children's Health 2007-2008, a nationally representative survey conducted via random digit dialing. Data were obtained by parental report. We included youth 12-17 years old without a current concussion (N = 36,060), and evaluated the association between previous concussion (binary) and current depression diagnosis (binary) using multiple logistic regression to control for age, sex, parental mental health, and socioeconomic status. Results: After controlling for age, sex, parental mental health, and socioeconomic status, history of concussion was associated with a 3.3-fold greater risk for depression diagnosis (95% CI: 2.0-5.5). Other factors significantly associated with depression diagnosis included poor or fair parental mental health (OR: 3.7, 95% CI: 2.8-4.9), and older age (15-17 years vs. 12-14 years, OR: 1.4, 95% CI: 1.1-1.8). Sex of the subject was not significantly related to depression diagnosis. Being above 200% of the poverty level was associated with approximately a 50% decreased risk of depression diagnosis (95% CI: 35%-70%). Conclusions: History of concussion was associated with a higher prevalence of diagnosed depression in a large nationally representative adolescent data set. Clinicians should screen for depression in their adolescent patients with concussion. Future studies should confirm this association using prospective methodology and examine potential treatment approaches. ?? 2014 Society for Adolescent Health and Medicine. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Chrisman", "given" : "Sara P D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Richardson", "given" : "Laura P.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Adolescent Health", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "582-586", "publisher" : "Elsevier Ltd", "title" : "Prevalence of diagnosed depression in adolescents with history of concussion", "type" : "article-journal", "volume" : "54" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1371/journal.pone.0094936", "ISBN" : "1932-6203 (Electronic) 1932-6203 (Linking)", "ISSN" : "19326203", "PMID" : "24736613", "abstract" : "OBJECTIVE: Our knowledge on the adverse correlates of traumatic brain injuries (TBI), including non-hospitalized cases, among adolescents is limited to case studies. We report lifetime TBI and adverse mental health and conduct behaviours associated with TBI among adolescents from a population-based sample in Ontario.\\n\\nMETHOD AND FINDINGS: Data were derived from 4,685 surveys administered to adolescents in grades 7 through 12 as part of the 2011 population-based cross-sectional Ontario Student Drug Use and Health Survey (OSDUHS). Lifetime TBI was defined as head injury that resulted in being unconscious for at least 5 minutes or being retained in the hospital for at least one night, and was reported by 19.5% (95%CI:17.3,21.9) of students. When holding constant sex, grade, and complex sample design, students with TBI had significantly greater odds of reporting elevated psychological distress (AOR\u200a=\u200a1.52), attempting suicide (AOR\u200a=\u200a3.39), seeking counselling through a crisis help-line (AOR\u200a=\u200a2.10), and being prescribed medication for anxiety, depression, or both (AOR\u200a=\u200a2.45). Moreover, students with TBI had higher odds of being victimized through bullying at school (AOR\u200a=\u200a1.70), being cyber-bullied (AOR\u200a=\u200a2.05), and being threatened with a weapon at school (AOR\u200a=\u200a2.90), compared with students who did not report TBI. Students with TBI also had higher odds of victimizing others and engaging in numerous violent as well as nonviolent conduct behaviours.\\n\\nCONCLUSIONS: Significant associations between TBI and adverse internalizing and externalizing behaviours were found in this large population-based study of adolescents. Those who reported lifetime TBI were at a high risk for experiencing mental and physical health harms in the past year than peers who never had a head injury. Primary physicians should be vigilant and screen for potential mental heath and behavioural harms in adolescent patients with TBI. Efforts to prevent TBI during adolescence and intervene at an early stage may reduce injuries and comorbid problems in this age group.", "author" : [ { "dropping-particle" : "", "family" : "Ilie", "given" : "Gabriela", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mann", "given" : "Robert E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boak", "given" : "Angela", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Adlaf", "given" : "Edward M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hamilton", "given" : "Hayley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Asbridge", "given" : "Mark", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rehm", "given" : "J\u00fcrgen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cusimano", "given" : "Michael D.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "PLoS ONE", "id" : "ITEM-2", "issue" : "4", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "10-15", "title" : "Suicidality, bullying and other conduct and mental health correlates of traumatic brain injury in adolescents", "type" : "article-journal", "volume" : "9" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[21], [22]", "manualFormatting" : "[21, 22]", "plainTextFormattedCitation" : "[21], [22]", "previouslyFormattedCitation" : "[21], [22]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[21, 22]. However studies exploring depression that occurs during recovery from concussion are less conclusive in determining prevalence. Two prospective studies found an 11% and 21.4% incidence of new onset of depression/anxiety in children within 6 months after their injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Max", "given" : "Jeffrey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keatley", "given" : "Eva", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilde", "given" : "Elisabeth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bigler", "given" : "Erin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schachar", "given" : "Russel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saunders", "given" : "Ann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ewing-Cobbs", "given" : "Linda", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chapman", "given" : "Sandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dennis", "given" : "Maureen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yang", "given" : "Tony", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levin", "given" : "Harvey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Int. J. Devl Neuroscience", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "239-245", "title" : "Depression in children and adolescents in the first 6 months after traumatic brain injury", "type" : "article-journal", "volume" : "30" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1076/jcen.24.3.270.982", "ISBN" : "1380-3395", "ISSN" : "1380-3395", "PMID" : "11992209", "abstract" : "Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children - IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Luis", "given" : "Cheryl a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mittenberg", "given" : "Wiley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical and experimental neuropsychology", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "270-279", "title" : "Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[23], [24]", "manualFormatting" : "[23, 24]", "plainTextFormattedCitation" : "[23], [24]", "previouslyFormattedCitation" : "[23], [24]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[23, 24]. Both of these studies drew their samples from children who were hospitalized for mild injuries, which potentially introduces selection bias as more severe cases are hospitalized. A recent cross-sectional study of post-concussive children 7 – 17 years old examined them 1 – 3 years post injury for depression and post-concussion symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/dmcn.12263", "ISSN" : "1469-8749", "PMID" : "23992222", "abstract" : "AIM: To determine whether post-injury depressive symptoms, and pre-injury major life stressors and genetic factors (HTR1A C(-1019)G alleles; rs6295) are more common in children with mild traumatic brain injury (mTBI) who develop postconcussion syndrome (PCS) symptoms compared with children with asymptomatic mTBI.\n\nMETHOD: This was a cross-sectional study of 47 symptomatic children (32 males, 15 females; mean age 14y [SD 3y 3mo]) who experienced post-concussive symptoms for 7 or more days and 42 asymptomatic children (26 males 16 females; mean age 13y 6mo [SD 3y 1mo]) after mTBI. Outcome measures were the Postconcussion Symptoms Inventory (PCSI), the Children's Depression Inventory (CDI), standard questionnaire of previous life events, and buccal DNA analysis to determine genotype and allele frequencies for the HTR1A C(-1019)G polymorphism.\n\nRESULTS: Depressive symptoms were uncommon. CDI scores did not differ between groups. Allelic and genotypic frequencies for HTR1A C(-1019)G were similar in both groups. Symptomatic children continued to have elevated PCS scores compared with asymptomatic children 1.72 (SD 0.69) years later and had experienced significantly more life stressors (Wald (1)=8.51, p=0.004).\n\nINTERPRETATION: HTR1A polymorphisms do not differ in children with PCS. Children who have experienced more significant life stresses are more likely to develop PCS symptoms after mTBI.", "author" : [ { "dropping-particle" : "", "family" : "Smyth", "given" : "Kim", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Sandeep S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crawford", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dewey", "given" : "Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Parboosingh", "given" : "Jillian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barlow", "given" : "Karen M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental medicine and child neurology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "73-7", "title" : "The role of serotonin receptor alleles and environmental stressors in the development of post-concussive symptoms after pediatric mild traumatic brain injury.", "type" : "article-journal", "volume" : "56" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[25]", "plainTextFormattedCitation" : "[25]", "previouslyFormattedCitation" : "[25]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[25]. Depression was found to be uncommon and was experienced by only 3% of their sample ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/dmcn.12263", "ISSN" : "1469-8749", "PMID" : "23992222", "abstract" : "AIM: To determine whether post-injury depressive symptoms, and pre-injury major life stressors and genetic factors (HTR1A C(-1019)G alleles; rs6295) are more common in children with mild traumatic brain injury (mTBI) who develop postconcussion syndrome (PCS) symptoms compared with children with asymptomatic mTBI.\n\nMETHOD: This was a cross-sectional study of 47 symptomatic children (32 males, 15 females; mean age 14y [SD 3y 3mo]) who experienced post-concussive symptoms for 7 or more days and 42 asymptomatic children (26 males 16 females; mean age 13y 6mo [SD 3y 1mo]) after mTBI. Outcome measures were the Postconcussion Symptoms Inventory (PCSI), the Children's Depression Inventory (CDI), standard questionnaire of previous life events, and buccal DNA analysis to determine genotype and allele frequencies for the HTR1A C(-1019)G polymorphism.\n\nRESULTS: Depressive symptoms were uncommon. CDI scores did not differ between groups. Allelic and genotypic frequencies for HTR1A C(-1019)G were similar in both groups. Symptomatic children continued to have elevated PCS scores compared with asymptomatic children 1.72 (SD 0.69) years later and had experienced significantly more life stressors (Wald (1)=8.51, p=0.004).\n\nINTERPRETATION: HTR1A polymorphisms do not differ in children with PCS. Children who have experienced more significant life stresses are more likely to develop PCS symptoms after mTBI.", "author" : [ { "dropping-particle" : "", "family" : "Smyth", "given" : "Kim", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Sandeep S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crawford", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dewey", "given" : "Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Parboosingh", "given" : "Jillian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barlow", "given" : "Karen M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental medicine and child neurology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "73-7", "title" : "The role of serotonin receptor alleles and environmental stressors in the development of post-concussive symptoms after pediatric mild traumatic brain injury.", "type" : "article-journal", "volume" : "56" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[25]", "plainTextFormattedCitation" : "[25]", "previouslyFormattedCitation" : "[25]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[25]. Differences in sample selection and inclusion criteria, definitions of concussion, follow up time and additional methodological issues make it difficult to draw substantive conclusions about the incidence of depression in children recovering from concussion. More studies are needed to close the gaps in knowledge or to confirm and add to some of these preliminary conflicting findings. Investigations specifically representing children with concussion need replication. Studies also need to focus on the period of recovery from concussion and to span both childhood and adolescence if we are to realize the magnitude of the problem. Research studies examining the association between depression and concussion have identified factors that may predict the incidence of depression after concussion. Many non injury-related factors are reported to be associated with the onset of depression after concussion: older child, family history of anxiety ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Max", "given" : "Jeffrey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keatley", "given" : "Eva", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilde", "given" : "Elisabeth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bigler", "given" : "Erin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schachar", "given" : "Russel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saunders", "given" : "Ann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ewing-Cobbs", "given" : "Linda", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chapman", "given" : "Sandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dennis", "given" : "Maureen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yang", "given" : "Tony", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levin", "given" : "Harvey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Int. J. Devl Neuroscience", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "239-245", "title" : "Depression in children and adolescents in the first 6 months after traumatic brain injury", "type" : "article-journal", "volume" : "30" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[23]", "plainTextFormattedCitation" : "[23]", "previouslyFormattedCitation" : "[23]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[23], lower socioeconomic status ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kirkwood", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Janusz", "given" : "Jennifer", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yeates", "given" : "Keith", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "Gerry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wade", "given" : "Shari", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stancin", "given" : "Terry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Drotar", "given" : "Dennis", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Child Neuropsychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "195-208", "title" : "Prevalence and correlates of depressive symptoms following traumatic brain injuries in children", "type" : "article", "volume" : "6" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[26]", "plainTextFormattedCitation" : "[26]", "previouslyFormattedCitation" : "[26]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[26], and post-injury stress ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1076/jcen.24.3.270.982", "ISBN" : "1380-3395", "ISSN" : "1380-3395", "PMID" : "11992209", "abstract" : "Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children - IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Luis", "given" : "Cheryl a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mittenberg", "given" : "Wiley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical and experimental neuropsychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "270-279", "title" : "Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[24]", "plainTextFormattedCitation" : "[24]", "previouslyFormattedCitation" : "[24]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[24]. In addition, many injury-related factors in the adult population have been identified as risk factors for depression, including; multiple brain injuries, number and severity of symptoms, mechanism of injury, hospitalization and imaging abnormalities ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1249/mss.0b013e3180383da5", "ISSN" : "0195-9131", "PMID" : "17545878", "abstract" : "PURPOSE: The purpose of our study was to investigate the association between prior head injury and the likelihood of being diagnosed with clinical depression among retired professional football players with prior head injury exposure.\n\nMETHODS: A general health questionnaire, including information about prior injuries, the SF-36 (Short Form 36), and other markers for depression, was completed by 2552 retired professional football players with an average age of 53.8 (+/-13.4) yr and an average professional football-playing career of 6.6 (+/-3.6) yr. A second questionnaire focusing on mild cognitive impairment (MCI)-related issues was completed by a subset of 758 retired professional football players (50 yr and older).\n\nRESULTS: Two hundred sixty-nine (11.1%) of all respondents reported having prior or current diagnosis of clinical depression. There was an association between recurrent concussion and diagnosis of lifetime depression (chi2=71.21, df=2, P<0.005), suggesting that the prevalence increases with increasing concussion history. Compared with retired players with no history of concussion, retired players reporting three or more previous concussions (24.4%) were three times more likely to be diagnosed with depression; those with a history of one or two previous concussions (36.3%) were 1.5 times more likely to be diagnosed with depression. The analyses controlled for age, number of years since retirement, number of years played, physical component score on the SF-36, and diagnosed comorbidities such as osteoarthritis, coronary heart disease, stroke, cancer, and diabetes.\n\nCONCLUSION: Our findings suggest a possible link between recurrent sport-related concussion and increased risk of clinical depression. The findings emphasize the importance of understanding potential neurological consequences of recurrent concussion.", "author" : [ { "dropping-particle" : "", "family" : "Guskiewicz", "given" : "Kevin M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Marshall", "given" : "Stephen W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bailes", "given" : "Julian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCrea", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harding", "given" : "Herndon P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Matthews", "given" : "Amy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mihalik", "given" : "Johna Register", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Medicine and science in sports and exercise", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2007", "6" ] ] }, "page" : "903-9", "title" : "Recurrent concussion and risk of depression in retired professional football players.", "type" : "article-journal", "volume" : "39" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1001/archpsyc.62.5.523", "ISBN" : "0003-990X", "ISSN" : "0003-990X", "PMID" : "15867105", "abstract" : "CONTEXT: Minimizing negative consequences of major depression following traumatic brain injury is an important public health objective. Identifying high-risk patients and referring them for treatment could reduce morbidity and loss of productivity. OBJECTIVE: To develop a model for early screening of patients at risk for major depressive episode at 3 months after traumatic brain injury. DESIGN: Prediction model using receiver operating characteristic curve. SETTING: Level I trauma center in a major metropolitan area. PARTICIPANTS: Prospective cohort of 129 adults with mild traumatic brain injury. MAIN OUTCOME MEASURES: Center for Epidemiologic Studies Depression Scale score and current major depressive episode module of the Structured Clinical Interview for the DSM-IV. RESULTS: A prediction model including higher 1-week Center for Epidemiologic Studies Depression Scale score, older age, and computed tomographic scans of intracranial lesions yielded 93% sensitivity and 62% specificity. CONCLUSION: This study supports the feasibility of identifying patients with mild traumatic brain injury who are at high risk for developing major depressive episode by 3 months' postinjury, which could facilitate selective referral for potential treatment and reduction of negative outcomes.", "author" : [ { "dropping-particle" : "", "family" : "Levin", "given" : "Harvey S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCauley", "given" : "Stephen R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Josic", "given" : "Claudia Pedroza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boake", "given" : "Corwin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brown", "given" : "Sharon a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goodman", "given" : "Heather S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Merritt", "given" : "Shirley G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brundage", "given" : "Susan I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of general psychiatry", "id" : "ITEM-2", "issue" : "May 2005", "issued" : { "date-parts" : [ [ "2005" ] ] }, "page" : "523-528", "title" : "Predicting depression following mild traumatic brain injury.", "type" : "article-journal", "volume" : "62" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1097/HTR.0b013e3181e4622a", "ISSN" : "1550-509X", "PMID" : "20631632", "abstract" : "OBJECTIVE: To examine the influence of depression on postconcussion symptom reporting in patients following mild traumatic brain injury (MTBI).\n\nPARTICIPANTS: Sixty patients referred to a specialty clinic following MTBI, 58 outpatients with Structured Clinical Interview for DSM-diagnosed depression, and 72 healthy community control participants.\n\nPROCEDURE: Participants with MTBI were divided into 2 subgroups on the basis of self-reported symptoms of depression (23 MTBI-depressed, 37 MTBI-not depressed). All participants completed a postconcussion symptom questionnaire.\n\nMAIN OUTCOME MEASURE: British Columbia Post-concussion Symptom Inventory.\n\nRESULTS: There were significant differences in total reported postconcussion symptoms among all 4 groups (all P < .002; Cohen's d = 0.68-3.24, large to very large effect sizes; MTBI-depressed > depressed outpatients > MTBI-no depression > healthy controls). There were significant differences in the number of symptoms endorsed (P < .05), with the highest number of symptoms endorsed by the MTBI-depressed group, followed by depressed outpatients, MTBI-no depression, and healthy controls.\n\nCONCLUSIONS: Patients who experience MTBIs and who have a postinjury recovery course complicated by significant depression report more postconcussion symptoms, and more severe symptoms, than (a) outpatients with depression, and (b) patients with MTBIs who do not have significant symptoms of depression.", "author" : [ { "dropping-particle" : "", "family" : "Lange", "given" : "Rael T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rose", "given" : "Alice", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of head trauma rehabilitation", "id" : "ITEM-3", "issue" : "2", "issued" : { "date-parts" : [ [ "2011" ] ] }, "page" : "127-37", "title" : "Depression strongly influences postconcussion symptom reporting following mild traumatic brain injury.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[27]\u2013[29]", "manualFormatting" : "[27, 29]", "plainTextFormattedCitation" : "[27]\u2013[29]", "previouslyFormattedCitation" : "[27]\u2013[29]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[27, 29]. To date, there have been very few studies conducted with children. One pediatric prospective cohort with orthopedic controls demonstrated that the severity of injury and post-injury stress predicted the onset of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1076/jcen.24.3.270.982", "ISBN" : "1380-3395", "ISSN" : "1380-3395", "PMID" : "11992209", "abstract" : "Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children - IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Luis", "given" : "Cheryl a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mittenberg", "given" : "Wiley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical and experimental neuropsychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "270-279", "title" : "Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[24]", "plainTextFormattedCitation" : "[24]", "previouslyFormattedCitation" : "[24]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[24]. Research determining both the incidence of depression and the factors that predict risk for depression after concussion is in the early stages. More work needs to be done to understand the incidence of depression in children recovering from concussion and to highlight factors that predict depression in children who are still in recovery from concussion. Determining the factors that increase risk for depression post-concussion can lead to strategies for effective prevention and early intervention.The purpose of this study is to explore the risk of depression in a cohort of children and youth recovering from concussion, and to identify predictors of depression during the recovery period. It was hypothesized that depression would be associated with prolonged recovery from concussion. It was also hypothesized that there would be gender and age differences in depression, with higher rates among adolescent girls. Finally, it was hypothesized that injury related factors (i.e. number of head injuries, symptom scores and hospitalization) would increase the risk of developing depression. MethodsA prospective cohort study was conducted with children recovering from concussion through the acquired brain injury (ABI) clinic (n=477) at a tertiary care Children’s Hospital. This tertiary care centre, located in south-western Ontario, serves a region of approximately 2.3 million people. Approximately 45% of referrals to this clinic are received from the emergency department and hospital wards and 55% are received from community physicians and outlying hospitals. This provides a mixture of children who have had both acute and complex care needs. SampleDue to the interest in depression, a protocol of screening for depression was implemented as a pilot project in the ABI clinic from April-June 2013 with full implementation to all consecutive patients from August to December 2013. Thus a prospective cohort of 92 consecutive children who were newly referred or had follow up appointments scheduled were administered the CDI if they were between the ages of 8 and 18 years. Data of those who met the following inclusion criteria were included for analysis: a diagnosis of mTBI/concussioncompletion of a Children’s Depression Inventory Screen - 2 ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kovacs", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher" : "Multi-Health Systems", "title" : "Children's Depression Inventory-2", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[30]", "plainTextFormattedCitation" : "[30]", "previouslyFormattedCitation" : "[30]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[30]completion of one or more Post-Concussion Symptom Inventory ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Gioia", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "MW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "publisher-place" : "USA", "title" : "Acute Concussion Evaluation", "type" : "patent" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[7]", "plainTextFormattedCitation" : "[7]", "previouslyFormattedCitation" : "[7]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[7] checklistsParticipants were not excluded if they required hospitalization or had intracranial lesions or skull fractures. The Hamilton Integrated Research Ethics Board approved the prospective collection of data from the clinical Acquired Brain Injury database. Consent was covered through this process.ProceduresEvery visit to the ABI follow-up clinic includes a review of the medical history and a physical examination. Parents and children each independently completed a Post Concussion Symptom Inventory (PCSI) ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Gioia", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "MW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "publisher-place" : "USA", "title" : "Acute Concussion Evaluation", "type" : "patent" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[7]", "plainTextFormattedCitation" : "[7]", "previouslyFormattedCitation" : "[7]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[7] and the Children’s Depression Inventory-2 (Short version) (CDI-2S) ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kovacs", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher" : "Multi-Health Systems", "title" : "Children's Depression Inventory-2", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[30]", "plainTextFormattedCitation" : "[30]", "previouslyFormattedCitation" : "[30]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[30] at the appointment. The PCSI was completed at each clinic appointment with data available for a maximum of three evaluations; time 3, therefore, would be the most current follow up score. The scores from the CDI-2S were obtained every three months, if children were being followed long term, however it was decided to use only those CDI scores from the first administration as there were very few children with more than 1 set of scores. Demographic and other injury information are also compiled as part of the health record and database. Data collection occurred over a period of eight months in 2013. Measures The Children’s Depression Inventory-2 (CDI-2) is both a self-report and parent-report measure of the extent and severity of depressive symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kovacs", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher" : "Multi-Health Systems", "title" : "Children's Depression Inventory-2", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[30]", "plainTextFormattedCitation" : "[30]", "previouslyFormattedCitation" : "[30]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[30]. The screening tool (CDI-2S) consists of 12 questions and requires one of three response options: the child chooses the statement that best describes their feelings or moods in the past two weeks. Statements represent the range of severity of the symptom from 0 (none) to 2 (definite). Scores are totaled and raw scores are converted to T scores. A T score of 65 (1.5 SD above the mean) is generally considered to indicate a clinically significant level of depressive symptomatology. This screening tool has a high correlation with the full-length self rated form (r=.95, p<.001) and has been validated for use with medically ill children ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpsychores.2012.08.016", "ISSN" : "1879-1360", "PMID" : "23062811", "abstract" : "OBJECTIVE: This is the first study to validate and to compare the Children's Depression Inventory (CDI) and its short version (CDI:S) as screening tools for medically ill children.\n\nMETHODS: A sample of 406 pediatric hospital patients, aged 9 to 12 years (56.2% male, 77.1% inpatients), completed the German CDI. Criterion validity of the 26-item CDI and the 10-item CDI:S was calculated by receiver operating characteristic (ROC) curves. DSM-IV diagnoses of depression based on the structured diagnostic interview for mental disorders in children and adolescents (Kinder-DIPS) served as the reference standard. Areas under the ROC curves as well as sensitivities and specificities for the optimal cutoffs were compared for both versions.\n\nRESULTS: Diagnoses of major or minor depression were established for 7.4% of the children. Areas under the curve for the 26-item CDI (87.7%) and the 10-item CDI:S (88.2%) were comparable. For the CDI, the cutoff\u226512 yielded the best balance between sensitivity (83.3%) and specificity (82.7%). At the optimal cutoff\u22653, the CDI:S resulted in a high sensitivity of 93.3% and a specificity of 70.7%. Thus, the CDI:S proved to be as sensitive as the CDI, but was less specific than the full-length version.\n\nCONCLUSION: Both the CDI and the CDI:S are valid screening instruments for depression in medically ill children. The sensitive and brief CDI:S is a promising tool in time-pressed settings such as pediatric care, but has to be followed by a thorough diagnostic assessment to rule out false positive cases.", "author" : [ { "dropping-particle" : "", "family" : "Allgaier", "given" : "Antje-Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fr\u00fche", "given" : "Barbara", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pietsch", "given" : "Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saravo", "given" : "Barbara", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baethmann", "given" : "Martina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schulte-K\u00f6rne", "given" : "Gerd", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of psychosomatic research", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2012", "11" ] ] }, "page" : "369-74", "publisher" : "Elsevier Inc.", "title" : "Is the Children's Depression Inventory Short version a valid screening tool in pediatric care? A comparison to its full-length version.", "type" : "article-journal", "volume" : "73" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[31]", "plainTextFormattedCitation" : "[31]", "previouslyFormattedCitation" : "[31]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[31]. There are 3 questions dealing with depressed mood and irritability, 3 questions regarding physical symptoms, 1 about diminished pleasure, 1 dealing with cognitive symptoms and the rest are about feelings of low self esteem, worthlessness and hopelessness. The parent measure is a parallel questionnaire that includes 17 questions with scores that are grouped into emotional, functional and total score domains. Again, parents are asked to consider the child’s moods and feelings in the past two weeks.The Post-Concussion Symptom scale ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Gioia", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "MW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "publisher-place" : "USA", "title" : "Acute Concussion Evaluation", "type" : "patent" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[7]", "plainTextFormattedCitation" : "[7]", "previouslyFormattedCitation" : "[7]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[7] is a symptom inventory derived from the original sideline assessment developed by the Pittsburgh Steelers of the National Football League ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Lovell", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Podell", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Johnston", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pardini", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Applied Neuropsychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "166-174", "title" : "Measurement of symptoms following sports-related concussion: reliability and normative data for the post-concussion scale.", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[32]", "plainTextFormattedCitation" : "[32]", "previouslyFormattedCitation" : "[32]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[32]. This clinically driven tool has many variants and has been adopted and standardized into such tools as the Acute Concussion Evaluation ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Gioia", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "MW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "publisher-place" : "USA", "title" : "Acute Concussion Evaluation", "type" : "patent" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[7]", "plainTextFormattedCitation" : "[7]", "previouslyFormattedCitation" : "[7]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[7], the Sport Concussion Assessment Tool ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "McCrory", "given" : "P R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meeuwisse", "given" : "W. H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Johnston", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dvorak", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Aubry", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Molloy", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "259-263", "title" : "SCAT3", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[33]", "plainTextFormattedCitation" : "[33]", "previouslyFormattedCitation" : "[33]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[33] and the Immediate Post-Concussion and Cognitve Test ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "number" : "6", "publisher" : "NeuroHealth Systems", "publisher-place" : "Pittsburgh, PA", "title" : "Immediate Post-Concussion Assessment Cognitive Testing", "type" : "article" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[34]", "plainTextFormattedCitation" : "[34]", "previouslyFormattedCitation" : "[34]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[34], which is commonly used to make return to sport decisions. Most of the variants have a 7-point likert scale to measure intensity of symptoms and others have a yes/no dichotomous scale ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Alla S, Sullivan SJ, Hale L", "given" : "McCrory P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Br J Sports Med", "id" : "ITEM-1", "issue" : "Suppl 1", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "i3-12", "title" : "Self-report scales/checklists for the measurement of concussion symptoms: a systematic review.", "type" : "article-journal", "volume" : "43" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[35]", "plainTextFormattedCitation" : "[35]", "previouslyFormattedCitation" : "[35]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[35]. It is a quick and clinically useful way of tracking symptom resolution through serial administration over days or weeks. The Post Concussive Symptom Inventory (PCSI) ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Gioia", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "MW", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "publisher-place" : "USA", "title" : "Acute Concussion Evaluation", "type" : "patent" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[7]", "plainTextFormattedCitation" : "[7]", "previouslyFormattedCitation" : "[7]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[7] is one of the variations and lists 22 concussion symptoms in the domains of physical, cognitive, emotional and sleep and has a yes/no dichotomous scale ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Alla S, Sullivan SJ, Hale L", "given" : "McCrory P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Br J Sports Med", "id" : "ITEM-1", "issue" : "Suppl 1", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "i3-12", "title" : "Self-report scales/checklists for the measurement of concussion symptoms: a systematic review.", "type" : "article-journal", "volume" : "43" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[35]", "plainTextFormattedCitation" : "[35]", "previouslyFormattedCitation" : "[35]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[35]. Both children and parents fill in this checklist independently, answering yes (1) or no (0) to whether the child has experienced each symptom in the past three days. The “yes” scores are added for a total score out of 22. The scales are valid in measuring change in symptoms over time, however; psychometric evidence is stronger for adolescents than younger children ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/bjsm.2009.058255", "author" : [ { "dropping-particle" : "", "family" : "Gioia", "given" : "GA", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schneider", "given" : "JC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vaughan", "given" : "CG", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Isquith", "given" : "PK", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Sports Medicine", "id" : "ITEM-1", "issue" : "Suppl I", "issued" : { "date-parts" : [ [ "2009" ] ] }, "note" : "From Duplicate 2 ( ", "page" : "i13-i22", "title" : "Which symptom assessments and approaches are uniquely appropriate for paediatric concussion", "type" : "article-journal", "volume" : "43" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[36]", "plainTextFormattedCitation" : "[36]", "previouslyFormattedCitation" : "[36]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[36]. Symptoms of depression and post concussive symptoms are known to overlap; however, these measures actually have only two items that are worded similarly; irritability and fatigue. Sadness and decision-making are also asked about in both measures but are worded quite differently.Data AnalysisOur sample size of 92 is adequate to provide a valid model to estimate risk in logistic regression analyses. The value of 10 events per variable and higher is recommended by Peduzzi et al. for both proportional hazards and logistic regression analyses ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Peduzzi", "given" : "P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Concato", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kemper", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Holford", "given" : "TR", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feinstein", "given" : "AR", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Clinical Epidmiology", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "1996" ] ] }, "page" : "1373-1379", "title" : "A simulation study of the number of events per variable in logistic regression analysis.", "type" : "article-journal", "volume" : "49" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[37]", "plainTextFormattedCitation" : "[37]", "previouslyFormattedCitation" : "[37]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[37]. Below this the statistical model may not be valid. We will have 1 primary outcome (depressive symptoms indicated by a T score > 65 on CDI-2S) with 5 predictors. For analysis, children were categorized based on the CDI T-score of ≥ 65 (n=20) indicating depression or < 65 (n=72) indicating no depression. Initially, to test for group differences chi-square and student t-tests were conducted on demographic variables and clinical characteristics. As this was an exploratory study, significance was two tailed and set at p≤.05. Much of the data of interest was not normally distributed, not uncommon in brain injury research, so a decision was made to use non-parametric statistics for correlations and regression. Correlations between depression and injury and non-injury related variables were determined using Spearman’s Rho. Logistic regression was used to model the predictor variables of interest with the primary binary outcome: a clinically significant level of depressive symptoms either present (“yes” T score ≥ 65; coded 1) or not present (“no” T score < 65; coded 0). Predictor variables were selected based on our hypotheses, results from descriptive statistics and univariate analysis using binary logistic regression. The selected variables were subjected to linear regression analysis to test for collinearity. The data did not violate the multicollinearity assumption with variance inflation factors well below the cut off of 10 (range from 1.29 – 2.36). A combination of forward and backward selection was used for model fitting using the most significant candidate covariates and then eliminating those with p values over 0.6 ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/(sici)1097-0258(20000430)19:8<1059::aid-sim412>3.0.co;2-0", "ISBN" : "1097-0258", "ISSN" : "0277-6715", "PMID" : "10790680", "abstract" : "Logistic regression analysis may well be used to develop a prognostic model for a dichotomous outcome. Especially when limited data are available, it is difficult to determine an appropriate selection of covariables for inclusion in such models. Also, predictions may be improved by applying some sort of shrinkage in the estimation of regression coefficients. In this study we compare the performance of several selection and shrinkage methods in small data sets of patients with acute myocardial infarction, where we aim to predict 30-day mortality. Selection methods included backward stepwise selection with significance levels alpha of 0.01, 0.05, 0. 157 (the AIC criterion) or 0.50, and the use of qualitative external information on the sign of regression coefficients in the model. Estimation methods included standard maximum likelihood, the use of a linear shrinkage factor, penalized maximum likelihood, the Lasso, or quantitative external information on univariable regression coefficients. We found that stepwise selection with a low alpha (for example, 0.05) led to a relatively poor model performance, when evaluated on independent data. Substantially better performance was obtained with full models with a limited number of important predictors, where regression coefficients were reduced with any of the shrinkage methods. Incorporation of external information for selection and estimation improved the stability and quality of the prognostic models. We therefore recommend shrinkage methods in full models including prespecified predictors and incorporation of external information, when prognostic models are constructed in small data sets.", "author" : [ { "dropping-particle" : "", "family" : "Steyerberg", "given" : "E W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Eijkemans", "given" : "M J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Harrell", "given" : "F E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Habbema", "given" : "J D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Statistics in medicine", "id" : "ITEM-1", "issue" : "July 1999", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "1059-1079", "title" : "Prognostic modelling with logistic regression analysis: a comparison of selection and estimation methods in small data sets.", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[38]", "manualFormatting" : "[37]", "plainTextFormattedCitation" : "[38]", "previouslyFormattedCitation" : "[38]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[37]. All data analysis was done using IBM SPSS Statistics for Windows, Version 22.0 ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "IBM", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "number" : "22", "title" : "SPSS Statistics for windows", "type" : "article" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[39]", "manualFormatting" : "[38]", "plainTextFormattedCitation" : "[39]", "previouslyFormattedCitation" : "[39]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[38].Results The study sample examined of 92 children aged 7 – 18 years included 56 girls and 36 boys with a mean age of 15 years ± 2.5. Depression screens were administered a mean of 6.8 months (2 weeks-35 months) after injury (see Table 1). PCSI scores were obtained a mean of 9.2 weeks for Time 1, 5.6 months for Time 2 and 8.5 months for time 3. Information on demographic and clinical characteristics by outcomes is presented in Table 2. The study sample of 92 children differed from the larger dataset of 477 children followed in the ABI clinic in a few ways: there were more girls in our subset (64% compared with 44%); the PCSI means were higher in girls (9.91 vs 8.26) and 70% of the 92 children had symptoms for 3 months or more compared to only 52% in the larger dataset. << insert Table 1 about here >>Non-Injury Related FactorsIn comparing children classified as depressed versus non-depressed (Chi-Square analysis; χ2), there were no significant differences in age (p=0.85), sex (p=0.79), premorbid history of learning issues (p=0.61), or pre-morbid history of mental health issues (p=0.90). Significant differences, however, were noted in decreased academic standing after concussion (χ2=4.6, df=1, p=0.03) as well as in persistence of concussion symptoms (>3 months duration) (χ2=6.3, df=1, p=0.01). Children with depression were less likely to be succeeding in school after concussion. Prior to their injury 7.6% of children had documented learning issues whereas, after injury, 53% reported a decrease in school performance. This decrease in academic standing was identified by clinical interview with child and parent and was defined as those school difficulties noted post-concussive injury (e.g., decreased academic marks by more than 10%, reduced academic workload or clinician documented symptoms of decreased concentration, difficulty coding and decoding, reading or studying for increased periods of time).Correlational analysis using spearman rho for categorical variables (see Table 3) showed strong positive associations between depression scores (yes/no) and persistence of concussion symptoms (yes/no) over 3 months (r=0.483, p<0.01), and between depression scores and decrease in academic standing (r=0.431, p< 0.01).>>Insert Table 2 about here<<Injury Related FactorsIn comparing children classified as depressed versus not depressed, chi square analysis showed no significant differences in reports of multiple head injuries (p=0.46), cause of injury (p=0.35), computerized tomography abnormalities (p=0.67) or hospital admissions (p=0.67). Significant differences were, however, found in the number of concussion symptoms as reported on the PSCI. Children with depression had higher initial clinic PCSI mean scores (p=0.004) and higher PSCI scores reported on the third clinic visit (p=0.041). Length of hospital stay was also found to be significantly higher in children who were subsequently classified as depressed (T-score > 65 on the CDI-2-S) (p=0.003). Correlational analysis showed significant positive associations between depression scores and the number of concussion symptoms reported on the PCSI-time 1 (r=0.442, p< 0.01) and time 3 (r=0.602, p< 0.01) indicating a linear relationship.<< insert Table 3 about here >>Logistic regression results. The results of the logistic regression analysis show that the full model using the 5 independent variables of gender, number of concussions, admission to hospital, PCSI Time 1 score and experiencing symptoms over 3 months was significant (Χ2 (5)= 18.55, n=71, p< 0.002). This means that the odds for children to have a positive depression score at a mean time of 6 months after concussion is associated with these 5 variables (see Table 3). The model correctly classifies 81.7% of cases. The Nagelkerke R squared value of .357 indicates the model fits the data well. Table 3 presents the standardized coefficient Beta, Wald statistic and significance as well as the odds ratios (OR) and 95% confidence intervals for the variables in the model. The strongest predictors in the model were high PCSI scores (standardized coefficient beta= 0 .278, p=0.009) and admission to hospital (standardized coefficient beta= 2.464, p=0.030). Admission to hospital with an OR of 11.75 means that the odds that a child had a high depression score (T≥65) increased by a factor of 11 if the child was admitted to hospital compared to those who were not admitted. The odds ratio for early PCSI is 1.32, which indicates that for every one point increase in symptom scores (1 additional symptom) the odds of being depressed increase by a factor of 1.32.Length of hospital stay was a variable that could not be used in the multivariate model because of the potential for over-fitting due to the small sample as only 24 children had a stay over 24 hours. We did a univariate analysis using length of hospital stay to predict depression and found it to be significant Χ2 =8.06, p<0.005 (standardized coefficient Beta=0.447, p= 0.033). This single variable increased classification accuracy by 17% and has an OR of 1.56 indicating that for every extra day of stay in hospital the likelihood of depression increased by a factor of 1.5. << insert Table 4 about here >>DiscussionIn this prospective cohort of children and youth with concussion, we found the incidence of depression to be above that found in community samples cited in the literature and in standardized tests, which report a prevalence of 8% in this age group ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "978-1-59385-582-6", "author" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "editor" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New York", "title" : "Handbook of Depression in Children and Adolescents", "type" : "book" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1080/17518420701536095", "ISSN" : "1751-8423", "author" : [ { "dropping-particle" : "", "family" : "Carr", "given" : "Alan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental Neurorehabilitation", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "page" : "3-15", "title" : "Depression in young people: Description, assessment and evidence-based treatment", "type" : "article-journal", "volume" : "11" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1037/0022-006X.74.3.401", "ISBN" : "0022-006X (Print)\\r0022-006X (Linking)", "ISSN" : "0022-006X", "PMID" : "16822098", "abstract" : "Research on the prevention of depressive symptoms in children and adolescents was reviewed and synthesized with meta-analysis. When all 30 studies were included, selective prevention programs were found to be more effective than universal programs immediately following intervention. Both selective and indicated prevention programs were more effective than universal programs at follow-up, even when the 2 studies with college students were excluded. Effect sizes for selective and indicated prevention programs tended to be small to moderate, both immediately postintervention and at an average follow-up of 6 months. Most effective interventions are more accurately described as treatment rather than prevention. Suggestions for future research include testing potential moderators (e.g., age, gender, anxiety, parental depression) and mechanisms, designing programs that are developmentally appropriate and gender and culturally sensitive, including longer follow-ups, and using multiple measures and methods to assess both symptoms and diagnoses.", "author" : [ { "dropping-particle" : "", "family" : "Horowitz", "given" : "Jason L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Garber", "given" : "Judy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of consulting and clinical psychology", "id" : "ITEM-3", "issue" : "3", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "401-415", "title" : "The prevention of depressive symptoms in children and adolescents: A meta-analytic review.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[40]\u2013[42]", "manualFormatting" : "[39-41]", "plainTextFormattedCitation" : "[40]\u2013[42]", "previouslyFormattedCitation" : "[40]\u2013[42]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[39-41]. Twenty-two percent of children self-reported significant depressive symptomatology an average of 6 months following their injury. Youth in our study did report some premorbid histories of headache/migraine (9%), learning issues (7%) and mental health issues (7.5%); yet, none of these were significantly associated with ratings of post-concussion depression. Five predictors, sex, number of concussions, admission to hospital, PCSI score and experiencing prolonged symptoms explained 36% of the variance in depression scores. Our prevalence of 22% is congruent with other published studies that report an increase in depression after mild – moderate TBI ranging from 11 – 26% ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Max", "given" : "Jeffrey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keatley", "given" : "Eva", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilde", "given" : "Elisabeth", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bigler", "given" : "Erin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schachar", "given" : "Russel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saunders", "given" : "Ann", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ewing-Cobbs", "given" : "Linda", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Chapman", "given" : "Sandra", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dennis", "given" : "Maureen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yang", "given" : "Tony", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Levin", "given" : "Harvey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Int. J. Devl Neuroscience", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "239-245", "title" : "Depression in children and adolescents in the first 6 months after traumatic brain injury", "type" : "article-journal", "volume" : "30" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1076/jcen.24.3.270.982", "ISBN" : "1380-3395", "ISSN" : "1380-3395", "PMID" : "11992209", "abstract" : "Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children - IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Luis", "given" : "Cheryl a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mittenberg", "given" : "Wiley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical and experimental neuropsychology", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "270-279", "title" : "Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[23], [24]", "manualFormatting" : "[22, 23]", "plainTextFormattedCitation" : "[23], [24]", "previouslyFormattedCitation" : "[23], [24]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[22, 23] as well as findings of depression in other chronic medical conditions including chronic pain, post-traumatic stress disorder, epilepsy and soft tissue injuries ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Canada", "given" : "Public Health Agency of", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher-place" : "Ottawa", "title" : "The chief public health officer's report on the state of public health in Canada 2011", "type" : "report" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "ISBN" : "978-1-59385-582-6", "author" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "editor" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2008" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New York", "title" : "Handbook of Depression in Children and Adolescents", "type" : "book" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1037/0022-006X.74.3.401", "ISBN" : "0022-006X (Print)\\r0022-006X (Linking)", "ISSN" : "0022-006X", "PMID" : "16822098", "abstract" : "Research on the prevention of depressive symptoms in children and adolescents was reviewed and synthesized with meta-analysis. When all 30 studies were included, selective prevention programs were found to be more effective than universal programs immediately following intervention. Both selective and indicated prevention programs were more effective than universal programs at follow-up, even when the 2 studies with college students were excluded. Effect sizes for selective and indicated prevention programs tended to be small to moderate, both immediately postintervention and at an average follow-up of 6 months. Most effective interventions are more accurately described as treatment rather than prevention. Suggestions for future research include testing potential moderators (e.g., age, gender, anxiety, parental depression) and mechanisms, designing programs that are developmentally appropriate and gender and culturally sensitive, including longer follow-ups, and using multiple measures and methods to assess both symptoms and diagnoses.", "author" : [ { "dropping-particle" : "", "family" : "Horowitz", "given" : "Jason L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Garber", "given" : "Judy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of consulting and clinical psychology", "id" : "ITEM-3", "issue" : "3", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "401-415", "title" : "The prevention of depressive symptoms in children and adolescents: A meta-analytic review.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[16], [40], [42]", "manualFormatting" : "[15,39, 41]", "plainTextFormattedCitation" : "[16], [40], [42]", "previouslyFormattedCitation" : "[16], [40], [42]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[15,39, 41]. However, in a recent childhood concussion cross-sectional study conducted by Smyth et al., ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/dmcn.12263", "ISSN" : "1469-8749", "PMID" : "23992222", "abstract" : "AIM: To determine whether post-injury depressive symptoms, and pre-injury major life stressors and genetic factors (HTR1A C(-1019)G alleles; rs6295) are more common in children with mild traumatic brain injury (mTBI) who develop postconcussion syndrome (PCS) symptoms compared with children with asymptomatic mTBI.\n\nMETHOD: This was a cross-sectional study of 47 symptomatic children (32 males, 15 females; mean age 14y [SD 3y 3mo]) who experienced post-concussive symptoms for 7 or more days and 42 asymptomatic children (26 males 16 females; mean age 13y 6mo [SD 3y 1mo]) after mTBI. Outcome measures were the Postconcussion Symptoms Inventory (PCSI), the Children's Depression Inventory (CDI), standard questionnaire of previous life events, and buccal DNA analysis to determine genotype and allele frequencies for the HTR1A C(-1019)G polymorphism.\n\nRESULTS: Depressive symptoms were uncommon. CDI scores did not differ between groups. Allelic and genotypic frequencies for HTR1A C(-1019)G were similar in both groups. Symptomatic children continued to have elevated PCS scores compared with asymptomatic children 1.72 (SD 0.69) years later and had experienced significantly more life stressors (Wald (1)=8.51, p=0.004).\n\nINTERPRETATION: HTR1A polymorphisms do not differ in children with PCS. Children who have experienced more significant life stresses are more likely to develop PCS symptoms after mTBI.", "author" : [ { "dropping-particle" : "", "family" : "Smyth", "given" : "Kim", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Sandeep S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crawford", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dewey", "given" : "Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Parboosingh", "given" : "Jillian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barlow", "given" : "Karen M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental medicine and child neurology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "73-7", "title" : "The role of serotonin receptor alleles and environmental stressors in the development of post-concussive symptoms after pediatric mild traumatic brain injury.", "type" : "article-journal", "volume" : "56" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[25]", "plainTextFormattedCitation" : "[25]", "previouslyFormattedCitation" : "[25]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[25] only 3% of their sample had depression 1 – 3 years after injury. Although this was also a concussion cohort, other dissimilarities such as numbers of children admitted to hospital and length of time to follow up, in addition to the less rigorous study design and methods, may explain the different results. Other factors frequently hypothesized to be associated with depression including age, sex, cause of injury and the total number of head injuries had no significant relationship individually with depression in this study. These results were curious as sex in the general population of depressed adolescents has distinct differences with a 2:1 ratio of girls to boys ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1080/17518420701536095", "ISSN" : "1751-8423", "author" : [ { "dropping-particle" : "", "family" : "Carr", "given" : "Alan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental Neurorehabilitation", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2008" ] ] }, "page" : "3-15", "title" : "Depression in young people: Description, assessment and evidence-based treatment", "type" : "article-journal", "volume" : "11" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1037/0022-006X.74.3.401", "ISBN" : "0022-006X (Print)\\r0022-006X (Linking)", "ISSN" : "0022-006X", "PMID" : "16822098", "abstract" : "Research on the prevention of depressive symptoms in children and adolescents was reviewed and synthesized with meta-analysis. When all 30 studies were included, selective prevention programs were found to be more effective than universal programs immediately following intervention. Both selective and indicated prevention programs were more effective than universal programs at follow-up, even when the 2 studies with college students were excluded. Effect sizes for selective and indicated prevention programs tended to be small to moderate, both immediately postintervention and at an average follow-up of 6 months. Most effective interventions are more accurately described as treatment rather than prevention. Suggestions for future research include testing potential moderators (e.g., age, gender, anxiety, parental depression) and mechanisms, designing programs that are developmentally appropriate and gender and culturally sensitive, including longer follow-ups, and using multiple measures and methods to assess both symptoms and diagnoses.", "author" : [ { "dropping-particle" : "", "family" : "Horowitz", "given" : "Jason L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Garber", "given" : "Judy", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of consulting and clinical psychology", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "401-415", "title" : "The prevention of depressive symptoms in children and adolescents: A meta-analytic review.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "ISBN" : "978-1-59385-582-6", "author" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "editor" : [ { "dropping-particle" : "", "family" : "Abela", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hankin", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-3", "issued" : { "date-parts" : [ [ "2008" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New York", "title" : "Handbook of Depression in Children and Adolescents", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[40]\u2013[42]", "manualFormatting" : "[39-41]", "plainTextFormattedCitation" : "[40]\u2013[42]", "previouslyFormattedCitation" : "[40]\u2013[42]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[39-41]. Age is similar to this as rates of depression in adolescents have been shown to be double those seen in younger children [15]. Our sample had only twenty children in the 7 – 12 age group, which may have resulted in a type II error with not enough statistical power to show a true difference. Evidence has also shown an association between multiple head injuries and depression in adult football players [26]. Our data did not reflect these findings in children. This raises the question about whether there may be different types of depression after head injury; one with a quick onset and another that would be triggered by an accumulation of life stresses brought about by multiple injuries ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.apmr.2003.12.041", "ISBN" : "0003-9993", "ISSN" : "00039993", "PMID" : "15375816", "abstract" : "Dikmen SS, Bombardier CH, Machamer JE, Fann JR, Temkin NR. Natural history of depression in traumatic brain injury. Arch Phys Med Rehabil 2004;85:1457-64. Objective To examine prospectively the rates, risk factors, and phenomenology of depression over 3 to 5 years after traumatic brain injury (TBI). Design Inception cohort longitudinal study. Setting Level I trauma center. Participants Consecutive admissions of 283 adults with moderate to severe TBI. Interventions Not applicable. Main outcome measure Center for Epidemiologic Studies Depression (CES-D) Scale. Results The rates of moderate to severe depression ranged from 31% at 1 month to 17% at 3 to 5 years. With 1 exception, the relation between brain injury severity and depression was negligible. Less than high school education, preinjury unstable work history, and alcohol abuse predicted depression after injury. Examination of CES-D factors indicate that, in addition to somatic symptoms, both depressed affect and lack of positive affect contribute to elevated CES-D scores. Conclusions High rates of depressive symptoms cannot be dismissed on grounds that somatic symptoms related to brain injury are mistaken for depression. Depressed affect and lack of positive affect are also elevated in persons with TBI. Preinjury psychosocial factors are predictive of depression and knowing them should facilitate efforts to detect, prevent, and treat depression after TBI. \u00a9 2004 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.", "author" : [ { "dropping-particle" : "", "family" : "Dikmen", "given" : "Sureyya S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bombardier", "given" : "Charles H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacHamer", "given" : "Joan E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fann", "given" : "Jesse R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Temkin", "given" : "Nancy R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of Physical Medicine and Rehabilitation", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "1457-1464", "title" : "Natural history of depression in traumatic brain injury", "type" : "article-journal", "volume" : "85" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[43]", "plainTextFormattedCitation" : "[43]", "previouslyFormattedCitation" : "[43]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[43].Although the study findings contribute to debate in the literature about the mechanism of the development of post-concussion depression, there are no clear causal relationships. On the one hand, trauma to prefrontal structures, combined with other biological vulnerabilities (inherited traits of learning disabilities, temperament, etc.) is thought to provide a neurobiological susceptibility to depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "9781606233474", "author" : [ { "dropping-particle" : "", "family" : "Ingram", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "Second", "editor" : [ { "dropping-particle" : "", "family" : "Ingram", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Price", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New YOrk", "title" : "Vulnerability to Psychopathology: Risk across the lifespan", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[44]", "plainTextFormattedCitation" : "[44]", "previouslyFormattedCitation" : "[44]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[44]. On the other hand, stress (loss of meaningful activity, trauma, and family factors) can also influence the development of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Monroe", "given" : "Scott M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Simons", "given" : "Anne D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychological Bulletin", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "1991" ] ] }, "page" : "406-425", "title" : "Diathesis \u2014 Stress Theories in the Context of Life Stress Research Implications for the Depressive Disorders", "type" : "article-journal", "volume" : "110" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[45]", "plainTextFormattedCitation" : "[45]", "previouslyFormattedCitation" : "[45]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[45]. In our study, admission to hospital and length of stay increased the likelihood of showing elevated depressive symptoms in the first year after a concussive injury. It has been theorized that hospitalized youth may represent a subset of children who have more damage to frontal regions and neural networks that regulate emotions ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Bryant", "given" : "R A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Donnell", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Creamer", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McFarlane", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Clark", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Silove", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Am J Psychiatry", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "312-320", "title" : "The Psychiatric sequelaie of traumatic injury", "type" : "article-journal", "volume" : "167" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[46]", "plainTextFormattedCitation" : "[46]", "previouslyFormattedCitation" : "[46]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[46], as well, the hospitalization itself is very stressful which may explain the higher rates of depression after concussion found in studies using hospitalized samples ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1076/jcen.24.3.270.982", "ISBN" : "1380-3395", "ISSN" : "1380-3395", "PMID" : "11992209", "abstract" : "Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children - IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.", "author" : [ { "dropping-particle" : "", "family" : "Luis", "given" : "Cheryl a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mittenberg", "given" : "Wiley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical and experimental neuropsychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "270-279", "title" : "Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study.", "type" : "article-journal", "volume" : "24" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.apmr.2003.12.041", "ISBN" : "0003-9993", "ISSN" : "00039993", "PMID" : "15375816", "abstract" : "Dikmen SS, Bombardier CH, Machamer JE, Fann JR, Temkin NR. Natural history of depression in traumatic brain injury. Arch Phys Med Rehabil 2004;85:1457-64. Objective To examine prospectively the rates, risk factors, and phenomenology of depression over 3 to 5 years after traumatic brain injury (TBI). Design Inception cohort longitudinal study. Setting Level I trauma center. Participants Consecutive admissions of 283 adults with moderate to severe TBI. Interventions Not applicable. Main outcome measure Center for Epidemiologic Studies Depression (CES-D) Scale. Results The rates of moderate to severe depression ranged from 31% at 1 month to 17% at 3 to 5 years. With 1 exception, the relation between brain injury severity and depression was negligible. Less than high school education, preinjury unstable work history, and alcohol abuse predicted depression after injury. Examination of CES-D factors indicate that, in addition to somatic symptoms, both depressed affect and lack of positive affect contribute to elevated CES-D scores. Conclusions High rates of depressive symptoms cannot be dismissed on grounds that somatic symptoms related to brain injury are mistaken for depression. Depressed affect and lack of positive affect are also elevated in persons with TBI. Preinjury psychosocial factors are predictive of depression and knowing them should facilitate efforts to detect, prevent, and treat depression after TBI. \u00a9 2004 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.", "author" : [ { "dropping-particle" : "", "family" : "Dikmen", "given" : "Sureyya S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bombardier", "given" : "Charles H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacHamer", "given" : "Joan E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fann", "given" : "Jesse R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Temkin", "given" : "Nancy R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of Physical Medicine and Rehabilitation", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "1457-1464", "title" : "Natural history of depression in traumatic brain injury", "type" : "article-journal", "volume" : "85" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[24], [43]", "manualFormatting" : "[23, 42]", "plainTextFormattedCitation" : "[24], [43]", "previouslyFormattedCitation" : "[24], [43]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[23, 42]. Other factors associated with a high depression score in our data were academic difficulties and experiencing symptoms over three months in duration which both create a great amount of stress in the youth. One of the most stressful activities post-concussion is return to school ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/0009922814567305", "ISBN" : "0009922814", "ISSN" : "0009-9228", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stazyk", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giglia", "given" : "L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mahoney", "given" : "W.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Singh", "given" : "S. 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Thirty percent of children post concussion have reported school absence and dropping grades ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/0009922813478160", "ISSN" : "1938-2707", "PMID" : "23447397", "abstract" : "OBJECTIVES: (1) Assess pediatric primary care providers' understanding of cognitive rest for concussion and (2) describe their concussion management practices.\n\nMETHODS: This study included (1) a survey of general pediatric providers and (2) an electronic medical record (EMR) review of children 5 to 18 years old treated for concussion from September 1, 2010, to May 31, 2011. The survey asked about treatment recommendations for concussion, and results were coded to identify cognitive rest recommendations. The EMR review included the following: injury details, medical evaluation, and recommendations for resuming school and sports/recreation.\n\nRESULTS: In all, 89 of 201 providers responded to the survey, and 52 of the 84 clinicians who included comments about concussion management mentioned cognitive rest (62%, 95% confidence interval [CI] = 51%-72%). Of the 91 EMRs reviewed for patients' first visits following the concussion, only 10 (11%, 95% CI = 6%-19%) included written cognitive rest recommendations.\n\nCONCLUSIONS: Although the majority of pediatric providers identified cognitive rest as important in pediatric concussion management, few provided written recommendations in the EMR.", "author" : [ { "dropping-particle" : "", "family" : "Arbogast", "given" : "Kristy B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McGinley", "given" : "Alexander D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Master", "given" : "Christina L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grady", "given" : "Matthew F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "Roni L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zonfrillo", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical pediatrics", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2013", "5" ] ] }, "page" : "397-402", "title" : "Cognitive rest and school-based recommendations following pediatric concussion: the need for primary care support tools.", "type" : "article-journal", "volume" : "52" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Parsons", "given" : "JT", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bay", "given" : "RC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Valovich-McLeod", "given" : "TC", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Br J Sports Med", "id" : "ITEM-2", "issue" : "5", "issued" : { "date-parts" : [ [ "2013" ] ] }, "title" : "School absence, academic accommodation and health-related quality of life in adolescents with sport-related concussion", "type" : "article-journal", "volume" : "47" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[48], [49]", "manualFormatting" : "[47,48]", "plainTextFormattedCitation" : "[48], [49]", "previouslyFormattedCitation" : "[48], [49]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[47,48]. We found a significant relationship between a decrease in academic standing and depression scores. Findings of prolonged school absence and declining academic performance may indicate that the child is depressed or at risk for becoming depressed. On the other hand depression could very well precede a decrease in academic standing. Clearly school performance is worthy of attention for signaling potential poor outcomes. Prolonged recovery from concussion was also moderately associated with depression in our sample and in our depression prediction model, a child with symptoms over three months had a 1.2 fold increased odds of being depressed even when accounting for all other variables. Significant depressive symptoms, can predispose youth to depression in subsequent years and later into adulthood ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Klein", "given" : "Daniel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Shankman", "given" : "Stewart", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lewinsohn", "given" : "Peter", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Seeley", "given" : "John", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J. Am. Acad. child J. Am. Acad. Child Adolesc. Psychiatry", "id" : "ITEM-1", "issue" : "7", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "703-710", "title" : "Sub threshold depressive disorder in adolescents: Predictors of escalation to full-syndrome depressive disorders", "type" : "article-journal", "volume" : "48" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[50]", "plainTextFormattedCitation" : "[50]", "previouslyFormattedCitation" : "[50]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[50]. Once a depressive episode has resolved, deficits in academics and social relationships remain making the developmental cost of depression in childhood and adolescence very high ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Garland", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Solomons", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "BC Medical Journal", "id" : "ITEM-1", "issue" : "9", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "469-472", "title" : "Early detection of depression in young and elderly people", "type" : "article-journal", "volume" : "44" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[13]", "plainTextFormattedCitation" : "[13]", "previouslyFormattedCitation" : "[13]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[13].? It is therefore vital to identify those children who may be susceptible to depression early in their recovery post-concussion. Based on our results, we recommend that screening for depression in this vulnerable population should be a regular part of follow up: particularly for those who are admitted to hospital, have high symptom scores, experience protracted symptoms or are experiencing academic failure. Because we were unable to follow all children from inception, timing of depressive symptoms is an unknown. Longitudinal studies have reported depression diagnosis early after injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1176/appi.neuropsych.22.1.100.Predictors", "author" : [ { "dropping-particle" : "", "family" : "Rao", "given" : "Vani", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bertrand", "given" : "Melaine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rosenberg", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Makley", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schretlen", "given" : "David J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brandt", "given" : "Jason", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mielke", "given" : "Michelle M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J. Neuropsychiatry Clin Neurosci.", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "100-104", "title" : "Predictors of new-onset depression after mild traumatic brain injury", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1016/j.apmr.2003.12.041", "ISBN" : "0003-9993", "ISSN" : "00039993", "PMID" : "15375816", "abstract" : "Dikmen SS, Bombardier CH, Machamer JE, Fann JR, Temkin NR. Natural history of depression in traumatic brain injury. Arch Phys Med Rehabil 2004;85:1457-64. Objective To examine prospectively the rates, risk factors, and phenomenology of depression over 3 to 5 years after traumatic brain injury (TBI). Design Inception cohort longitudinal study. Setting Level I trauma center. Participants Consecutive admissions of 283 adults with moderate to severe TBI. Interventions Not applicable. Main outcome measure Center for Epidemiologic Studies Depression (CES-D) Scale. Results The rates of moderate to severe depression ranged from 31% at 1 month to 17% at 3 to 5 years. With 1 exception, the relation between brain injury severity and depression was negligible. Less than high school education, preinjury unstable work history, and alcohol abuse predicted depression after injury. Examination of CES-D factors indicate that, in addition to somatic symptoms, both depressed affect and lack of positive affect contribute to elevated CES-D scores. Conclusions High rates of depressive symptoms cannot be dismissed on grounds that somatic symptoms related to brain injury are mistaken for depression. Depressed affect and lack of positive affect are also elevated in persons with TBI. Preinjury psychosocial factors are predictive of depression and knowing them should facilitate efforts to detect, prevent, and treat depression after TBI. \u00a9 2004 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.", "author" : [ { "dropping-particle" : "", "family" : "Dikmen", "given" : "Sureyya S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bombardier", "given" : "Charles H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacHamer", "given" : "Joan E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fann", "given" : "Jesse R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Temkin", "given" : "Nancy R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of Physical Medicine and Rehabilitation", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "1457-1464", "title" : "Natural history of depression in traumatic brain injury", "type" : "article-journal", "volume" : "85" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[19], [43]", "manualFormatting" : "[18,45]", "plainTextFormattedCitation" : "[19], [43]", "previouslyFormattedCitation" : "[19], [43]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[18,45]. In our study significant depressive symptoms were reported at a mean of 6 months after injury, which may not represent the natural history of onset. Screening for depression should occur in the first weeks to months post-concussion with further research needed to determine the optimal time period. Early identification might lead to timely provision of management strategies to prevent the effects of depression. LimitationsThere are several limitations to this study. Our subset of data did differ from the larger dataset as 70% of the sub-sample had symptoms more than three months after their injury compared to 52% in the larger dataset, which suggests that this subset of children seems to have more complex recovery patterns than previously seen. This is most likely a reflection of the increasingly specialized nature of the clinic attracting more complex referrals. Referral bias may also have been introduced due to the tertiary nature of this clinic. Although referrals were from a variety of sources, 50 - 60% were from other hospitals and community physicians, which suggests that these children may have been more chronic in their recovery patterns when referred. However the sample does include the spectrum of concussion recovery trajectories and provided a unique opportunity to examine a protracted symptom group. The clinical nature of the database resulted in some inconsistencies in data collection as children did not return for follow up or information was not obtained which means there was missing data over time. This may have resulted in a lack of power to detect difference between those with depression scores and those without and also may have limited the model building in predicting depression.ConclusionDepression in the first year after childhood concussion is not a rare occurrence. Prevalence of depression during concussion recovery is 4 times that reported for childhood depression in published population data. This study adds to the knowledge regarding the risk of depression in youth recovering from concussion and some of the factors that play a role in increasing that risk. Children with a history including admission to hospital, high initial symptom scores and prolonged symptoms over three months should be followed closely with vigilance for the development of depressive symptoms. ReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY [1]Karlin A. Concussion in the pediatric and adolescent population: ‘different population, different concerns. Physical Medicine and Rehabilitation 2011;3: S369–79.[2]Bakhos L, Lockhart G, Myers R, Linakis J. Emergency department visits for concussion in young child athletes Pediatrics 2010;126:e550–e556.[3]Swaine B, Tremblay C, Platt R, Grimard G, Zhang X, Pless I. Previous head injury is a risk factor for subsequent head injury in children: a longitudinal cohort study. 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Table 1: Time from injury to Depression ScreenTime from injury to screenTotal Number N=84* (%)CDI T ≥65N=19 (%)< 1 month18 (21)4 (21)1 – 3 months20 (24)3 (16)3 – 6 months20 (24)5 (26)6 – 12 months7 (8)5 (26)> 12 months19 (23)2 (11)*Hospital records incomplete with some dates of injuryTable 2: Characteristics of sample by CDI-2 scores CDI ≤ 65 Non-depressedN=72 CDI ≥ 65 Depressed N=20 Test StatisticAge in years mean (sd)14.71 (2.6)14.59 (2.3)p=0.85Gender n (%) Male Female29 ( 40.3) 43 (59.7)7 (35) 13 (65) χ2=.798, df=1, p=0.44Premorbid Hx n (%) Headaches/migraines Learning issues Mental health 6 (6.5) 5 (5.4)4 (4.3)3 (3.2)2 (2.2)2 (2.2) p= 0.90 p=0.61 p=0.66Months from injury to CDI mean (sd)7.1 (8.8)6.6 (7.5)t(84)=-.26, p=.79Referred n (%) acutely from ED/wards tertiary care23 (32)33 (46)5 (7)11 (15)χ2=.562, df=2, p=.755PCSI Scores - mean (sd) Time 1 (N=90) Time 2 (N=51) Time 3 (N=35)7.06(5.4)6.41 (5.4)6.1 (4.5)11.05 (5.3)8.27 (7.0)10.11 (6.03)t89=2.95, p=.004**t59=1.62, p=.035t33=2.12, p=.041*Cause of injury n (%) Sport related MVA Falls/trips Other30 (47)8 (12.5) 9 (14)17 (26.5)13 (65)2 (10)4 (20)1 (5)χ2=8.97, df=8, p=0.35Multiple concussions n (%) 31 (56)7 (35)t(89)=-.738, p=.463Decrease in Academic Standing n (%) 29 (37.6)12 (15.5)F=5.71, df=1,p=0.024*Admitted to hospital n (%)21 (30)7 (35)χ2=.181, df=1, p=0.67Length of stay in hospital mean (sd)1.76 (1.2)6.14 (5.2)t(22)=3.33, p=0.003***significant at the 0.05 level**significant at the 0.01 levelTable 3: Correlation matrix for the relationship among non-injury and injury related concussion variablesVVar1gend2Age3LoFU4LOS5#con6PCSI17PCSI28PCSI39EPS110EPS311DAS12ChildT13ParT14AdmHosp1.Gender1.257*.111-.237-.039.173.090.123.079-.152.212.136.119-.1532. Age1-.033.131.078.147.081.133.071.145.219.165-.052.0223. LoFU1.333.051-.004.024.037.081.066.024-.051.191-.421**4. LOS1.422*.095-.090.341.262.321.229.269.198-5. #con1.078.117-.198.019.052.108.051.033-.374**6. PCSI 11.440**.171.186.456**.382**.442**.304**-.253*7. PCSI 21.346*-.056.365*.540**.200.438**-.2558. PCSI 31-.244.471*.325.602**.601**.0349. EPS11.231.187.188.009-.18010. EPS31.502**.483**.146-.06211. DAS1.431*.406**-.293*12.CDIT-Child1.210-.06813. CDIT-Par1.07714. Adm Hosp1LoFU=length of follow up, LOS= length of stay in hospital, #con=number of concussions, PCSI=post concussive symptoms inventory score (time 1,2,3), EPS1=experienced prolonged symptoms for 1 month, EPS3=experienced prolonged symptoms for 3 months, DIAS=decrease in academic standing, CDIT-child=CDI T score recorded by child, CDIT-par=CDI T score recorded by parent, Adm Hosp=Admitted to hospital* is significant at the .05 level (2 tailed)** is significant at the .01 level (2 tailed)TabTable 4: Logistic regression predicting likelihood of depression in concussion recoveryVARIABLESBS.E.WalddfSig.Exp(B)95% C.I.for EXP(B)LowerUpperSymptom score T-1.278.1066.8961.0091.3201.0731.624Adm to Hosp2.4641.1364.7051.03011.7481.268108.823Symptoms > 3 mos1.6191.2021.8141.1785.050.47853.312# HI.197.290.4611.4971.217.6902.148Gender (ref male)-.847.8251.0541.305.429.0852.160Constant-6.5332.1369.3561.002.001-child=CDI T score recorded by child, CDIT-par=CDI T score recorded by parent, Adm Hosp=Admitted to hospital* is significant at the .05 level (2 tailed)** is significant at the .01 level (2 tailed)Chapter ThreeTitle of Paper: Exploring prolonged recovery and depression in youth after concussion:A trajectory of recoveryAuthors: Kathy Stazyk BHSc. OT Reg (Ont), Sandra Moll Ph.D, OT Reg (Ont), Carol DeMatteo MSc., Dip P & OT, OT Reg (Ont), Cheryl Missiuna Ph.D, OT Reg (Ont)To be submitted to: Brain InjuryAbstractObjectives:The emotional impact of prolonged recovery from concussion can complicate children’s return to full participation in their daily lives. We aim to explore the lived experience of protracted recoveries with significant depressive symptomology from the perspective of youth and their families. Methods:A qualitative phenomenological design using semi-structured interviews was employed with six children 11 – 18 years of age who were 4 – 38 (mean=11) months post-injury. Inclusion criteria consisted of a concussion diagnosis and a T score of > 65 on the Childhood Depression Inventory-2. Parents were also interviewed. Data was transcribed, coded and analyzed for themes using NVivo 10 software. Findings:For children and their families, recovery from concussion and the associated depression evolved over time in four key stages. Stage one, the initial impact, included the incident causing the concussion, as well as acute symptoms and their management. Stage two, the fallout, included the functional consequences of symptoms and associated depression on their lives. The third stage, putting the pieces back together, described the way children and families begin to cope. The final stage, finding a new or renewed path, occured when children had either taken up their past lives or found meaning and value despite the remaining effects of concussion and/or depression. ConclusionsYouth recovering from concussion that is complicated by significant depressive symptoms experience a multilayered emotional process of recovery that has home, school, interpersonal/social and health care implications. Understanding this trajectory of recovery provides opportunities to plan and structure services that may ease the burden of suffering for families.The symptoms of concussion or mild traumatic brain injury can take a long time to resolve and may result in significant long-term difficulties ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.3109/02699052.2012.654590", "ISBN" : "5143437830", "ISSN" : "1362-301X", "PMID" : "22372409", "abstract" : "To determine whether age differences exist with respect to neuropsychological and electrophysiological functioning following a sport concussion.", "author" : [ { "dropping-particle" : "", "family" : "Baillargeon", "given" : "Annie", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lassonde", "given" : "Maryse", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Leclerc", "given" : "Suzanne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ellemberg", "given" : "Dave", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain injury : [BI]", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2012", "1" ] ] }, "page" : "211-20", "title" : "Neuropsychological and neurophysiological assessment of sport concussion in children, adolescents and adults.", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1542/peds.2005-0994", "author" : [ { "dropping-particle" : "", "family" : "Kirkwood", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yeates", "given" : "Keith Owen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wilson", "given" : "Pamela E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2006" ] ] }, "title" : "Pediatric Sport-Related Concussion : A Review of the Clinical Management of an Oft-Neglected Population", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.009", "ISSN" : "1558-1381", "PMID" : "22050943", "abstract" : "Each year in the United States, approximately 1.7 million people are diagnosed with a traumatic brain injury (TBI), about 75% of which are classified as mild TBIs or concussions. Although symptoms typically resolve in a matter of weeks, both children and adults may suffer from postconcussion syndrome for months or longer. A progressive tauopathy, chronic traumatic encephalopathy, is believed to stem from repeated brain trauma. Alzheimer-like dementia, Parkinsonism, and motor neuron disease are also associated with repetitive brain trauma. 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Headaches, fatigue, dizziness, slowed thinking, balance difficulties, emotional dysregulation and sleep disturbances are but a few of the symptoms that can disrupt the daily lives of children and their families ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.009", "ISSN" : "1558-1381", "PMID" : "22050943", "abstract" : "Each year in the United States, approximately 1.7 million people are diagnosed with a traumatic brain injury (TBI), about 75% of which are classified as mild TBIs or concussions. Although symptoms typically resolve in a matter of weeks, both children and adults may suffer from postconcussion syndrome for months or longer. A progressive tauopathy, chronic traumatic encephalopathy, is believed to stem from repeated brain trauma. Alzheimer-like dementia, Parkinsonism, and motor neuron disease are also associated with repetitive brain trauma. 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Children are especially vulnerable to post-concussive symptoms and report more significant cognitive symptoms than adults a year after the injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.pmr.2011.08.009", "ISSN" : "1558-1381", "PMID" : "22050943", "abstract" : "Each year in the United States, approximately 1.7 million people are diagnosed with a traumatic brain injury (TBI), about 75% of which are classified as mild TBIs or concussions. Although symptoms typically resolve in a matter of weeks, both children and adults may suffer from postconcussion syndrome for months or longer. A progressive tauopathy, chronic traumatic encephalopathy, is believed to stem from repeated brain trauma. Alzheimer-like dementia, Parkinsonism, and motor neuron disease are also associated with repetitive brain trauma. Effective diagnoses, treatments, and education plans are required to reduce the future burden and incidence of long-term effects of head injuries.", "author" : [ { "dropping-particle" : "", "family" : "Daneshvar", "given" : "Daniel H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Riley", "given" : "David O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nowinski", "given" : "Christopher J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McKee", "given" : "Ann C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stern", "given" : "Robert a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cantu", "given" : "Robert C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Physical medicine and rehabilitation clinics of North America", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2011", "11" ] ] }, "page" : "683-700, ix", "title" : "Long-term consequences: effects on normal development profile after concussion.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[3]", "plainTextFormattedCitation" : "[3]", "previouslyFormattedCitation" : "[3]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[3].Sixty-six percent of traumatic brain injuries occur in those under 20 years of age with the most common cause being sport in school-aged children ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/00042752-200403000-00004", "ISBN" : "1050-642X (Print)\\r1050-642X (Linking)", "ISSN" : "1050-642X", "PMID" : "15014340", "abstract" : "OBJECTIVE: To examine the incidence of head blows and concussions in competition taekwondo. DESIGN: Incidence cohort design. SETTING: Taekwondo tournament in 2001, in South Korea. PARTICIPANTS: A total of 2328 competitors (female, 676; male, 1652; age, 11-19 years) from 424 schools participated in the tournament. All recipients of head blows were interviewed immediately after the match. All matches were recorded on videotape. MAIN OUTCOME MEASURES: Head blow and concussion rates were calculated. Also, factors associated with head blows and concussions were analyzed. RESULTS: The incidence of head blows and concussions was 226 and 50 per 1000 athlete exposures, respectively. Only 17% of competitors reported that they had had a concussion in the last 12 months. A multinomial logistic model showed that head blows and concussions were associated with young age and a lack of blocking skills. CONCLUSIONS: The incidence of head blows and concussions is high in competition taekwondo. Promoting blocking skills to prevent head blows could decrease concussions in taekwondo.", "author" : [ { "dropping-particle" : "", "family" : "Koh", "given" : "Jae O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cassidy", "given" : "J David", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "72-79", "title" : "Incidence study of head blows and concussions in competition taekwondo.", "type" : "article-journal", "volume" : "14" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[4]", "plainTextFormattedCitation" : "[4]", "previouslyFormattedCitation" : "[4]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[4]. Incidence data reported from emergency department visits of youth who are participating in organized sports shows a dramatic increase, doubling in the ten years between 1997-2007 ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1542/peds.2009-3101", "ISBN" : "1098-4275 (Electronic) 0031-4005 (Linking)", "ISSN" : "0031-4005", "PMID" : "20805145", "abstract" : "OBJECTIVES: The objective of this study was to characterize emergency department (ED) visits for pediatric sport-related concussion (SRC) in pre-high school- versus high school-aged athletes. METHODS: A stratified probability sample of US hospitals that provide emergency services in the National Electronic Injury Surveillance System (1997-2007) and All Injury Program (2001-2005) was used. Concussion-related ED visits were analyzed for 8- to 13- and 14- to 19-year-old patients. Population data were obtained from the US Census Bureau; sport participation data were obtained from National Sporting Goods Association. RESULTS: From 2001 to 2005, US children who were aged 8 to 19 years had an estimated 502 000 ED visits for concussion. The 8- to 13-year-old group accounted for approximately 35% of these visits. Approximately half of all ED visits for concussion were SRC. The 8- to 13-year-old group sustained 40% of these, which represents 58% of all concussions in this group. Approximately 25% of all SRC visits in the 8- to 13-year-old group occurred during organized team sport (OTS). During the study period, approximately 4 in 1000 children aged 8 to 13 years and 6 in 1000 children aged 14 to 19 years had an ED visit for SRC, and 1 in 1000 children aged 8 to 13 years and 3 in 1000 children aged 14 to 19 years had an ED visit for concussion sustained during OTS. From 1997 to 2007, although participation had declined, ED visits for concussions in OTS in 8- to 13-year-old children had doubled and had increased by >200% in the 14- to 19-year-old group. CONCLUSIONS: The number of SRCs in young athletes is noteworthy. Additional research is required.", "author" : [ { "dropping-particle" : "", "family" : "Bakhos", "given" : "Lisa L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lockhart", "given" : "Gregory R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Myers", "given" : "Richard", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Linakis", "given" : "James G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "e550-e556", "title" : "Emergency department visits for concussion in young child athletes.", "type" : "article-journal", "volume" : "126" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[5]", "plainTextFormattedCitation" : "[5]", "previouslyFormattedCitation" : "[5]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[5]. These increasing numbers, along with the well-documented longer recovery time in children, increases the potential for poor health. In a longitudinal study of children with acquired brain injury, quality of life (QOL) was impacted regardless of the severity of injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.3109/02699052.2013.848380", "ISSN" : "1362-301X", "PMID" : "24328806", "abstract" : "OBJECTIVE: Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI.\n\nMETHODS: The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL.\n\nRESULTS: The QoL of children with ABI was significantly poorer (p < 0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS.\n\nCONCLUSIONS: QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "Carol a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hanna", "given" : "Steven E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yousefi-Nooraie", "given" : "Reza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lin", "given" : "Chia-Yu a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mahoney", "given" : "William J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Law", "given" : "Mary C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCauley", "given" : "Dayle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain injury : [BI]", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "114-21", "title" : "Quality-of-life after brain injury in childhood: time, not severity, is the significant factor.", "type" : "article-journal", "volume" : "28" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[6]", "plainTextFormattedCitation" : "[6]", "previouslyFormattedCitation" : "[6]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[6]. In a cohort study of 8 – 15 year old children with mild traumatic brain injury (mTBI). Yeates and colleagues (2012) found that protracted symptoms were associated with significant declines in health-related QOL as well as a 50 percent increase in academic intervention at 3 and 12 months post injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Yeates", "given" : "K O", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kaizar", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rusin", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bangert", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dietrich", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Nuss", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wright", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Arch Pediatr Adolesc Med", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "E1-E8", "title" : "Reliable Change in Postconcussive Symptmos and Its Functional Consequences Among Children With Mild Traumatic Brain Injury", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[7]", "plainTextFormattedCitation" : "[7]", "previouslyFormattedCitation" : "[7]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[7]. Children with protracted symptoms after concussion reported a similar QOL as their peers with cancer ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Duffy A", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012", "9", "26" ] ] }, "publisher-place" : "Ottawa", "title" : "Concussions ruin quality of life for young athletes", "type" : "article-newspaper" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[8]", "plainTextFormattedCitation" : "[8]", "previouslyFormattedCitation" : "[8]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[8]. Depression after concussion seems to contribute to poorer health outcomes than concussion alone ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1080/02699050500110264", "ISSN" : "0269-9052", "PMID" : "16263640", "abstract" : "To study the variables that relate to outcome after mild traumatic brain injury (TBI).", "author" : [ { "dropping-particle" : "", "family" : "Mooney", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Speed", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sheppard", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain injury : [BI]", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2005", "11" ] ] }, "page" : "975-87", "title" : "Factors related to recovery after mild traumatic brain injury.", "type" : "article-journal", "volume" : "19" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[9]", "plainTextFormattedCitation" : "[9]", "previouslyFormattedCitation" : "[9]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[9]. When a depressive episode occurs during recovery from concussion, it can be difficult to detect due to overlapping symptoms from the concussion. Sleep, emotional and cognitive symptoms, for example, are similar to those of depression. A depression that occurs in the first 3 months following the injury intensifies and prolongs these post-concussive symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1001/archpsyc.62.5.523", "ISBN" : "0003-990X", "ISSN" : "0003-990X", "PMID" : "15867105", "abstract" : "CONTEXT: Minimizing negative consequences of major depression following traumatic brain injury is an important public health objective. Identifying high-risk patients and referring them for treatment could reduce morbidity and loss of productivity. OBJECTIVE: To develop a model for early screening of patients at risk for major depressive episode at 3 months after traumatic brain injury. DESIGN: Prediction model using receiver operating characteristic curve. SETTING: Level I trauma center in a major metropolitan area. PARTICIPANTS: Prospective cohort of 129 adults with mild traumatic brain injury. MAIN OUTCOME MEASURES: Center for Epidemiologic Studies Depression Scale score and current major depressive episode module of the Structured Clinical Interview for the DSM-IV. RESULTS: A prediction model including higher 1-week Center for Epidemiologic Studies Depression Scale score, older age, and computed tomographic scans of intracranial lesions yielded 93% sensitivity and 62% specificity. CONCLUSION: This study supports the feasibility of identifying patients with mild traumatic brain injury who are at high risk for developing major depressive episode by 3 months' postinjury, which could facilitate selective referral for potential treatment and reduction of negative outcomes.", "author" : [ { "dropping-particle" : "", "family" : "Levin", "given" : "Harvey S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McCauley", "given" : "Stephen R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Josic", "given" : "Claudia Pedroza", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boake", "given" : "Corwin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brown", "given" : "Sharon a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goodman", "given" : "Heather S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Merritt", "given" : "Shirley G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brundage", "given" : "Susan I", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of general psychiatry", "id" : "ITEM-1", "issue" : "May 2005", "issued" : { "date-parts" : [ [ "2005" ] ] }, "page" : "523-528", "title" : "Predicting depression following mild traumatic brain injury.", "type" : "article-journal", "volume" : "62" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[10]", "plainTextFormattedCitation" : "[10]", "previouslyFormattedCitation" : "[10]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[10]. The concurrent nature of the symptoms can make it difficult to disentangle depression from the symptoms of concussion in order to identify and treat it appropriately ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Bryant", "given" : "R A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "O'Donnell", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Creamer", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McFarlane", "given" : "A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Clark", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Silove", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Am J Psychiatry", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "312-320", "title" : "The Psychiatric sequelaie of traumatic injury", "type" : "article-journal", "volume" : "167" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[11]", "plainTextFormattedCitation" : "[11]", "previouslyFormattedCitation" : "[11]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[11]. Ongoing symptoms, whether they are caused by the concussion alone or due to depression, can affect the child’s ability to function. This creates a significant burden on individuals, families and society as the child’s school performance and social function often declines. In addition, physical health problems such as sleep issues, fatigue and pain are more likely ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.amepre.2006.07.001", "ISSN" : "0749-3797", "PMID" : "17175409", "abstract" : "Depression in childhood and adolescence creates significant burden to individuals, families, and societies by increasing morbidity, increasing mortality, and negatively affecting quality of life during times of significantly depressed mood. Several studies have estimated the cost of depression in the United States and elsewhere, but none have included the costs associated with depression in children or younger adolescents. This paper reviews data currently available on the cost of depression in childhood and the cost effectiveness of interventions to treat and prevent depression in this population.", "author" : [ { "dropping-particle" : "", "family" : "Lynch", "given" : "Frances L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Clarke", "given" : "Gregory N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "American journal of preventive medicine", "id" : "ITEM-1", "issue" : "6 Suppl 1", "issued" : { "date-parts" : [ [ "2006", "12" ] ] }, "page" : "S143-51", "title" : "Estimating the economic burden of depression in children and adolescents.", "type" : "article-journal", "volume" : "31" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[12]", "plainTextFormattedCitation" : "[12]", "previouslyFormattedCitation" : "[12]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[12].The recommended management of concussion is a balance of rest with gradual return to activities ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/bjsports-2012-092132", "ISSN" : "1473-0480", "PMID" : "23613516", "abstract" : "BACKGROUND: There are many reasons why concussion in children needs to be considered different from adults. The Zurich (2008) recommendations on the management of concussion in children are restricted to children less than to 10 years of age. It does not include recommendations for children aged 5-10 years. The aim of this study is to review the current literature on (1) concussion assessment at the sideline and during recovery stages, especially in the age group 5-15 years, and (2) the management of concussion in children and adolescents. METHODS: A literature review using the MEDLINE database was undertaken. Articles were selected that included evaluation and/or management in children aged 5-15 years. RESULTS: There are no sideline assessment tools validated for use in this age group. There are a number of different symptom scales that have been validated during different stages of the follow-up assessment in children. No single paediatric concussion assessment tool has been validated for use from sideline through to all stages of recovery. Reliability studies have been published on Balance Error Scoring System in children, but validity studies in this age group have not been published. The management of concussion includes withdrawal from play on the day and cognitive and physical rest. The priority of concussion management in children is to return to learn; while this is usually rapid, there are some children in whom a graduated return to school is required, which should include a number of accommodations. CONCLUSIONS: A young child is physically, cognitively and emotionally very different from adults, and requires the use of a different set of tools for the diagnosis, recovery-assessment and management of concussion. Age-specific, validated diagnostic tools are required, and management of concussion in children should focus attention on return to learn before considering return to play.", "author" : [ { "dropping-particle" : "", "family" : "Davis", "given" : "Gavin a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Purcell", "given" : "Laura K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British journal of sports medicine", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013", "4", "23" ] ] }, "page" : "1-5", "title" : "The evaluation and management of acute concussion differs in young children.", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1177/0009922814558256", "ISBN" : "0009922814", "ISSN" : "0009-9228", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stazyk", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Singh", "given" : "S. K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giglia", "given" : "L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hollenberg", "given" : "R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Malcolmson", "given" : "C. 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H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Turner", "given" : "M.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Sports Medicine", "id" : "ITEM-3", "issue" : "5", "issued" : { "date-parts" : [ [ "2013", "3", "11" ] ] }, "page" : "250-258", "title" : "Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012", "type" : "article-journal", "volume" : "47" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[13]\u2013[15]", "manualFormatting" : "[13,15]", "plainTextFormattedCitation" : "[13]\u2013[15]", "previouslyFormattedCitation" : "[13]\u2013[15]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[13,15]. Finding the proper balance, however, can be very difficult. For example, children are advised to rest when they are symptomatic; however, prolonged rest can lengthen the recovery time and contribute to depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/JSM.0b013e3181c6c22c", "ISSN" : "1536-3724", "PMID" : "20051730", "abstract" : "To evaluate the safety and effectiveness of subsymptom threshold exercise training for the treatment of post-concussion syndrome (PCS).", "author" : [ { "dropping-particle" : "", "family" : "Leddy", "given" : "John J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kozlowski", "given" : "Karl", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Donnelly", "given" : "James P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pendergast", "given" : "David R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Epstein", "given" : "Leonard H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Willer", "given" : "Barry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010", "1" ] ] }, "page" : "21-7", "title" : "A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome.", "type" : "article-journal", "volume" : "20" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[16]", "plainTextFormattedCitation" : "[16]", "previouslyFormattedCitation" : "[16]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[16]. Going back to activity too soon, on the other hand, can exacerbate current symptoms and may even elicit the return of symptoms and lengthen recovery. Pre-injury stress has been shown to contribute to protracted symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/dmcn.12263", "ISSN" : "1469-8749", "PMID" : "23992222", "abstract" : "AIM: To determine whether post-injury depressive symptoms, and pre-injury major life stressors and genetic factors (HTR1A C(-1019)G alleles; rs6295) are more common in children with mild traumatic brain injury (mTBI) who develop postconcussion syndrome (PCS) symptoms compared with children with asymptomatic mTBI.\n\nMETHOD: This was a cross-sectional study of 47 symptomatic children (32 males, 15 females; mean age 14y [SD 3y 3mo]) who experienced post-concussive symptoms for 7 or more days and 42 asymptomatic children (26 males 16 females; mean age 13y 6mo [SD 3y 1mo]) after mTBI. Outcome measures were the Postconcussion Symptoms Inventory (PCSI), the Children's Depression Inventory (CDI), standard questionnaire of previous life events, and buccal DNA analysis to determine genotype and allele frequencies for the HTR1A C(-1019)G polymorphism.\n\nRESULTS: Depressive symptoms were uncommon. CDI scores did not differ between groups. Allelic and genotypic frequencies for HTR1A C(-1019)G were similar in both groups. Symptomatic children continued to have elevated PCS scores compared with asymptomatic children 1.72 (SD 0.69) years later and had experienced significantly more life stressors (Wald (1)=8.51, p=0.004).\n\nINTERPRETATION: HTR1A polymorphisms do not differ in children with PCS. Children who have experienced more significant life stresses are more likely to develop PCS symptoms after mTBI.", "author" : [ { "dropping-particle" : "", "family" : "Smyth", "given" : "Kim", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Sandeep S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Crawford", "given" : "Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Dewey", "given" : "Deborah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Parboosingh", "given" : "Jillian", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Barlow", "given" : "Karen M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental medicine and child neurology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "1" ] ] }, "page" : "73-7", "title" : "The role of serotonin receptor alleles and environmental stressors in the development of post-concussive symptoms after pediatric mild traumatic brain injury.", "type" : "article-journal", "volume" : "56" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[17]", "plainTextFormattedCitation" : "[17]", "previouslyFormattedCitation" : "[17]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[17]. Additional stressors associated with prolonged symptoms, including the loss of meaningful activity and disruption to everyday routines, are thought to contribute to the onset of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1097/HTR.0b013e31825ad658", "author" : [ { "dropping-particle" : "", "family" : "Silverberg", "given" : "Noah D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Iverson", "given" : "Grant L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J Head Trauma Rehabil", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "250-259", "title" : "Is Rest After Concussion \u201c The Best Medicine ?\u201d: Recommendations for Activity Resumption Following Concussion in Athletes , Civilians , and Military Service Members", "type" : "article-journal", "volume" : "28" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[18]", "plainTextFormattedCitation" : "[18]", "previouslyFormattedCitation" : "[18]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[18]. Managing concussion recovery when it is combined with the onset of depression is, therefore, complex. Many questions about the phenomenon of prolonged concussion recovery associated with depressive symptoms remain unanswered. A qualitative study of 13 athletes aged 10 – 13 recovering typically from concussion found that, although no long term impact on school or sport was experienced, higher levels of anger and frustration related to performance post-injury were found ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1136/bjsports-2012-092101.6", "author" : [ { "dropping-particle" : "", "family" : "Provvidenza", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keightley", "given" : "Michelle L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Reed", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Green", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "British Journal of Sports Medicine", "id" : "ITEM-1", "issue" : "e1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "title" : "Exploring parent and youth perspectives of the influence of concussion on school, sport and life: a qualitative study", "type" : "article-journal", "volume" : "47" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[19]", "plainTextFormattedCitation" : "[19]", "previouslyFormattedCitation" : "[19]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[19]. Qualitative studies focused on prolonged recovery after concussion from the family’s perspective are thus far non-existent. This project was undertaken to explore how children and their families experience concussive injury and subsequent recovery as well as the emotional/depressive symptoms that may be a part of the process. Understanding how families make sense of their experiences, their perceptions of the impact on the child and family unit, and determining what is helpful or not during this time can help in planning the types of services and resources needed at various stages to prevent or improve poor outcomes. MethodsDesignA hermeneutic phenomenological approach was employed to examine the lived experience of participants with the phenomenon of prolonged recovery from concussion complicated by depressive symptoms. Hermeneutics is the art and science of interpretation and is described as an attitude or disposition rather than a distinct methodology ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Henriksson", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Friesen", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "editor" : [ { "dropping-particle" : "", "family" : "Friesen", "given" : "N", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Henrisksson", "given" : "C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saevi", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "number-of-pages" : "1-", "publisher" : "Sense Publishers", "publisher-place" : "Rotterdam", "title" : "Hermeneutic Phenomenology in Education: Method and Practice", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[20]", "plainTextFormattedCitation" : "[20]", "previouslyFormattedCitation" : "[20]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[20]. In this type of phenomenology, the “hermeneutic circle” is central to understanding and interpretation. The ever-expanding circle between the whole and part of the text and in the dynamic between the researcher and the participant is integral to analysis as “to understand the part, you look to the whole; to understand the whole, you look to the part” ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "VanManen", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "second", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "1990" ] ] }, "number-of-pages" : "202", "publisher" : "State University of New York Press", "publisher-place" : "Albany, New York", "title" : "Researching Lived Experience: human science for action sensitive pedagogy", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[21]", "plainTextFormattedCitation" : "[21]", "previouslyFormattedCitation" : "[21]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[21].Ethical approval for this study was obtained from the Hamilton Integrated Research Ethics Board overseeing the McMaster University Faculty of Health Sciences. Informed consent was obtained from all parents and assent from the youths was obtained at the time of the interview. SamplingParticipants were recruited through the health care team of the Acquired Brain Injury clinic at a tertiary-care children’s hospital serving South-Western Ontario from December 2013 to April 2014. Purposive sampling was employed to generate a group of key informants who experienced similar events. Consequently large numbers of participants were not required to capture meaningful accounts. Children who met the following inclusion criteria were sought: 1) diagnosis of MTBI/concussion; 2) between the ages of 10 – 18 years; 3) post-concussive symptoms present ≥ 3 months post-injury; 4) evidence of depression on both parent and child reports (operationalized as a Child Depression Inventory-2 screen score 65); 5) child not under psychiatric care in the year prior to concussion. In addition, the parent had to be willing to participate and both the child and family had to be able to communicate in English (for participating in the interviews). Twelve potential recruits were identified, however two were excluded due to other diagnoses, and four declined to participate. The final sample of six participants (four girls and two boys) included five families (since one family had two girls who both met the inclusion criteria). Four of the five families were two-parent families. Two families had both parents participating in the interview, two had mothers only, and one had the father only. Youth were interviewed with their parent/parents, in the family home between March and August of 2014. Table 1 provides characteristics of the sample.<< insert Table 1 about here >>ProceduresIn-depth interviews of 45 to 80 minutes in length were conducted by the first author, in the family home. Children chose whether to have parents present during their interview or whether they wished to be interviewed separately. Most interviews were conducted with the parents nearby. In three cases, the process was sequential with children interviewed first and then the parents. In two cases, the parent and child were interviewed together, with each having a turn answering the questions. All interviews were audiotaped and transcribed. Five key open-ended questions guided the interview: Tell me the story of your concussion. Tell me about any mood changes you have experienced since your concussion. What has the impact of this been on you? What has it been like for your family? What are the things that have been helpful or challenging throughout this whole experience? Follow-up probes were used to gather an in-depth understanding of their beliefs and experiences. A second telephone interview was completed with three of six of the participants as a member checking strategy, after they had an opportunity to review a summary of the study findings. Additional sources of data included scores from the depression screening tool that was completed at the time of interview, as well as field notes completed by the first author throughout the process of data collection and analysis. Screening toolThe Children’s Depression Inventory-2 (CDI-2S) was used to evaluate the presence of significant depressive symptoms ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kovacs", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher" : "Multi-Health Systems", "title" : "Children's Depression Inventory-2", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[22]", "plainTextFormattedCitation" : "[22]", "previouslyFormattedCitation" : "[22]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[22]. The CDI-2S is both a self-report and parent-report measure of the extent and severity of depressive symptoms in children 7 – 17 years of age. The screening tool consists of 12 questions and the child chooses the statement that best describes their feelings or moods in the past 2 weeks. Statements represent the range of severity of the symptom from 0 (none) to 2 (definite). There are 3 questions dealing with depressed mood and irritability, 3 questions regarding physical symptoms, 1 about diminished pleasure, 1 dealing with cognitive symptoms and the rest are about feelings of low self esteem, worthlessness and hopelessness. Scores from all questions are totaled and raw scores are converted to T scores. A T score of 65 (1.5 SD above the mean) is considered to indicate a clinically significant level of depressive symptomatology ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Kovacs", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2011" ] ] }, "publisher" : "Multi-Health Systems", "title" : "Children's Depression Inventory-2", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[22]", "plainTextFormattedCitation" : "[22]", "previouslyFormattedCitation" : "[22]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[22]. This screening tool has a high correlation with the full-length self rated form (r=.95, p<.001) and has been validated for use with medically ill children ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpsychores.2012.08.016", "ISSN" : "1879-1360", "PMID" : "23062811", "abstract" : "OBJECTIVE: This is the first study to validate and to compare the Children's Depression Inventory (CDI) and its short version (CDI:S) as screening tools for medically ill children.\n\nMETHODS: A sample of 406 pediatric hospital patients, aged 9 to 12 years (56.2% male, 77.1% inpatients), completed the German CDI. Criterion validity of the 26-item CDI and the 10-item CDI:S was calculated by receiver operating characteristic (ROC) curves. DSM-IV diagnoses of depression based on the structured diagnostic interview for mental disorders in children and adolescents (Kinder-DIPS) served as the reference standard. Areas under the ROC curves as well as sensitivities and specificities for the optimal cutoffs were compared for both versions.\n\nRESULTS: Diagnoses of major or minor depression were established for 7.4% of the children. Areas under the curve for the 26-item CDI (87.7%) and the 10-item CDI:S (88.2%) were comparable. For the CDI, the cutoff\u226512 yielded the best balance between sensitivity (83.3%) and specificity (82.7%). At the optimal cutoff\u22653, the CDI:S resulted in a high sensitivity of 93.3% and a specificity of 70.7%. Thus, the CDI:S proved to be as sensitive as the CDI, but was less specific than the full-length version.\n\nCONCLUSION: Both the CDI and the CDI:S are valid screening instruments for depression in medically ill children. The sensitive and brief CDI:S is a promising tool in time-pressed settings such as pediatric care, but has to be followed by a thorough diagnostic assessment to rule out false positive cases.", "author" : [ { "dropping-particle" : "", "family" : "Allgaier", "given" : "Antje-Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fr\u00fche", "given" : "Barbara", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Pietsch", "given" : "Kathrin", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Saravo", "given" : "Barbara", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baethmann", "given" : "Martina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schulte-K\u00f6rne", "given" : "Gerd", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of psychosomatic research", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2012", "11" ] ] }, "page" : "369-74", "publisher" : "Elsevier Inc.", "title" : "Is the Children's Depression Inventory Short version a valid screening tool in pediatric care? A comparison to its full-length version.", "type" : "article-journal", "volume" : "73" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[23]", "plainTextFormattedCitation" : "[23]", "previouslyFormattedCitation" : "[23]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[23]. Children and their parents completed the depression screen independently of each other during follow up for their concussion at the tertiary care clinic. Agreement between the parent and child’s score indicating significant depressive symptoms (T≥65) was used to determine eligibility for this study. Data AnalysisInterviews were transcribed word for word and uploaded to NVivo 10 ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2012" ] ] }, "number" : "10", "publisher" : "QSR International Pty. Ltd.", "title" : "NVivo qualitative data analysis software", "type" : "article" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[24]", "plainTextFormattedCitation" : "[24]", "previouslyFormattedCitation" : "[24]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[24] for coding and organization. A hermeneutic iterative process was adopted using a “wholistic approach” and narrowing to selective data to analyze and widening the lens again ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "VanManen", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "second", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "1990" ] ] }, "number-of-pages" : "202", "publisher" : "State University of New York Press", "publisher-place" : "Albany, New York", "title" : "Researching Lived Experience: human science for action sensitive pedagogy", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[21]", "plainTextFormattedCitation" : "[21]", "previouslyFormattedCitation" : "[21]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[21]. Initially, transcripts were read in whole form and re-read to code statements by questioning those data segments of interest and asking “what is going on here?” Codes were grouped into sub categories. Data was also explored using content analysis to expand the lens outward to the whole and confirm sub-categories. Themes came out of a process of writing summary descriptions of each interview/story as these reflected similar concepts over time and meeting with the research team to generate different perspectives and agreement. Once the themes were developed a framework analysis was used to build a matrix of the cases and themes to complete the analysis. Fieldnotes and memoing were used to facilitate researcher reflexivity. Quality and rigour were addressed using detailed audit trails of project notes, decisions, codes/themes and memos. Member checking was conducted by sending a summary report of the themes to participants who then commented on the extent that the summary captured their own experiences and provided additional examples. Verification of the interpretation was received from three participants and added to the trustworthiness of the study.FindingsParticipants described their prolonged recovery from concussion and subsequent depression as a trajectory of 4 stages: “the impact”, “the fall-out”, “piecing it back together” and “the new or renewed path” (see figure 1). Each of these stages encompasses a set of common experiences after concussion, including a multilayered emotional process of recovery within the context of home, school, interpersonal relationships and health care. Rich descriptions of functional changes were provided most noticeably in the middle two stages of the fallout and putting the pieces back together. Exemplars are provided by the children and parents and labeled C1-6 for the children and P1-7 for the participating parents.The ImpactThe first “impact” stage includes the concussive incident, the diagnosis and early management as well as the acute physical and cognitive symptoms associated with the concussion. The themes in this stage are the feelings of shock and the uncertainty of figuring out whether to respond and how to respond to the injury. The concussive injury occurred at school for three of six participants (a fall and gym class collisions). Two of the other injuries occurred in competitive sport and one was the result of a pedestrian motor vehicle accident. One 18 year-old who has had 6 concussions since she was eleven described her reaction to her concussions like this “The first one is just like a big shock, you don’t really know what to do. Then your second one you’re able to recognize more easily ‘cause you know the symptoms” (C2).Symptoms commonly progressed to headaches, dizziness, nausea, fatigue and sensory sensitivities. One teenage girl, who received her second concussion in her first basketball game back after her initial injury, described her confusion this way.I don’t remember blacking out but I remember being very confused and everyone was like; “What’s wrong?” and I just wanted everyone to like shut up so I could figure out what was going on. I remember sitting on the bench during the game and the lights were starting to bother me and the noise and it’s like, I kind of knew that I had gotten another one. (C5)Variation in the responses to injury depended on how many injuries have been experienced and also those around the child. Coaches, for example, often knew what to do and informed parents immediately whereas some other caregivers seemed to be unaware of the significance of the injury and did not communicate this or mobilize assistance. One 11 year old described the reaction of a caregiver after she fell off of a climbing apparatus:So when I told her that I had hit my head she said that I would… I would be fine, that I just scared myself. She didn’t do anything for like an hour. Then I kept complaining about it because it really hurt and so finally she put ice on it. (C6)This same girl’s parents had talked about coming to the recognition about what they were dealing with:No they didn’t notify us so I just…she’s kind of accident prone, and so I didn’t take her to the doctor immediately because she wasn’t sort of exhibiting any signs so when the next day they called us from school and told us that she wasn’t feeling well and that she wanted to come home so we took her to the doctor and they diagnosed her with a mild concussion. Yeah they said keep her away from straining her eyes, not too much TV or reading or video games and then just keep her home until the end of the weekend (P7).All youth had received the diagnosis of concussion or had come to the understanding that they were dealing with a significant injury some immediately and others within 24 hours of the incident. Most families did go to their family physician but a couple of the families had professional background knowledge in this area and were able to recognize the concussion and respond with the appropriate activity limitations. The FalloutThe fallout describes the stage where the concussion symptoms persist beyond 1 – 2 weeks and the functional impact permeates into all aspects of the day-to-day lives of children and their families. Concussion symptoms and depressive symptoms co-occurred during this stage and were rarely discussed as separate entities. For both the youth and parents, this stage is burdened with multiple losses and the emotions of anger, frustration, sadness and loneliness that signify grief reactions. Emotional sequelae affected functioning at home, at school, and with peers. Personal fall-out Youth found the activity restrictions inherent in concussion recovery protocols difficult to adhere to and talked about how bored they were or how hard it was to be out of contact with friends. They alluded to resentment or irritation with the restrictions they were given. One 11-year-old girl stated “I wasn’t allowed to read or go on the computer, play video games, watch TV, play my iPod. Basically, I kind of just sat there.” (C6). Sport/leisure, friendships and school performance were frequently discussed as problematic due to the youth’s inability to participate fully in each of these areas for many weeks to months. Four of 6 described sport and exercise as a lifestyle they had previously adopted to relieve stress or as a potential future career path. The interruption of these activities added stress and uncertainty to their lives. Three of the sport-oriented girls with multiple concussions discussed having to quit their sport (two have done this and one is afraid that the next injury will result in this decision). A 16-year-old girl discussed the multiple losses she experienced of which sport was a significant loss:One of the hardest parts for me was, like, I had everything. I was good at school, I can do sports, I had lots of friends, everything was set for me and so it was really difficult getting the concussions cause I kind of lost everything right away. So it was really hard losing my sports and I think that was really hard because they have been a part of my life for so long and it’s a way that I like to get rid of stress and anxiety and so I found with my concussions that I had way more anxiety because I didn’t have an outlet for that. (C5)Social disruptions were also experienced. Missing out on peer group activities, feeling misunderstood or not believed were some of the challenges as well as much more extensive loss as some children experienced a total rejection by their entire peer group. This latter was described by three of the six (2 girls/1boy) with the youngest girl (11) having been bullied prior to her concussion. A 16-year-old girl had this understanding of how concussion contributed to her losing her whole peer group.They didn’t understand and they just thought like “oh she’s just like being grouchy or she’s just like mad at us, like she’s not talking.” And like it was just too much for me to do school and then the social part; so my friends kind of… they really ditched me. So that was hard because I lost my friend group too in the middle of all that, so I was kind of alone. (C5)A theme of not being believed was common to participants in the fall-out phase. Several participants described that the invisible nature of their difficulties generated a lack of understanding and support from peers and teachers and sometimes led to feelings of guilt on the part of the injured youth. School absence and decline in performance was a shared experience in the fall-out after concussion. Four participants were away from school for one to three weeks, and two were off for more than two months. Participants talked about not being able to keep up and were frustrated with the concentration and memory difficulties that made school and homework so much harder. The personal impact of all of these losses affected the youth’s sense of identity. All of the participants experienced a change in their sense of self due to the physical symptoms, which changed their perceptions of themselves as an athlete, high achieving student or outgoing and fun friend. A 17-year-old boy talked about his changing sense of self and identity.Yeah and I knew like …I could see myself changing a lot in the way I interacted with people and things I’d say and I became very introverted as a person. (C3) Family fall-out In the context of their home environment, the youth talked about being increasingly irritable, angry and frustrated which led to conflict with parents and siblings. One participant, for example, described ongoing tensions in the family precipitated by her sister’s frustration with her post-concussion limitations. When she doesn’t get things, then she’ll ask me for help but then she’ll be very frustrated with herself but it comes out towards me. Then I was trying to help her so that makes me frustrated and then my parents get frustrated and then they’re yelling at each other. (C2)Families mirrored the children’s emotional responses of anger and frustration with prolonged recovery and some families found blame as an outlet. The mother of a grade nine student who lost his school semester and his high level hockey position that he had worked so hard for because of an injury acquired in gym class stated: And as the shock of realizing how bad things were has worn off, the resentment and anger has come in; this insane outrage with the school, with the teacher, with the kid that did it…(P4)Parents also expressed much sadness about watching their child suffer through multiple losses. One mother empathizing with her daughter’s pain said:Yeah we were worried about her state of mind, you know, her loneliness and angry for her that her friends would be so mean. That’s hard to watch (P5).Many parents described their struggles in knowing how to support their child. They struggled to know how and when to push their child to move forward, and when to hold them back in order to protect them from repercussions of the concussion symptoms. This led to self-doubt regarding their parenting abilities, especially in knowing when to push and when to help. The father of two daughters who both had a history of multiple concussions and mood disorders, talked about parenting being a balancing act.Stressful, very stressful as a parent, especially with us, the way that we’ve taught you girls “don’t give up on things” and “keep trying’ and “don’t just walk away from…” but when you are trying and you can’t get it-it’s even harder and then we have to find that fine line between “OK relax” or “don’t give up attitude” right? That’s the hardest part for myself has been trying to balance that. (P2)For both the youth and parents, this stage is fraught with emotions that result from the grieving of losses. Anger and frustration seem to be predominant in this phase of recovery from concussion.<<Insert figure 1 about here>>Piecing it Back TogetherThis stage was a time of struggle to find ways of getting through the fallout, despite the persistence of symptoms and emotional challenges. Families and youth attempted to find resources and strategies to move forward without any predictable time frame for getting better. Anxiety appeared to be the hallmark emotion of this stage as children and parents tried to balance recovery with reengagement in activity. Personal Pieces Many of the youth (4 of 6) talked about experiencing fear and anxiety with the reintroduction of a stressful activity. Return to school was typically one of the first activities re-established after concussion and seemed to intensify symptoms and causes anxiety due to the student trying to keep up with the curriculum, educator expectations and the youth’s own expectations of themselves and their pre-injury identity. In order to be successful at school, accommodations and supportive relationships with educators were identified as very important. Every participant had some type of accommodation; 2 had IEP’s put in place since their injury, 5 dropped classes and were excused from tests and exams and a few were doing online courses. In order to resolve some of the losses in social and leisure areas, many youth found engagement in meaningful activity an important part of trying to get their life back on track. Music, faith, coaching and volunteer work with others were some of the strategies that gave individuals a sense of purpose and relieved boredom. One family of a 14 year-old boy dealt with this in a unique way by purchasing snakes for their son to care for.He was driving me crazy. So actually because of his stress and his boredom and his irritability; because of that we ended up letting him get snakes [pythons] because?it was just something that he could deal with. It wasn't too much stimulation and the activity engaged him completely. (P4)Another teen’s experience with volunteer work was important for her to get through her recovery.I helped out at a retirement home volunteering and that did a world of good for me and it gave me something to look forward to everyday to get out. They were such nice people because they wanted company so that was very helpful for me. It made me learn a lot about myself and it almost gave me a purpose too. (C2)New activity alternatives were not always found and a couple of the teens chose to risk returning to their sport or exercising as their symptoms began to lessen. One felt this helped her to gradually resolve her symptoms, yet another received another sport concussion a few months after the interview. Efforts to balance re-engaging in activity while remaining symptom free and preventing another concussion appeared to be challenging in the absence of external support. Family Pieces Family support was recognized as extremely important in the weeks and months after a concussive injury; both emotional and practical support such as driving to appointments or helping with organizational and life skills. The mother of a teen with multiple concussions reported:Yeah I took a lot of time. Even just to come pick her up because she couldn’t make it through the day. I did a lot of that, or go make appointments with her school to advocate for her or we had a lot of doctor’s appointments. She was on Amitriptyline every night so she was groggy every morning, so we were driving her to school because she would be late. So there was a lot of just, you know, being there when she needed us. So I took a lot of time; like you know, hours here, hours there. (P5)A tension remained in family dynamics as parents tried to balance their protectiveness with providing autonomy as the children began to feel better. The fear and risk of another concussion was on the minds of most parents and children. The mother of a 14-year-old boy described her fear reactions. Yeah and you're scared to let them do anything and I'm like “Oh my God” like you know, he's telling me how he slipped on the driveway and I was immediately overcome with murderous rage and I wanted to yell at my husband like “have you lost your mind, what is wrong with you. Take the trash out, for God's sakes or at least salt the driveway” (chuckles) like, you know “come on he just got over a concussion; what if he slips and falls and hurts himself again”. ?So you know, you don't want to wrap them in bubble wrap but that's a very hard impulse to fight…(P4) Anxiety is the hallmark emotion of this stage as children and parents balance recovery with reengagement. New or Renewed PathThis final stage represents the process of children coming to terms with the differences in themselves and their lives. Development of new goals or ways of coping signified moving forward and some resolution of their concussion experience. There is a sense of increased confidence and some optimism, but a grudging acceptance of their new reality is a common theme.New Personal Path Most youth recognize a marked change in themselves from before their injury/injuries and have adjusted their goals and expectations to reflect their new sense of self. One or two others felt that that they were able take up their old life as symptoms began to dissipate. One 14-year-old did not feel much had changed but reflected on the impact of the injury on his goals. He stated, “I want a good hockey scholarship into a few colleges. I now know what you need to get there so finding out things that I could have done and now I can't, it's kind of a set back” (C4). One teen 10 months after her injury was beginning to feel some resolution:Only very recently have I finally got back my energy to like meet new people and go out and do social things. So now I’m kind of starting to just rebuild everything and I can finally run now without getting headaches and so right now I’m kind of just trying to rebuild everythingShe is anticipating finishing high school next year talked about her future and the continuing uncertainty, based on her current abilities.And a part of the concussion is I don’t know if I have the marks for Nursing, so it kind of really depends on this grade 12 year, on how well I do. There is this program in {city}, for fashion management….(C5) All participants described themselves as still having residual effects from the concussion or depression. Most acknowledged differences in themselves; how they think, behave and interact compared to before their concussions. Uncertainty about whether they will ever feel like before was commonly remarked upon but 4 of the 6 related related a reluctant acceptance that things may always be harder. An 18-year-old girl described how she expects things to be harder.It’s been 2 years already and a lot of people have said I’m still going to have symptoms until I’m old so I feel university is going to be hard for me. (C2)Family Path Parents seemed to reflect back on the time since their child’s injury to try to make meaning and sense out of their experiences. One mother related the positive consequences of going through such a terrible experience.And every time she sort of got knocked down [with adverse experiences] she sort of just hunkered down and we’d do what we had to do to make sure she was okay. So, I think in a way it’s made us a better family, you know, if you look at it that way. (P5)Another family theorized about the differences in their child since the concussion and stated “..maybe she was destined down this path anyway and the concussion just sped it up” (P7). It was a way for them to make sense of her anxiety and learning disability diagnosis. <<<Insert table 2 about here>>Experiences of Health Care There were various points along the trajectory when families linked with the health care system. The common element in almost all of the narratives was that there was no map or predictable path to services. One parent stated “I think that that's the worse thing about these things is that you cannot gauge where?you're going; there's no end limit in sight, you know- 6 weeks for a cast…”(P4).In the initial post acute phase the struggle to recognize what they were dealing with was a not easy for some families. This mother of a 16-year-old girl felt unprepared for the repercussions of her daughter’s symptoms.But I don’t know that we were at all prepared for the side effects, you know? And I almost feel like we stumbled into those thinking, “well why isn’t she getting her schoolwork done? She is an honour student and she is not doing her schoolwork? And we thought…. “Is she goofing off?” We didn’t know that this could just be another side effect. So I almost wonder if a system would be helpful to actually, you know, have someone to talk to about those things rather than just measuring your performance. (P5)The mother of the two teens with concussions and depression/anxiety had similar thoughts regarding information needs.I just think it [mental health outcomes] needs to be brought to the forefront at the beginning because I don't think it matters how old you are, you are going to experience some type of psychological effect. And the more parents are made aware of these potential changes, that they can watch for them and try to help out their child the best that they can because I think maybe in some circumstances some kids don't have those resources to talk to their parents (P1)The emotional and mental health consequences of concussion did not seem to be easily recognized by health care providers. Families related that their concerns were not always heard or addressed. They didn’t always feel believed by health care providers. Parents of a teen girl described their sense of not being heard, particularly around the mental health issues.He [family physician] knew nothing about the mental health part of it, nothing and so he couldn't help us so finally we get to [a concussion specialist] and he was the one who then started her on the medications and then recommended her to [another specialist] so she saw her and she recommended the [mental health specialists]. ?But it was just the process to get there was very time consuming and frustrating. Because when we first went to the doctor and they asked "what is your main concern?" Our main concern is the anxiety and the things that she thinks happened when they didn't happen; he just fluffed them off. ?It wasn't at the forefront like it was for us. We know concussions take time, really the only medicine is time to heal and rest. We know that, but its the psychological effects after and nobody around here is aware of them. (P1)This theme of a chain of referrals to get to someone who recognizes the connection between mental health and concussion and can help was recurrent in the stories of families. The father of the two girls with concussion and mental health issues described his cyclical feelings of frustration, anxiety and relief in seeking services that were not readily available:…just the general doctors not knowing. So we're spending time, effort to go to the physician's to get answers and they don't know so they just keep passing you on to somebody that hopefully knows. ?So again the frustration part that "oh I'm going here to get this resolved" and then ok go to the next one and then the time frame for that, and then the next time frame. ?The anxiety for everybody is still going on because we still don't get an answer; they just keep passing it off. (P2)Some parents voiced concern that services seemed to be mostly directed toward assessment and measurement of progress. These parents suggested more opportunities were needed for talking and listening to concerns. In their endless quest for answers and help, many families did end up accessing services not covered in the public domain of health care such as allied health professionals, alternative choices or sports injury clinics. Some families felt that finding the right medication was key especially to manage headache symptoms, restore sleep or reduce anxiety. DiscussionThis is the first study of its kind to explore the experiences of adolescents going through prolonged concussion recovery complicated by depressive symptoms from the perspective of both the youth and their parents. The main finding was that prolonged recovery from concussion follows a trajectory of four phases, which were labeled as: the impact, the fall-out, piecing it back together and a new or renewed path. This trajectory has key emotional elements that seemed to be commonly experienced in each phase. Similar themes were found in study of military personnel with persistent symptoms after concussion who described their common experiences in terms of the onset, symptom experiences, recovery and acceptance ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.3109/02699052.2013.857788", "ISBN" : "0269-9052", "ISSN" : "1362-301X", "PMID" : "24328802", "abstract" : "OBJECTIVE: Best practice guidelines outline ways in which mild traumatic brain injury (mTBI) and persistent post-concussive symptoms (PPCS) should be managed. In line with the existing evidence base, DMRC Headley Court established a treatment programme for UK servicemen and women with mTBI. This study explored the experiences of a sample of UK military personnel living with PPCS, who also received psycho-educational intervention (Phase 2) at this unit. SETTING: DMRC Headley Court, Southeast England. PARTICIPANTS: Sixteen service personnel who had completed the intervention within 24 months prior to interview. DESIGN: Semi-structured qualitative interview study, with purposive sampling and thematic analysis. RESULTS: Participants described their mTBI in terms of: (1) onset; (2) subsequent symptom experience; (3) recovery; and (4) acceptance. All participants reported a significant degree of confusion and chaos in the aftermath of their traumatic event. These themes highlighted how, following enrolment onto the Phase 2 intervention at DMRC Headley Court, participants reported being (largely) able to manage PPCS. Further, many reported acceptance of their condition and described how they had managed to re-establish a sense of order. CONCLUSIONS: Following a flexible and tailored intervention for PPCS, patients report feeling empowered and describe having a renewed sense of stability.", "author" : [ { "dropping-particle" : "", "family" : "Brunger", "given" : "Helen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ogden", "given" : "Jane", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Malia", "given" : "Kit", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Eldred", "given" : "Clare", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Terblanche", "given" : "Ronel", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mistlin", "given" : "Alan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain Injury", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "71-80", "title" : "Adjusting to persistent post-concussive symptoms following mild traumatic brain injury and subsequent psycho-educational intervention: a qualitative analysis in military personnel.", "type" : "article-journal", "volume" : "28" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[25]", "plainTextFormattedCitation" : "[25]", "previouslyFormattedCitation" : "[25]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[25]. For youth in our study the experience of prolonged recovery from concussion manifested initially with physical symptoms that were managed with prescribed rest, both physical and cognitive. The resulting losses from this lengthy inactivity due to ongoing symptoms were experienced in both valued activities, and most importantly to children, the loss of social opportunities and relationships. The cognitive and emotional process of coming to terms with these multiple losses resembled a grief response that ran parallel to each phase of our trajectory ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Jackson", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Social Work Today", "id" : "ITEM-1", "issue" : "4", "issued" : { "date-parts" : [ [ "2014" ] ] }, "page" : "18", "title" : "Grieving chronic illness and injury \u2014 Infinite losses", "type" : "article-journal", "volume" : "14" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[26]", "plainTextFormattedCitation" : "[26]", "previouslyFormattedCitation" : "[26]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[26]. Many children described that the intense emotional responses or depressive symptoms occurred within days to several weeks post-injury. Multiple losses and the intense emotional responses to these have been described in other findings from qualitative studies with adults after traumatic brain injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Howes", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Benton", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Edwards", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychology and Health", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2005" ] ] }, "page" : "129-142", "title" : "Women's experience of brain injury: An interpretive phenomenological analysis", "type" : "article-journal", "volume" : "20" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.3109/09638281003775394", "author" : [ { "dropping-particle" : "", "family" : "Levack", "given" : "W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kayes", "given" : "NM", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fadyl", "given" : "JK", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Disability and Rehabilitation", "id" : "ITEM-2", "issue" : "12", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "986-999", "title" : "Experience of recovery and outcome following traumatic brain injury: a metasynthesis of qualitative research.", "type" : "article-journal", "volume" : "32" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[27], [28]", "manualFormatting" : "[27, 28]", "plainTextFormattedCitation" : "[27], [28]", "previouslyFormattedCitation" : "[27], [28]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[27, 28]. It has been argued that depressive symptoms after mTBI/concussion are more frequent than in moderate to severe brain injuries due to awareness of differences in functional consequences in those with milder injuries ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.apmr.2003.12.041", "ISBN" : "0003-9993", "ISSN" : "00039993", "PMID" : "15375816", "abstract" : "Dikmen SS, Bombardier CH, Machamer JE, Fann JR, Temkin NR. Natural history of depression in traumatic brain injury. Arch Phys Med Rehabil 2004;85:1457-64. Objective To examine prospectively the rates, risk factors, and phenomenology of depression over 3 to 5 years after traumatic brain injury (TBI). Design Inception cohort longitudinal study. Setting Level I trauma center. Participants Consecutive admissions of 283 adults with moderate to severe TBI. Interventions Not applicable. Main outcome measure Center for Epidemiologic Studies Depression (CES-D) Scale. Results The rates of moderate to severe depression ranged from 31% at 1 month to 17% at 3 to 5 years. With 1 exception, the relation between brain injury severity and depression was negligible. Less than high school education, preinjury unstable work history, and alcohol abuse predicted depression after injury. Examination of CES-D factors indicate that, in addition to somatic symptoms, both depressed affect and lack of positive affect contribute to elevated CES-D scores. Conclusions High rates of depressive symptoms cannot be dismissed on grounds that somatic symptoms related to brain injury are mistaken for depression. Depressed affect and lack of positive affect are also elevated in persons with TBI. Preinjury psychosocial factors are predictive of depression and knowing them should facilitate efforts to detect, prevent, and treat depression after TBI. \u00a9 2004 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.", "author" : [ { "dropping-particle" : "", "family" : "Dikmen", "given" : "Sureyya S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bombardier", "given" : "Charles H.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "MacHamer", "given" : "Joan E.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fann", "given" : "Jesse R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Temkin", "given" : "Nancy R.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of Physical Medicine and Rehabilitation", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "1457-1464", "title" : "Natural history of depression in traumatic brain injury", "type" : "article-journal", "volume" : "85" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[29]", "plainTextFormattedCitation" : "[29]", "previouslyFormattedCitation" : "[29]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[29].A meta-synthesis of qualitative studies of those with TBI found a consistent theme of loss of identity ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.3109/09638281003775394", "author" : [ { "dropping-particle" : "", "family" : "Levack", "given" : "W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kayes", "given" : "NM", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Fadyl", "given" : "JK", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Disability and Rehabilitation", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "986-999", "title" : "Experience of recovery and outcome following traumatic brain injury: a metasynthesis of qualitative research.", "type" : "article-journal", "volume" : "32" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[28]", "plainTextFormattedCitation" : "[28]", "previouslyFormattedCitation" : "[28]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[28]. This theme was also highlighted by youth in our study and has been a key finding in qualitative studies of those with depression alone ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISSN" : "00414301", "PMID" : "20402069", "abstract" : "The objective of this study was to investigate the relationship between sense of identity and depression in a group of adolescents. Thirty-one depressed adolescents and 31 control subjects were included in the study. They were evaluated using the Sense of Identity Assessment Form (SIAF), Hamilton Depression Rating Scale (HDRS), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Depressed adolescents were reevaluated during the eighth week of antidepressant treatment. Higher baseline SIAF scores were detected in depressed adolescents as compared with non-depressed subjects. After antidepressant treatment, there was a significant decrease in SIAF scores in the depression group. Correlation analysis indicated that there are significant, positive relationships between SIAF, depression, and anxiety scores. The regression analysis results suggested that the change in SIAF scores can accurately predict 91.6% of the remitters and 42.8% of the non-remitters. Collectively, these findings indicate that there is a close association between depression symptoms and identity confusion-related distress in adolescents.", "author" : [ { "dropping-particle" : "", "family" : "Demir", "given" : "Ba\u00fcaran", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kaynak-Demir", "given" : "Hadiye", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "S\u00f6nmez", "given" : "Emel Irmak", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Turkish Journal of Pediatrics", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "68-72", "title" : "Sense of identity and depression in adolescents", "type" : "article-journal", "volume" : "52" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Karp", "given" : "DA", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Qualitative Health Research", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "1994" ] ] }, "page" : "6-30", "title" : "Living with depression: Illness and identity turning points", "type" : "article-journal", "volume" : "4" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[30], [31]", "manualFormatting" : "[30, 31]", "plainTextFormattedCitation" : "[30], [31]", "previouslyFormattedCitation" : "[30], [31]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[30, 31]. Chronic disease literature is also abundant with descriptions of the loss of self and previous self-image ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/1467-9566.ep10491512", "ISBN" : "0141-9889", "ISSN" : "0141-9889", "PMID" : "10261981", "abstract" : "Physical pain, psychological distress and the deleterious effects of medical procedures all cause the chronically ill to suffer as they experience their illnesses. However, a narrow medicalized view of suffering, solely defined as physical discomfort, ignores or minimizes the broader significance of the suffering experienced by debilitated chronically ill adults. A fundamental form of that suffering is the loss of self in chronically ill persons who observe their former self-images crumbling away without the simultaneous development of equally valued new ones. As a result of their illnesses, these individuals suffer from (1) leading restricted lives, (2) experiencing social isolation, (3) being discredited and (4) burdening others. Each of these four scores of suffering is analysed in relation to its effects on the consciousness of the ill person. The data are drawn from a qualitative study of 57 chronically ill persons with varied diagnoses.", "author" : [ { "dropping-particle" : "", "family" : "Charmaz", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Sociology of health & illness", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "1983" ] ] }, "page" : "168-195", "title" : "Loss of self: a fundamental form of suffering in the chronically ill.", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Ahlstrom", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical nursing", "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2007" ] ] }, "page" : "76-83", "title" : "Experiences of loss and chronic sorrow in persons with severe chronic illness", "type" : "article-journal", "volume" : "16" }, "uris" : [ "" ] }, { "id" : "ITEM-3", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Dejean", "given" : "D", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Giacomini", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Vanstone", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brundisini", "given" : "F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-3", "issue" : "February", "issued" : { "date-parts" : [ [ "2013" ] ] }, "page" : "1-31", "title" : "Patient Experiences of Depression and Anxiety with Chronic Disease : A Systematic Review and Qualitative Meta-Synthesis \u2014 Pre-Edit Draft", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[32]\u2013[34]", "manualFormatting" : "[32-34]", "plainTextFormattedCitation" : "[32]\u2013[34]", "previouslyFormattedCitation" : "[32]\u2013[34]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[32-34]. Prolonged recovery from concussion with its activity restrictions and subsequent functional deficits could arguably situate itself as a chronic condition with variable symptomology and uncertain outcome. The youth and family’s experience of and their reactions to poor outcomes from concussion can be understood in the context of a theory of chronic illness. Bury’s social theory of chronic illness as a biographical disruption is very helpful in understanding prolonged recovery from concussion ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/1467-9566.ep11339939", "ISBN" : "1467-9566", "ISSN" : "0141-9889", "PMID" : "10260456", "abstract" : "The paper is based on semi-structured interviews with a series of rheumatoid arthritis patients. Chronic illness is conceptualised as a particular type of disruptive event. This disruption highlights the resources (cognitive and material) available to individuals, modes of explanation for pain and suffering, continuities and discontinuities between professional and lay thought, and sources of variation in experience.", "author" : [ { "dropping-particle" : "", "family" : "Bury", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Sociology of health & illness", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "1982" ] ] }, "page" : "167-182", "title" : "Chronic illness as biographical disruption.", "type" : "article-journal", "volume" : "4" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[35]", "plainTextFormattedCitation" : "[35]", "previouslyFormattedCitation" : "[35]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[35]. This framework is described with 3 central premises: 1) that chronic illness disrupts the “taken for granted” structures of daily life and assumptions about the future; 2) it forces a rethinking of the individual’s self-concept and “biography” and 3) it results in a practical response to the disruption of “mobilizing resources” ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/1467-9566.00191", "ISBN" : "1467-9566", "ISSN" : "0141-9889", "abstract" : "Taking as its point of departure Bury's (1982) concept of chronic illness as biographical disruption, this paper provides a critical assessment of its fortunes since that time. Having 'rescued' the concept from recent postmodern and disability critiques, the paper provides a series of further reflections on its strengths and weaknesses, including the notion of 'normal illness'; the importance of timing and context; the significance of continuity as well, as loss; and the role of biographical disruption itself in the aetiology of illness. This, in turn, provides the basis for a broader set of reflections on the vicissitudes of the biographically embodied self in conditions of late modernity: a situation of chronic reflexivity in which our badies/selves are continually problematised if not pathologised. The paper concludes, given this 'balance sheet', with a discussion of some potentially fruitful lines of future research, including links with the life-events and inequalities literature.", "author" : [ { "dropping-particle" : "", "family" : "Williams", "given" : "Simon J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "40-67", "title" : "Chronic illness as biographical disruption or biographical disruption as chronic illness? Reflections on a core concept", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[36]", "plainTextFormattedCitation" : "[36]", "previouslyFormattedCitation" : "[36]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[36]. The onset of the condition or “disruption” parallels the “impact and fall-out” phases of our trajectory where participants experienced a disruption of the physical self and decreased confidence in the body subsequently leading to a loss of confidence in their social interactions or self-identity. As the participant’s symptoms seemed to worsen and result in more loss, they began to perceive stigmatization in their social networks, which resulted in further withdrawal. The coping or adaptation response in Bury’s concept of mobilizing resources is reflective of the latter two stages of our trajectory, “piecing it back together and new or renewed path” where the youth try to maintain meaning or find new meaning in order to redefine themselves in their disrupted lives ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/1467-9566.t01-1-00337", "ISBN" : "1467-9566", "ISSN" : "1467-9566", "PMID" : "14498927", "abstract" : "Over the last quarter of a century, research on the illness experience has thrived. Publications on this subject are reviewed in relation to three themes: subjectivity; coping actions and strategies for managing everyday life; and the social structure. Sociology of Health and Illness has contributed significantly to this field. In conclusion, research perspectives are suggested for tackling the problems in passing from a micro to a macro level of analysis.", "author" : [ { "dropping-particle" : "", "family" : "Pierret", "given" : "Janine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Sociology of health & illness", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2003" ] ] }, "page" : "4-22", "title" : "The illness experience: state of knowledge and perspectives for research.", "type" : "article-journal", "volume" : "25" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[37]", "plainTextFormattedCitation" : "[37]", "previouslyFormattedCitation" : "[37]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[37]. These parallel stages and the corresponding emotional responses are depicted in Figure 2. Bury’s theory is particularly relevant in this exploratory study of children and their parents due to the emphasis on the social nature of the disruption and the interruption of family or parental roles.Parental narratives layered on top of the youth’s experience provided a rich understanding of the meaning of the experience of prolonged recovery from concussion. Parents felt unprepared for the consequences of their child’s concussion. A study looking at specific needs of adolescents and their parents after concussion identified the number one need is for “clear information about the consequences of the injury and the course of recovery” ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.apmr.2007.08.080", "ISBN" : "1362-301X (Electronic)\\r0269-9052 (Linking)", "ISSN" : "00039993", "PMID" : "18568711", "abstract" : "PRIMARY OBJECTIVE: To identify the specific service needs of adolescents with mild traumatic brain injury (MTBI) and those of their parents through the perspective of expert service providers as well as to compare it to the perspective of adolescents and their parents obtained in a prior study. STUDY DESIGN: Qualitative design including a focus group held with experts in the field of adolescent TBI and a validation survey of other professionals. METHODS AND PROCEDURES: Eight experts from a variety of disciplines participated in a focus group where important needs of adolescents were discussed. Results were then validated through a questionnaire to 33 professionals. MAIN OUTCOMES AND RESULTS: Experts questioned through both methods are generally in agreement and acknowledge that adolescents are unique, but they often find them challenging. Like adolescents themselves, experts identify the need for information as the most important but are wary of offering too much detail and fear that this could encourage malingering of symptoms and problems. Service providers also recognize the importance of supporting adolescents and parents when returning to activities (school and physical activities). CONCLUSIONS: The notion that teens represent a specific group of consumers of healthcare services is supported by findings in this study. These results provide important information to those involved in the structuring of service provision to adolescents following MTBI.", "author" : [ { "dropping-particle" : "", "family" : "Swaine", "given" : "Bonnie R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Gagnon", "given" : "Isabelle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Champagne", "given" : "Fran\u00e7ois", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lefebvre", "given" : "H\u00e9l\u00e8ne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Friedman", "given" : "Debbie", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Atkinson", "given" : "Jeff", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Feldman", "given" : "Debbie", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Brain injury : [BI]", "id" : "ITEM-1", "issue" : "7-8", "issued" : { "date-parts" : [ [ "2008" ] ] }, "page" : "581-588", "title" : "Identifying the specific needs of adolescents after a mild traumatic brain injury: a service provider perspective.", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[38]", "plainTextFormattedCitation" : "[38]", "previouslyFormattedCitation" : "[38]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[38]. Health care services were difficult to negotiate given the complexity of both physical and mental health needs of the child. Information and services are more readily available in the acute stage post injury than for the longer term. It was also easier to access information and services for the physical repercussions, more so than for the mental health consequences of concussion. There seemed to be a disconnect between knowledge and practice as mental health impacts from concussion are purported but the mixed responses of health care providers and the lack of awareness from parent perspectives points to a knowledge translation problem. Pediatric guidelines for management of concussion have recently been published online ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "URL" : "", "accessed" : { "date-parts" : [ [ "2015", "3", "20" ] ] }, "author" : [ { "dropping-particle" : "", "family" : "Foundation", "given" : "Ontario Neurotrauma", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "title" : "Guidelines for Pediatric Concussion", "type" : "webpage" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[39]", "plainTextFormattedCitation" : "[39]", "previouslyFormattedCitation" : "[39]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[39]. Making parents aware of resources that lay out the course of clinical care would help them feel more control over the uncertainty that is central in protracted recoveries. Recently, an algorithm for decision-making with mental health issues has been outlined in the Ontario Neurotrauma Foundation guidelines, which is an important resource for front line health care providers ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "URL" : "", "accessed" : { "date-parts" : [ [ "2015", "3", "20" ] ] }, "author" : [ { "dropping-particle" : "", "family" : "Foundation", "given" : "Ontario Neurotrauma", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "title" : "Guidelines for Pediatric Concussion", "type" : "webpage" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[39]", "plainTextFormattedCitation" : "[39]", "previouslyFormattedCitation" : "[39]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[39].In addition to information and better and more timely access to health care resources, parents also drew attention to their very emotional experiences of watching their children suffer and the self-doubt they experience in relation to their own parenting. They talked about a need for space to be able to discuss these issues with experts who understand and can hear their concerns. Other forms of parent support may be helpful particularly during the fall-out and piecing it back together phases. A psycho-educational stress management program for parents of children with ABI has been shown to decrease parental anxiety and depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1037/0022-006X.74.3.445", "ISSN" : "0022-006X", "PMID" : "16822102", "abstract" : "This study examined whether an online problem-solving intervention could improve parental adjustment following pediatric traumatic brain injury (TBI). Families of children with moderate-to-severe TBI were recruited from the trauma registry of a large children's hospital and randomly assigned to receive online family problem solving therapy (FPS; n = 20) or Internet resources (IRC; n = 20) in addition to usual care. The FPS group reported significantly less global distress, depressive symptoms, and anxiety at follow-up than did the IRC group after controlling for baseline symptoms. The FPS group also reported significant improvements in problem-solving skills, although the groups did not differ significantly at follow-up. Findings suggest that an online, skill-building approach can be effective in facilitating parental adaptation after TBI.", "author" : [ { "dropping-particle" : "", "family" : "Wade", "given" : "Shari L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carey", "given" : "JoAnne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wolfe", "given" : "Christopher R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of consulting and clinical psychology", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "445-454", "title" : "An online family intervention to reduce parental distress following pediatric brain injury.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[40]", "plainTextFormattedCitation" : "[40]", "previouslyFormattedCitation" : "[40]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[40] and parent-to-parent support groups have been helpful to parents of children with developmental disabilities ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/mrdd.20175", "author" : [ { "dropping-particle" : "", "family" : "Singer", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ethridge", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Aldana", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Mental Retardatdion and Developmental Disabilities Research Reviews", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "page" : "357-369", "title" : "Primary and secondary effects of parenting and stress management interventions for parents of children with developmental disabilitie: A meta-analysis", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[41]", "plainTextFormattedCitation" : "[41]", "previouslyFormattedCitation" : "[41]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[41]. LimitationsThere are several study limitations that should be noted. The first is that the sample had only six participants and their families. This did not allow us to achieve full saturation although Guest and collegues reported that basic elements of metathemes are present after 6 interviews ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/1525822X05279903", "ISBN" : "1525822X", "ISSN" : "1525-822X", "PMID" : "19638638", "abstract" : "Guidelines for determining nonprobabilistic sample sizes are virtually nonexistent. Purposive samples are the most commonly used form of nonprobabilistic sampling, and their size typically relies on the concept of \"saturation,\" or the point at which no new information or themes are observed in the data. Although the idea of saturation is helpful at the conceptual level, it provides little practical guidance for estimating sample sizes, prior to data collection, necessary for conducting quality research. Using data from a study involving sixty in-depth interviews with women in two West African countries, the authors systematically document the degree of data saturation and variability over the course of thematic analysis. They operationalize saturation and make evidence-based recommendations regarding nonprobabilistic sample sizes for interviews. Based on the data set, they found that saturation occurred within the first twelve interviews, although basic elements for metathemes were present as early as six interviews. Variability within the data followed similar patterns.", "author" : [ { "dropping-particle" : "", "family" : "Guest", "given" : "G.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bunce", "given" : "A.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Johnson", "given" : "L.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Field Methods", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "59-82", "title" : "How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability", "type" : "article-journal", "volume" : "18" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "[42]", "plainTextFormattedCitation" : "[42]" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }[42]. Our sample consisted of only one pre-teen while all others were adolescents and all were middle to upper middle class with five of six having intact families. These factors could explain an appraisal of experiences that are not transferable to a wider range of children with concussion. A broader sample of families that would capture differing levels of family stress such as socioeconomic status and stability as well as different cultural values may have helped ensure some transferability. Although the sample did capture a cross-section of various time points after injury thereby providing insights into the temporal sequence of recovery, prolonged engagement over time would enhance these findings. The study did begin to highlight some important differences that family support may contribute to the children’s experiences of their recovery from concussion and this should be explored in future studies. ConclusionYouth experiencing prolonged recovery from concussion experienced a life-changing event. Emotional responses underpin a trajectory of recovery that mirrors a grief response as the youth learn to cope and adapt to their new realities. Youth cannot be treated in isolation as their parents experience their own emotional distress and need support in balancing their parenting approaches with the recommended concussion management strategies. The trajectory of emotional responses and phases of recovery may indicate a need for specialized services in order to manage the complex physical and emotional needs of families experiencing an unexpected and prolonged course of recovery. ReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY [1]Baillargeon A, Lassonde M, Leclerc S, Ellemberg D. Neuropsychological and neurophysiological assessment of sport concussion in children, adolescents and adults. Brain Injury 2012;26:211–20.[2]Kirkwood M, Yeates K, Wilson P. 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Table 1: Participant CharacteristicsMean Age in years (range)15 (11-18)Sex (Male/Female)2M/4FInjurySport relatedGym classMVAFall2211Grade range5-12Months from injury to recruitment9 (1-28)Months from injury to interview17 (4-39)Diagnosed with new mood disorder4Prior historyAnxietyMigraines13Multiple head injuries 4Figure 1: Trajectory of Prolonged Recovery from ConcussionFigure 2: Emotional and social implications along the trajectory of recovery from concussionChapter Four: DiscussionThe purpose of this thesis was to explore the phenomena of depression after concussion in children and youth. A quantitative prospective study was conducted to explore prediction and risk of significant depressive symptoms after concussion and a qualitative phenomenological study was conducted to examine the lived experience in children and families of prolonged recovery from concussion complicated by depressive symptoms. The results of the first study add to our understanding about the risk, correlates and predictors of depression after concussion in this population. The findings from the second study provide a conceptual framework for understanding the trajectory of emotional and functional recovery, based on the perspective of youth and families living with prolonged concussion symptoms and delayed recovery that is complicated by significant depressive symptomatology. This discussion will begin by reviewing the findings from each study in the context of current literature. Research directions are suggested throughout and the chapter concludes by discussing the clinical implications of this research.In the first study (Chapter Two), a prospective cohort of children who were being followed after a concussive injury demonstrated an increased risk of developing depression within the first year after their injury. Significant depressive symptomatology was found during routine screening at regular follow-up appointments. The rate of depression in this population was two to four times greater than expected in the general population. Those who experience hospital admission and many post-concussion symptoms are significantly more likely to have elevated depressive symptoms when controlling for age, number of head injuries and delayed symptom recovery. The binary logistic regression model included five variables: sex, symptom scores, hospital admission, prolonged symptoms over 3 months and multiple head injuries. This model accounted for 36% of the variance in the outcome. High symptom scores have been implicated in studies that have predicted protracted recoveries ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpeds.2013.03.012", "ISSN" : "1097-6833", "PMID" : "23628374", "abstract" : "OBJECTIVE: To identify predictors of prolonged symptoms in athletes who sustain concussions.\n\nSTUDY DESIGN: This was a multicenter prospective cohort study of patients in 2 sport concussion clinics. Possible predictors of prolonged symptoms from concussion were compared in 2 groups, those whose symptoms resolved within 28 days and those whose symptoms persisted beyond 28 days. Candidate predictor variables were entered into a logistic regression model that was used to generate aORs.\n\nRESULTS: A total of 182 patients met the inclusion criteria during the study period. The mean patient age was 15.2 \u00b1 3.04 years. More than one-third of the patients (n = 65) underwent computerized neurocognitive testing on their initial visit. On univariate analyses, Post-Concussion Symptom Scale (PCSS) score and all composite scores on computerized neurocognitive testing were apparently associated with prolonged symptom duration. Sex, age, loss of consciousness at time of injury, and amnesia at time of injury were not associated with prolonged symptom duration. After adjusting for potential confounding, only total PCSS score was associated with the odds of suffering prolonged symptoms.\n\nCONCLUSION: Further efforts to develop clinical tools for predicting which athletes will suffer prolonged recoveries after concussion should focus on initial symptom score.", "author" : [ { "dropping-particle" : "", "family" : "Meehan", "given" : "William P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mannix", "given" : "Rebekah C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stracciolini", "given" : "Andrea", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Elbin", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Collins", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2013", "9" ] ] }, "page" : "721-5", "publisher" : "Elsevier Ltd", "title" : "Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not.", "type" : "article-journal", "volume" : "163" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1542/peds.2013-2988", "ISSN" : "1098-4275", "PMID" : "24958583", "abstract" : "BACKGROUND AND OBJECTIVES: Up to 30% of children who have concussion initially evaluated in the emergency department (ED) display delayed symptom resolution (DSR). Greater initial symptom severity may be an easily quantifiable predictor of DSR. We hypothesized that greater symptom severity immediately after injury increases the risk for DSR.\n\nMETHODS: We conducted a prospective longitudinal cohort study of children 8 to 18 years old presenting to the ED with concussion. Acute symptom severity was assessed using a graded symptom inventory. Presence of DSR was assessed 1 month later. Graded symptom inventory scores were tested for association with DSR by sensitivity analysis. We conducted a similar analysis for post-concussion syndrome (PCS) as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th revision. Potential symptoms characteristic of DSR were explored by using hierarchical cluster analysis.\n\nRESULTS: We enrolled 234 subjects; 179 (76%) completed follow-up. Thirty-eight subjects (21%) experienced DSR. Initial symptom severity was not significantly associated with DSR 1 month after concussion. A total of 22 subjects (12%) had PCS. Scores >10 (possible range, 0-28) were associated with an increased risk for PCS (RR, 3.1; 95% confidence interval 1.2-8.0). Three of 6 of the most characteristic symptoms of DSR were also most characteristic of early symptom resolution. However, cognitive symptoms were more characteristic of subjects reporting DSR.\n\nCONCLUSIONS: Greater symptom severity measured at ED presentation does not predict DSR but is associated with PCS. Risk stratification therefore depends on how the persistent symptoms are defined. Cognitive symptoms may warrant particular attention in future study. Follow-up is recommended for all patients after ED evaluation of concussion to monitor for DSR.", "author" : [ { "dropping-particle" : "", "family" : "Grubenhoff", "given" : "Joseph a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Deakyne", "given" : "Sara J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brou", "given" : "Lina", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bajaj", "given" : "Lalit", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Comstock", "given" : "R Dawn", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Kirkwood", "given" : "Michael W", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2014", "7" ] ] }, "page" : "54-62", "title" : "Acute concussion symptom severity and delayed symptom resolution.", "type" : "article-journal", "volume" : "134" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Grubenhoff et al., 2014; Meehan, Mannix, Stracciolini, Elbin, & Collins, 2013)", "plainTextFormattedCitation" : "(Grubenhoff et al., 2014; Meehan, Mannix, Stracciolini, Elbin, & Collins, 2013)", "previouslyFormattedCitation" : "(Grubenhoff et al., 2014; Meehan, Mannix, Stracciolini, Elbin, & Collins, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Grubenhoff et al., 2014; Meehan, Mannix, Stracciolini, Elbin, & Collins, 2013). Symptom scores were also found to be a predictor of depression in studies with adults with concussion ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1176/appi.neuropsych.22.1.100.Predictors", "author" : [ { "dropping-particle" : "", "family" : "Rao", "given" : "Vani", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bertrand", "given" : "Melaine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Rosenberg", "given" : "Paul", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Makley", "given" : "Michael", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schretlen", "given" : "David J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brandt", "given" : "Jason", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mielke", "given" : "Michelle M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "J. Neuropsychiatry Clin Neurosci.", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "100-104", "title" : "Predictors of new-onset depression after mild traumatic brain injury", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Rao et al., 2010)", "plainTextFormattedCitation" : "(Rao et al., 2010)", "previouslyFormattedCitation" : "(Rao et al., 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Rao et al., 2010). Clearly, increased symptom reporting predicts poor outcomes but may not help discern between protracted recoveries and the onset of depression. Whether or not a child had been admitted to hospital was also a significant predictor in this study. The majority of admissions were just overnight but perhaps indicate a more serious injury clinically and, therefore, suggest that there may be underlying neurobiological processes that could trigger a depression. Alternatively, hospital admission could also reflect a more stressful experience from the child’s perspective triggering more anxiety and depression from environmental factors. Although some of the factors associated with the development of depression in children being followed for a concussive injury were examined, they provide an increased understanding of who may be at risk but do not answer the question of the causal mechanism of depression. The second study (Chapter Three) found that children and family’s experience with prolonged recovery from concussion and depression moved along multiple stages in a trajectory of recovery. This trajectory highlights the functional impact of activity disruptions not only on the child’s performance at school and in extra-curricular activities, but on the child’s identity, self-worth and perceptions of competence. The loss of social connections, meaningful activities and dreams for the future had a profound impact on many of the participants. The trajectory also highlighted the emotional sequelae associated with functional changes, moving from an initial stage of shock and confusion to the fall-out stage of anger, frustration and sadness, and then to fear and anxiety about re-engaging in activities and, finally, to some sense of acceptance of a different life path. The trajectory highlighted not only how the process impacts children, but also how it impacts on their families. The struggles that parents experienced throughout the process, including fears for their child, uncertainty about how best to support them, and frustration with the healthcare system are a number of key issues to consider in the recovery process.Although there are studies in the literature that highlight functional changes that children experience in terms of disruption to school performance and performance in instrumental activities of daily living, little attention has been paid to the evolution of participation over time. One study looking at the effects of concussion on leisure activities a year after injury has shown a statistically significant reduction in instrumental daily activities as well as social, physical and cultural activities ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.3109/17518423.2012.704955", "ISBN" : "1751-8423", "ISSN" : "1751-8423", "PMID" : "23030702", "abstract" : "OBJECTIVE: The aim is to describe how children and youths perform leisure activities, 1 year after a mild traumatic brain injury (MTBI).\\n\\nMETHODS: Basis is to compile previously collected material; patients were extracted from a prospective randomized controlled trial of MTBI. A retrospective analysis was conducted among 73 children and youths between 16 and 18 years of age. The entire group administrated the Interest Checklist at baseline and at 1-year follow-up.\\n\\nRESULTS: Statistical significant difference was found in 31 of 50 different activities. The result showed that children and youths did not return to perform leisure activities. Fewer returned in the intervention group than in the control group.\\n\\nCONCLUSION: An occupational therapist can help children and youths to have balance in their life and continue a functional life after a MTBI. Continued research is needed, how to prevent MTBI and how to support children and youths to continue with leisure activities.", "author" : [ { "dropping-particle" : "", "family" : "Jonsson", "given" : "Cecilia", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Andersson", "given" : "Elisabeth Elgmark", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Developmental Neurorehabilitation", "id" : "ITEM-1", "issue" : "February", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "1-8", "title" : "Mild traumatic brain injury: A description of how children and youths between 16 and 18 years of age perform leisure activities after 1 year", "type" : "article-journal", "volume" : "16" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Jonsson & Andersson, 2012)", "plainTextFormattedCitation" : "(Jonsson & Andersson, 2012)", "previouslyFormattedCitation" : "(Jonsson & Andersson, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Jonsson & Andersson, 2012). In terms of school performance, a study conducted in a tertiary care sports medicine clinic found that 61% of children reported a decline in grades, 69% needed school accommodations and this increased to 87% when the youth were depressed ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jpeds.2014.08.034", "ISSN" : "1097-6833", "PMID" : "25262302", "abstract" : "OBJECTIVE: To identify pre-existing characteristics associated with prolonged recovery from concussion in a sample of patients referred to a pediatric sports medicine clinic.\n\nSTUDY DESIGN: This was a retrospective, exploratory cohort study of 247 patients age 5-18\u00a0years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010, through December 31, 2011. A random sample of all eligible patient visits (3740) was chosen for further review and abstraction. Statistical comparisons between subsets of patients were conducted using exact \u03c7(2) tests, logistic regression, quantile regression, and Kaplan-Meier survival curves.\n\nRESULTS: The median time until returning to school part-time was 12\u00a0days (IQR 6-21); until returning to school full-time without accommodations was 35\u00a0days (IQR 11-105); until becoming symptom-free was 64\u00a0days (IQR 18-119); and until being fully cleared to return to sports was 75\u00a0days (IQR 30-153). Furthermore, 73% of all patients were symptomatic for >4\u00a0weeks, 73% were prescribed some form of school accommodation, and 61% reported a decline in grades. Characteristics associated with a prolonged recovery included a history of depression or anxiety; an initial complaint of dizziness; abnormal convergence or symptom provocation following oculomotor examination on physical examination; and history of prior concussion.\n\nCONCLUSIONS: Pediatric and adolescent patients with concussion may experience cognitive and emotional morbidity that can last for several months following injury. Clinicians should consider specific pre-existing characteristics and presenting symptoms that may be associated with a more complicated recovery for concussion patients.", "author" : [ { "dropping-particle" : "", "family" : "Corwin", "given" : "Daniel J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Zonfrillo", "given" : "Mark R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Master", "given" : "Christina L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Arbogast", "given" : "Kristy B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Grady", "given" : "Matthew F", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Robinson", "given" : "Roni L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Goodman", "given" : "Arlene M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wiebe", "given" : "Douglas J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Journal of pediatrics", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014", "9", "25" ] ] }, "page" : "1-9", "publisher" : "Elsevier\u00a0Inc", "title" : "Characteristics of Prolonged Concussion Recovery in a Pediatric Subspecialty Referral Population.", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Corwin et al., 2014)", "plainTextFormattedCitation" : "(Corwin et al., 2014)", "previouslyFormattedCitation" : "(Corwin et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Corwin et al., 2014). Findings from our study highlight how disruption or change in meaningful activities has the potential to strongly influence the youth’s developmental trajectory. Activity disruptions can lead to poorer psychosocial outcomes in the short term, but can also lead to long-term resiliency through adapting activities and building a new sense of self. While grieving and depression were identified as key emotional responses to the multiple losses, the youth in our study eventually engaged in new activities to help them cope and “restore a sense of value and purpose to life” ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/000841740407100509", "ISBN" : "0008-4174", "ISSN" : "0008-4174", "PMID" : "15633880", "abstract" : "BACKGROUND: According to the existential philosophers, meaning, purpose and choice are necessary for quality of life. Qualitative researchers exploring the perspectives of people who have experienced health crises have also identified the need for meaning, purpose and choice following life disruptions. Although espousing the importance of meaning in occupation, occupational therapy theory has been primarily preoccupied with purposeful occupations and thus appears inadequate to address issues of meaning within people's lives. PURPOSE: This paper proposes that the fundamental orientation of occupational therapy should be the contributions that occupation makes to meaning in people's lives, furthering the suggestion that occupation might be viewed as comprising dimensions of meaning: doing, being, belonging and becoming. Drawing upon perspectives and research from philosophers, social scientists and occupational therapists, this paper will argue for a renewed understanding of occupation in terms of dimensions of meaning rather than as divisible activities of self-care, productivity and leisure. PRACTICE IMPLICATIONS: Focusing on meaningful, rather than purposeful occupations more closely aligns the profession with its espoused aspiration to enable the enhancement of quality of life.", "author" : [ { "dropping-particle" : "", "family" : "Hammell", "given" : "Karen Whalley", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Canadian journal of occupational therapy. Revue canadienne d'ergotherapie", "id" : "ITEM-1", "issue" : "5", "issued" : { "date-parts" : [ [ "2004" ] ] }, "page" : "296-305", "title" : "Dimensions of meaning in the occupations of daily life.", "type" : "article-journal", "volume" : "71" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Hammell, 2004)", "plainTextFormattedCitation" : "(Hammell, 2004)", "previouslyFormattedCitation" : "(Hammell, 2004)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Hammell, 2004), despite ongoing depressive symptoms. This is a positive message of hope that children and their families may need as they struggle through the early stages of uncertainty and grief. It also points to the importance of engagement in meaningful activities in the process of recovery. In terms of the emotional impact of prolonged recovery from depression, the study findings are consistent with other studies in the literature that have explored the emotional changes associated with the onset of illness and disability. For example, links were made to the theory of biographical disruption, which explains how the “sufferer” tries to recreate meaning through “repairing ruptures between body, self and society” disrupted by illness and uncertainty ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1111/1467-9566.00191", "ISBN" : "1467-9566", "ISSN" : "0141-9889", "abstract" : "Taking as its point of departure Bury's (1982) concept of chronic illness as biographical disruption, this paper provides a critical assessment of its fortunes since that time. Having 'rescued' the concept from recent postmodern and disability critiques, the paper provides a series of further reflections on its strengths and weaknesses, including the notion of 'normal illness'; the importance of timing and context; the significance of continuity as well, as loss; and the role of biographical disruption itself in the aetiology of illness. This, in turn, provides the basis for a broader set of reflections on the vicissitudes of the biographically embodied self in conditions of late modernity: a situation of chronic reflexivity in which our badies/selves are continually problematised if not pathologised. The paper concludes, given this 'balance sheet', with a discussion of some potentially fruitful lines of future research, including links with the life-events and inequalities literature.", "author" : [ { "dropping-particle" : "", "family" : "Williams", "given" : "Simon J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2000" ] ] }, "page" : "40-67", "title" : "Chronic illness as biographical disruption or biographical disruption as chronic illness? Reflections on a core concept", "type" : "article-journal", "volume" : "22" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Williams, 2000)", "plainTextFormattedCitation" : "(Williams, 2000)", "previouslyFormattedCitation" : "(Williams, 2000)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Williams, 2000). In addition, the response of children and their families could be conceptualized as a process of grieving. Grief is a natural response to loss and is distinct from depression although accumulated losses and stress in grieving youth can increase the risk of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Ferszt", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Leveillee", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychological Review", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "12-13", "title" : "Telling the difference between grief and depression", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ferszt & Leveillee, 2009)", "plainTextFormattedCitation" : "(Ferszt & Leveillee, 2009)", "previouslyFormattedCitation" : "(Ferszt & Leveillee, 2009)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Ferszt & Leveillee, 2009). This study has provided unique insights into the emotional trajectory that is linked to activity disruptions following concussion associated with depression. As reviewed earlier, differentiating the emotional sequelae of concussion from depression can be difficult as there are similarities in symptoms. The CDI-2 screening test chosen for use in this study has only two items that overlap with the PCSI - irritability and fatigue – so it could assist in discerning between the emotional sequelae of concussion and depression. Research has demonstrated that emotional symptoms occur early in recovery, from 1 – 3 weeks ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.apmr.2012.03.032", "ISSN" : "1532-821X", "PMID" : "22503738", "abstract" : "To prospectively examine the relationship of sport-related concussion with depression and neurocognitive performance and symptoms among male and female high school and college athletes. A secondary objective was to explore age and sex differences.", "author" : [ { "dropping-particle" : "", "family" : "Kontos", "given" : "Anthony P", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Covassin", "given" : "Tracey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Elbin", "given" : "R J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Parker", "given" : "Tonya", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of physical medicine and rehabilitation", "id" : "ITEM-1", "issue" : "10", "issued" : { "date-parts" : [ [ "2012", "10" ] ] }, "page" : "1751-6", "publisher" : "Elsevier Inc.", "title" : "Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes.", "type" : "article-journal", "volume" : "93" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1542/peds.2014-0158", "author" : [ { "dropping-particle" : "", "family" : "Eisenberg", "given" : "Matthew A", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Meehan", "given" : "William", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Mannix", "given" : "Rebekah", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-2", "issued" : { "date-parts" : [ [ "2014" ] ] }, "title" : "Duration and Course of Post-Concussive Symptoms", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Eisenberg, Meehan, & Mannix, 2014; Kontos, Covassin, Elbin, & Parker, 2012)", "plainTextFormattedCitation" : "(Eisenberg, Meehan, & Mannix, 2014; Kontos, Covassin, Elbin, & Parker, 2012)", "previouslyFormattedCitation" : "(Eisenberg, Meehan, & Mannix, 2014; Kontos, Covassin, Elbin, & Parker, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Eisenberg, Meehan, & Mannix, 2014; Kontos, Covassin, Elbin, & Parker, 2012) which makes time a factor to consider; the further away from the injury, the more concerning emotional symptoms may be. A persistent view of the self as worthless, disconnecting from social supports and experiencing overwhelming emotions that impede function are also strong indicators of a concerning depressive episode outside of the emotional and grief responses to injury ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.jad.2010.01.076", "ISBN" : "1573-2517", "ISSN" : "01650327", "PMID" : "20189657", "abstract" : "Background: This study examined the distinctiveness of symptoms of Prolonged Grief Disorder (PGD), depression, and posttraumatic stress disorder (PTSD). We compared the fit of a one-factor model with the fit of four hierarchical models in which symptoms formed three distinct correlated higher-order dimensions, and PTSD-items were modeled in different ways. Methods: Self-reported data were available from two samples; 572 mourners recruited via the internet and 408 mourners recruited via healthcare workers. Results: In Sample 1, the unitary model did not fit the data. The four hierarchical models all fit better. The model in which PTSD-items constituted four lower-order factors of reexperiencing, avoidance, dysphoria, and hyperarousal fit the data best. The fit was further improved, when one weak PGD-item and one weak PTSD-item were removed, and error-terms of similar items were allowed to correlate. Findings from Sample 1 were replicated in Sample 2. Limitations: This study relied on self-reported data. Not all PGD-criteria and depression-criteria were assessed. Conclusions: This is the first confirmatory factor analysis study showing that symptoms of PGD, depression, and PTSD represent distinguishable syndromes. PGD-symptoms should be addressed in the assessment and treatment of bereaved people seeking treatment. \u00a9 2010 Elsevier B.V. All rights reserved.", "author" : [ { "dropping-particle" : "", "family" : "Boelen", "given" : "Paul a.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Schoot", "given" : "Rens", "non-dropping-particle" : "Van De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hout", "given" : "Marcel a.", "non-dropping-particle" : "Van Den", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Keijser", "given" : "Jos", "non-dropping-particle" : "De", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bout", "given" : "Jan", "non-dropping-particle" : "Van Den", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of Affective Disorders", "id" : "ITEM-1", "issue" : "1-3", "issued" : { "date-parts" : [ [ "2010" ] ] }, "page" : "374-378", "publisher" : "Elsevier B.V.", "title" : "Prolonged Grief Disorder, depression, and posttraumatic stress disorder are distinguishable syndromes", "type" : "article-journal", "volume" : "125" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Boelen, Van De Schoot, Van Den Hout, De Keijser, & Van Den Bout, 2010)", "manualFormatting" : "(Boelen, Van De Schoot, Van Den Hout, De Keijser, & Van Den Bout, 2010; Ferszt & Leveillee, 2009)", "plainTextFormattedCitation" : "(Boelen, Van De Schoot, Van Den Hout, De Keijser, & Van Den Bout, 2010)", "previouslyFormattedCitation" : "(Boelen, Van De Schoot, Van Den Hout, De Keijser, & Van Den Bout, 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Boelen, Van De Schoot, Van Den Hout, De Keijser, & Van Den Bout, 2010; ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Ferszt", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Leveillee", "given" : "M", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Psychological Review", "id" : "ITEM-1", "issue" : "3", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "12-13", "title" : "Telling the difference between grief and depression", "type" : "article-journal", "volume" : "5" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ferszt & Leveillee, 2009)", "manualFormatting" : "Ferszt & Leveillee, 2009)", "plainTextFormattedCitation" : "(Ferszt & Leveillee, 2009)", "previouslyFormattedCitation" : "(Ferszt & Leveillee, 2009)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }Ferszt & Leveillee, 2009)Disentangling the symptoms of depression from prolonged recovery after concussion is difficult to do clinically, particularly if the depression is mild. Grief and mild depression are just a few of the potential overlapping emotional responses to concussive injury and the recovery period. These conditions may be one threshold of a dimension of emotional responses that may not require pharmacological treatment, but may instead respond well to other types of interventions, including occupational therapy, psychotherapy and family based interventions ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.yebeh.2005.10.012", "ISSN" : "1525-5050", "PMID" : "16356779", "abstract" : "Depression is one of the most prevalent of the psychiatric disorders and is common among individuals with epilepsy. Depression often begins in adolescence. The present review focuses on adolescent depression. In particular, this review first summarizes the definition, description, and classification of adolescent depression. Next, potential causes of adolescent depression are reviewed from a vulnerability-stress perspective. This part of the review focuses on the role of stressors and how stressors interact with genetic, biological, cognitive, personality, and interpersonal vulnerabilities to predict adolescent depression. Last, clinical aspects of adolescent depression are reviewed, including treatment and prevention of depression and the relation to epileptic disorders in adolescence. In sum, a substantial percentage of youth with epilepsy and seizures exhibit depression, and many are not diagnosed or treated in a timely manner. The present review shows that there are valid, empirically based assessments, treatments, and preventions for depression in adolescence that hold promise for reducing the significant burden associated with depression.", "author" : [ { "dropping-particle" : "", "family" : "Hankin", "given" : "Benjamin L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Epilepsy & behavior : E&B", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2006", "2" ] ] }, "page" : "102-14", "title" : "Adolescent depression: description, causes, and interventions.", "type" : "article-journal", "volume" : "8" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1542/peds.2007-1144", "ISBN" : "0031-4005", "ISSN" : "1098-4275", "PMID" : "17974723", "abstract" : "OBJECTIVES: To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings. METHODS: By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 5 phases, as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) draft revision and iteration among members of the steering committee. RESULTS: Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan. CONCLUSIONS: This part of the guidelines is intended to assist primary care clinicians in the identification and initial management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists but cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for adolescent depression management. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines.", "author" : [ { "dropping-particle" : "", "family" : "Zuckerbrot", "given" : "Rachel a", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cheung", "given" : "Amy H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Jensen", "given" : "Peter S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stein", "given" : "Ruth E K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Laraque", "given" : "Danielle", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Pediatrics", "id" : "ITEM-2", "issue" : "5", "issued" : { "date-parts" : [ [ "2007" ] ] }, "page" : "e1299-e1312", "title" : "Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management.", "type" : "article-journal", "volume" : "120" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Hankin, 2006; Zuckerbrot, Cheung, Jensen, Stein, & Laraque, 2007)", "plainTextFormattedCitation" : "(Hankin, 2006; Zuckerbrot, Cheung, Jensen, Stein, & Laraque, 2007)", "previouslyFormattedCitation" : "(Hankin, 2006; Zuckerbrot, Cheung, Jensen, Stein, & Laraque, 2007)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Hankin, 2006; Zuckerbrot, Cheung, Jensen, Stein, & Laraque, 2007). Integrating the StudiesThe advantage of conducting a quantitative and a qualitative study with a similar population was to be able to elucidate the stories or potential explanations behind some of the numbers. The point at which depression occurs for children after a concussion was not identified in the quantitative analysis, as it was not an inception cohort. Mean time from injury to depression, however, was approximately 6 months (range 2 weeks – 35 months). Participants in the qualitative study revealed that the onset of depressive symptoms occurred within 3 months of their injury. There is evidence of both early and late onset depression after mild to moderate TBI with specific symptomatology differentiating the two ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.apnu.2012.06.002", "ISBN" : "0883-9417 DO - ", "ISSN" : "08839417", "PMID" : "23164404", "abstract" : "Despite advances in research on symptoms, stress, and depression after traumatic brain injury, there has been limited focus on the collective relationships between neurocognitive performance, chronic stress, and somatic and depressive symptoms. Guided by our adaptation of the allostatic load theory, we examined relationships between chronic stress, somatic and depressive symptoms, and cognitive performance using the Immediate Postconcussion Assessment and Cognitive Testing cognitive battery. Only somatic symptoms and chronic stress explained variation in depressive symptoms (R2 = .71, P < .0001), not neurocognitive performance, preinjury, or injury-specific variables. Our findings suggest that increased chronic stress and somatic symptoms can contribute significantly to depressive symptoms after mild to moderate traumatic brain injury. \u00a9 2012 Elsevier Inc..", "author" : [ { "dropping-particle" : "", "family" : "Bay", "given" : "Esther", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Covassin", "given" : "Tracey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of Psychiatric Nursing", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "477-486", "publisher" : "Elsevier Inc.", "title" : "Chronic Stress, Somatic and Depressive Symptoms Following Mild to Moderate Traumatic Brain Injury", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Bay & Covassin, 2012)", "plainTextFormattedCitation" : "(Bay & Covassin, 2012)", "previouslyFormattedCitation" : "(Bay & Covassin, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Bay & Covassin, 2012). Early onset depression (within days) is characterized by somatic and anxiety-like symptoms whereas late onset depression is described as having more psychological symptoms and cognitive difficulties ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1016/j.apnu.2012.06.002", "ISBN" : "0883-9417 DO - ", "ISSN" : "08839417", "PMID" : "23164404", "abstract" : "Despite advances in research on symptoms, stress, and depression after traumatic brain injury, there has been limited focus on the collective relationships between neurocognitive performance, chronic stress, and somatic and depressive symptoms. Guided by our adaptation of the allostatic load theory, we examined relationships between chronic stress, somatic and depressive symptoms, and cognitive performance using the Immediate Postconcussion Assessment and Cognitive Testing cognitive battery. Only somatic symptoms and chronic stress explained variation in depressive symptoms (R2 = .71, P < .0001), not neurocognitive performance, preinjury, or injury-specific variables. Our findings suggest that increased chronic stress and somatic symptoms can contribute significantly to depressive symptoms after mild to moderate traumatic brain injury. \u00a9 2012 Elsevier Inc..", "author" : [ { "dropping-particle" : "", "family" : "Bay", "given" : "Esther", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Covassin", "given" : "Tracey", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Archives of Psychiatric Nursing", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2012" ] ] }, "page" : "477-486", "publisher" : "Elsevier Inc.", "title" : "Chronic Stress, Somatic and Depressive Symptoms Following Mild to Moderate Traumatic Brain Injury", "type" : "article-journal", "volume" : "26" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Bay & Covassin, 2012)", "plainTextFormattedCitation" : "(Bay & Covassin, 2012)", "previouslyFormattedCitation" : "(Bay & Covassin, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Bay & Covassin, 2012). Participants in the qualitative study described both early and late onset depression. Causal mechanisms of depression after concussion are complex and can be obscured by directionality of the associated relationships. For example, is it the prolonged symptoms causing depression or is it the depression that leads to prolonged symptoms? Similarly, decreased academic standing and depression were also significantly correlated in our findings. Accounts from participants in the qualitative study described times when the stressful activity of return to school triggered anxiety and depression and times when the depression was experienced within days of the injury and affected their motivation to go to school and their performance. Longitudinal research with a large sample including a comparison group is needed to clarify risks and predictors. Theory is necessary to guide research. Vulnerability stress theory was introduced in Chapter One as one way of thinking about the onset of depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "9781606233474", "author" : [ { "dropping-particle" : "", "family" : "Ingram", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "edition" : "Second", "editor" : [ { "dropping-particle" : "", "family" : "Ingram", "given" : "R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Price", "given" : "J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2010" ] ] }, "publisher" : "Guilford Press", "publisher-place" : "New YOrk", "title" : "Vulnerability to Psychopathology: Risk across the lifespan", "type" : "book" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ingram, 2010)", "plainTextFormattedCitation" : "(Ingram, 2010)", "previouslyFormattedCitation" : "(Ingram, 2010)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Ingram, 2010). Given the current findings, it would seem that the outcomes from concussion might also be considered from a differential susceptibility framework ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1017/S0954579410000611", "ISBN" : "0954579410", "ISSN" : "1469-2198", "PMID" : "21262036", "abstract" : "Two extant evolutionary models, biological sensitivity to context theory (BSCT) and differential susceptibility theory (DST), converge on the hypothesis that some individuals are more susceptible than others to both negative (risk-promoting) and positive (development-enhancing) environmental conditions. These models contrast with the currently dominant perspective on personal vulnerability and environmental risk: diathesis stress/dual risk. We review challenges to this perspective based on emerging theory and data from the evolutionary, developmental, and health sciences. These challenges signify the need for a paradigm shift in conceptualizing Person x Environment interactions in development. In this context we advance an evolutionary--neurodevelopmental theory, based on DST and BSCT, of the role of neurobiological susceptibility to the environment in regulating environmental effects on adaptation, development, and health. We then outline current thinking about neurogenomic and endophenotypic mechanisms that may underpin neurobiological susceptibility, summarize extant empirical research on differential susceptibility, and evaluate the evolutionary bases and implications of BSCT and DST. Finally, we discuss applied issues including methodological and statistical considerations in conducting differential susceptibility research; issues of ecological, cultural, and racial--ethnic variation in neurobiological susceptibility; and implications of differential susceptibility for designing social programs. We conclude that the differential susceptibility paradigm has far-reaching implications for understanding whether and how much child and adult development responds, for better and for worse, to the gamut of species-typical environmental conditions.", "author" : [ { "dropping-particle" : "", "family" : "Ellis", "given" : "Bruce J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Boyce", "given" : "W Thomas", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Belsky", "given" : "Jay", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bakermans-Kranenburg", "given" : "Marian J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ijzendoorn", "given" : "Marinus H", "non-dropping-particle" : "van", "parse-names" : false, "suffix" : "" } ], "container-title" : "Development and psychopathology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2011", "2" ] ] }, "page" : "7-28", "title" : "Differential susceptibility to the environment: an evolutionary--neurodevelopmental theory.", "type" : "article-journal", "volume" : "23" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ellis, Boyce, Belsky, Bakermans-Kranenburg, & van Ijzendoorn, 2011)", "plainTextFormattedCitation" : "(Ellis, Boyce, Belsky, Bakermans-Kranenburg, & van Ijzendoorn, 2011)", "previouslyFormattedCitation" : "(Ellis, Boyce, Belsky, Bakermans-Kranenburg, & van Ijzendoorn, 2011)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Ellis, Boyce, Belsky, Bakermans-Kranenburg, & van Ijzendoorn, 2011). A model using the concepts of the differential susceptibility theory to explain differing outcomes of concussion has been developed (see Figure 1). This model considers the outcome of children to be highly dependent on their environment: both early childhood experiences and the context around the concussive incident that includes the child’s resources and support or conversely their stress during healing from concussion. Multiple concussions are hypothesized to lead to poorer outcomes, including both prolonged recovery and depression. Validating this framework, which emphasizes both environmental stressors and vulnerabilities both to the concussion and from the injury itself, would require further hypothesis-driven studies. Implications for Clinical PracticeThere are many emotional and practical implications of the findings concerning post-concussive risk of depression as well as the trajectory of recovery that could inform resource and service planning. In the acute stage of symptom management, the development of a clinical pathway that projects potential recovery patterns and check-in points regarding when and how to access health care would be very helpful for families. Families were frustrated with the lack ofFigure 1: Model explaining childhood concussion outcomes based on the differential susceptibility framework * Adapted from the Differential Susceptibility Theory (Ellis, Boyce, Belsky, Bakermans-Kranenburg & Van Ijzendoorm, 2011)recognition of the mental health consequences of concussion as well as what they perceived to be a dearth of available services or effective interventions for the ongoing symptoms of concussion. Families were looking for guidance from the health care system and reassurance that service providers were knowledgeable about their child’s condition. A clinical pathway could inform frontline service providers as well as families. This pathway could recommended weekly or monthly check ups, depending on presentation and length of recovery. Decision-making practices about assessments, transition supports and services that should be sought at various points along the trajectory could be outlined. Some of this work has already begun in that recovery patterns are guiding the new return to activity protocols ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/0009922814558256", "ISBN" : "0009922814", "ISSN" : "0009-9228", "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "C.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Stazyk", "given" : "K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Singh", "given" : "S. 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DeMatteo et al., 2014)", "plainTextFormattedCitation" : "(C. DeMatteo et al., 2014)", "previouslyFormattedCitation" : "(C. DeMatteo et al., 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(DeMatteo et al., 2014) and practice guidelines for managing pediatric concussion have been developed ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Zemek", "given" : "Roger L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Duval", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "DeMatteo", "given" : "Carol", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2014" ] ] }, "publisher-place" : "Toronto, Ontario", "title" : "Guidelines for diagnosing and managing pediatric concussion", "type" : "report" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Zemek, Duval, & DeMatteo, 2014)", "plainTextFormattedCitation" : "(Zemek, Duval, & DeMatteo, 2014)", "previouslyFormattedCitation" : "(Zemek, Duval, & DeMatteo, 2014)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Zemek, Duval, & DeMatteo, 2014). Although this knowledge has been synthesized and made available ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "URL" : "", "accessed" : { "date-parts" : [ [ "2015", "5", "5" ] ] }, "author" : [ { "dropping-particle" : "", "family" : "DeMatteo", "given" : "CA", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Canchild.ca", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2013" ] ] }, "title" : "Concussion Management: Return to Activity Guidelines for Children and Youth", "type" : "webpage" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(CA DeMatteo, 2013)", "manualFormatting" : "(DeMatteo, 2013)", "plainTextFormattedCitation" : "(CA DeMatteo, 2013)", "previouslyFormattedCitation" : "(CA DeMatteo, 2013)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(DeMatteo, 2013), it has not yet been fully adopted by frontline providers. Adapting guidelines to a local community context may result in increased uptake by service providers; for example, decision-making algorithms could list local services and specialists when referrals are recommended.Another clinical implication in the acute stage, when children and families are first introduced to concussion management protocols that advocate a graduated return to all activity, is that health care providers need to be aware of the emotional impact of implementing activity restrictions. Discussion with families about finding ways that the youth can remain socially connected and maintain a sense of self through valued activities may help prevent some of the loss of self experienced by the youth who go through prolonged recoveries. This work also highlights that the treatment of youth should not occur in isolation of their families. Parental uncertainty and distress affects the family and parents can be overly cautious and protective or, conversely, question the need for concussion management strategies. Parents of children with concussion experience psychological distress and are at increased risk for anxiety and depression themselves ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1093/jpepsy/jsm133", "ISBN" : "1465-735X (Electronic)\\r0146-8693 (Linking)", "ISSN" : "01468693", "PMID" : "18227110", "abstract" : "OBJECTIVE: To examine the relationship of mild traumatic brain injuries (TBI) and post-concussive symptoms (PCS) to post injury family burden and parental distress, using data from a prospective, longitudinal study. METHODS: Participants included 71 children with mild TBI with loss of consciousness (LOC), 110 with mild TBI without LOC, and 97 controls with orthopedic injuries not involving the head (OI), and their parents. Shortly after injury, parents and children completed a PCS interview and questionnaire, and parents rated premorbid family functioning. Parents also rated family burden and parental distress shortly after injury and at 3 months post injury. RESULTS: Mild TBI with LOC was associated with greater family burden at 3 months than OI, independent of socioeconomic status and premorbid family functioning. Higher PCS shortly after injury was related to higher ratings of family burden and distress at 3 months. CONCLUSIONS: Mild TBI are associated with family burden and distress more than mild injuries not involving the head, although PCS may influence post injury family burden and distress more than the injury per se. Clinical implications of the current findings are noted in the Discussion section.", "author" : [ { "dropping-particle" : "", "family" : "Ganesalingam", "given" : "Kalaichelvi", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Yeates", "given" : "Keith Owen", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ginn", "given" : "Melissa Susan", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Taylor", "given" : "H. 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Families of children with moderate-to-severe TBI were recruited from the trauma registry of a large children's hospital and randomly assigned to receive online family problem solving therapy (FPS; n = 20) or Internet resources (IRC; n = 20) in addition to usual care. The FPS group reported significantly less global distress, depressive symptoms, and anxiety at follow-up than did the IRC group after controlling for baseline symptoms. The FPS group also reported significant improvements in problem-solving skills, although the groups did not differ significantly at follow-up. Findings suggest that an online, skill-building approach can be effective in facilitating parental adaptation after TBI.", "author" : [ { "dropping-particle" : "", "family" : "Wade", "given" : "Shari L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carey", "given" : "JoAnne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wolfe", "given" : "Christopher R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of consulting and clinical psychology", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "445-454", "title" : "An online family intervention to reduce parental distress following pediatric brain injury.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Ganesalingam et al., 2008; Wade, Carey, & Wolfe, 2006)", "plainTextFormattedCitation" : "(Ganesalingam et al., 2008; Wade, Carey, & Wolfe, 2006)", "previouslyFormattedCitation" : "(Ganesalingam et al., 2008; Wade, Carey, & Wolfe, 2006)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Ganesalingam et al., 2008; Wade, Carey, & Wolfe, 2006). Educational intervention directly after concussion has been shown to affect outcomes; however, application to those later in the recovery process has not been researched ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1080/13803390801978849", "ISSN" : "1380-3395", "PMID" : "18608646", "abstract" : "Mild traumatic brain injury (MTBI) is common and results in persisting disability for a minority of cases. Evidence guiding clinical management of this more complex group is lacking. This study systematically reviews psychological/neuropsychological treatments for adults with MTBI, with an emphasis on external validity. A total of 8 further studies were found adding to 10 from previous reviews. Although the methodological quality remains poor, mild supportive evidence was found for educational interventions provided early following injury. However, the routine provision of interventions for all MTBI cases may not be effective. Continuing and novel research efforts are needed to identify factors associated with poor outcomes to enable efficient targeting of healthcare resources.", "author" : [ { "dropping-particle" : "", "family" : "Snell", "given" : "Deborah L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Surgenor", "given" : "Lois J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hay-Smith", "given" : "E Jean C", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Siegert", "given" : "Richard J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of clinical and experimental neuropsychology", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2009" ] ] }, "page" : "20-38", "title" : "A systematic review of psychological treatments for mild traumatic brain injury: an update on the evidence.", "type" : "article-journal", "volume" : "31" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Snell, Surgenor, Hay-Smith, & Siegert, 2009)", "plainTextFormattedCitation" : "(Snell, Surgenor, Hay-Smith, & Siegert, 2009)", "previouslyFormattedCitation" : "(Snell, Surgenor, Hay-Smith, & Siegert, 2009)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Snell, Surgenor, Hay-Smith, & Siegert, 2009). Other resources such as family therapy, parent-to- parent support or online support have shown promise in TBI and other special needs populations ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1002/mrdd.20175", "author" : [ { "dropping-particle" : "", "family" : "Singer", "given" : "G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ethridge", "given" : "B", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Aldana", "given" : "S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Mental Retardatdion and Developmental Disabilities Research Reviews", "id" : "ITEM-1", "issued" : { "date-parts" : [ [ "2007" ] ] }, "page" : "357-369", "title" : "Primary and secondary effects of parenting and stress management interventions for parents of children with developmental disabilitie: A meta-analysis", "type" : "article-journal", "volume" : "13" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "DOI" : "10.1037/0022-006X.74.3.445", "ISSN" : "0022-006X", "PMID" : "16822102", "abstract" : "This study examined whether an online problem-solving intervention could improve parental adjustment following pediatric traumatic brain injury (TBI). Families of children with moderate-to-severe TBI were recruited from the trauma registry of a large children's hospital and randomly assigned to receive online family problem solving therapy (FPS; n = 20) or Internet resources (IRC; n = 20) in addition to usual care. The FPS group reported significantly less global distress, depressive symptoms, and anxiety at follow-up than did the IRC group after controlling for baseline symptoms. The FPS group also reported significant improvements in problem-solving skills, although the groups did not differ significantly at follow-up. Findings suggest that an online, skill-building approach can be effective in facilitating parental adaptation after TBI.", "author" : [ { "dropping-particle" : "", "family" : "Wade", "given" : "Shari L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Carey", "given" : "JoAnne", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wolfe", "given" : "Christopher R", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Journal of consulting and clinical psychology", "id" : "ITEM-2", "issue" : "3", "issued" : { "date-parts" : [ [ "2006" ] ] }, "page" : "445-454", "title" : "An online family intervention to reduce parental distress following pediatric brain injury.", "type" : "article-journal", "volume" : "74" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Singer, Ethridge, & Aldana, 2007; Wade et al., 2006)", "plainTextFormattedCitation" : "(Singer, Ethridge, & Aldana, 2007; Wade et al., 2006)", "previouslyFormattedCitation" : "(Singer, Ethridge, & Aldana, 2007; Wade et al., 2006)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Singer, Ethridge, & Aldana, 2007; Wade et al., 2006). A further clinical implication rising from this research is the need to develop consistent monitoring of significant depressive symptoms in children and youth who have had a concussion, in order to provide intervention to affected youth and their families. Screening is known to improve health outcomes when linked to effective follow-up and treatment ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1503/cmaj.1030823", "ISSN" : "1488-2329", "PMID" : "15632399", "author" : [ { "dropping-particle" : "", "family" : "Macmillan", "given" : "Harriet L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patterson", "given" : "Christopher J S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wathen", "given" : "C Nadine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Screening", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2005" ] ] }, "page" : "33-35", "title" : "Screening for depression in primary care : Task Force on Preventive Health Care", "type" : "article-journal", "volume" : "172" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Macmillan, Patterson, & Wathen, 2005)", "plainTextFormattedCitation" : "(Macmillan, Patterson, & Wathen, 2005)", "previouslyFormattedCitation" : "(Macmillan, Patterson, & Wathen, 2005)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Macmillan, Patterson, & Wathen, 2005). Targeted screening in high-risk patients has been a highly recommended approach to identify patients with depression ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "ISBN" : "0002-838X", "ISSN" : "0002838X", "PMID" : "12358212", "abstract" : "Depression is a common psychiatric disorder in children, adolescents, adults, and the elderly. Primary care physicians, not mental health professionals, treat the majority of patients with symptoms of depression. Persons who are depressed have feelings of sadness, loneliness, irritability, worthlessness, hopelessness, agitation, and guilt that may be accompanied by an array of physical symptoms. A diagnosis of major depression requires that symptoms be present for two weeks or longer. Identifying patients with depression can be difficult in busy primary care settings where time is limited, but certain depression screening measures may help physicians diagnose the disorder. Patients who score above the predetermined cut-off levels on the screening measures should be interviewed more specifically for a diagnosis of a depressive disorder and treated within the primary care physician's scope of practice or referred to a mental health subspecialist as clinically indicated. Targeted screening in high-risk patients such as those with chronic diseases, pain, unexplained symptoms, stressful home environments, or social isolation, and those who are postnatal or elderly may provide an alternative approach to identifying patients with depression.", "author" : [ { "dropping-particle" : "", "family" : "Sharp", "given" : "Lisa K.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Lipsky", "given" : "Martin S.", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "American Family Physician", "id" : "ITEM-1", "issue" : "6", "issued" : { "date-parts" : [ [ "2002" ] ] }, "page" : "1001-1008", "title" : "Screening for depression across the lifespan: A review of measures for use in primary care settings", "type" : "article-journal", "volume" : "66" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Sharp & Lipsky, 2002)", "plainTextFormattedCitation" : "(Sharp & Lipsky, 2002)", "previouslyFormattedCitation" : "(Sharp & Lipsky, 2002)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Sharp & Lipsky, 2002) but has rarely been implemented with children who have had a concussion. A self-report measure of depressive symptoms can be built into concussion follow-up protocols. This study, conducted in a busy concussion clinic, showed that elevated symptoms reported on the CDI-2 screen were not always disclosed during the general interview. Concussion increases the risk for elevated depressive symptoms and other indicators could be identified that are known to multiply the risk such as a first-degree relative with history of depression, chronic pain (e.g., backache, headache), impoverished home environment, experiencing major life changes, fatigue or sleep disturbance ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1503/cmaj.1030823", "ISSN" : "1488-2329", "PMID" : "15632399", "author" : [ { "dropping-particle" : "", "family" : "Macmillan", "given" : "Harriet L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Patterson", "given" : "Christopher J S", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Wathen", "given" : "C Nadine", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Screening", "id" : "ITEM-1", "issue" : "1", "issued" : { "date-parts" : [ [ "2005" ] ] }, "page" : "33-35", "title" : "Screening for depression in primary care : Task Force on Preventive Health Care", "type" : "article-journal", "volume" : "172" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Macmillan et al., 2005)", "plainTextFormattedCitation" : "(Macmillan et al., 2005)", "previouslyFormattedCitation" : "(Macmillan et al., 2005)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Macmillan et al., 2005). The timing of the onset of depression is not yet clear; this study would suggest that an initial screening should occur between one and three months post-injury and could facilitate discussion with the youth of the functional implications of their concussion and their feelings.Intervention for depression has been well researched but often with unclear results ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Merry", "given" : "SN", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hetrick", "given" : "SE", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Cox", "given" : "GR", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Brudevold-Iversen", "given" : "T", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Bir", "given" : "JJ", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "McDowell", "given" : "H", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Cochrane Library", "id" : "ITEM-1", "issue" : "12", "issued" : { "date-parts" : [ [ "2011" ] ] }, "title" : "Psychological and educational interventions for preventing depression in children and adolescents", "type" : "article-journal" }, "uris" : [ "" ] }, { "id" : "ITEM-2", "itemData" : { "author" : [ { "dropping-particle" : "", "family" : "Nordheim", "given" : "L", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Ekeland", "given" : "E", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Hagen", "given" : "K", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Heian", "given" : "", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "The Cochrane Library", "id" : "ITEM-2", "issue" : "1", "issued" : { "date-parts" : [ [ "2009" ] ] }, "title" : "Exercise in prevetnion and treatemtn of anxiety and depression among children and young people", "type" : "article-journal" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Merry et al., 2011; Nordheim, Ekeland, Hagen, & Heian, 2009)", "plainTextFormattedCitation" : "(Merry et al., 2011; Nordheim, Ekeland, Hagen, & Heian, 2009)", "previouslyFormattedCitation" : "(Merry et al., 2011; Nordheim, Ekeland, Hagen, & Heian, 2009)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Merry et al., 2011; Nordheim, Ekeland, Hagen, & Heian, 2009); treatment for prolonged recovery from concussion has even more limited research ADDIN CSL_CITATION { "citationItems" : [ { "id" : "ITEM-1", "itemData" : { "DOI" : "10.1177/1941738111433673", "ISSN" : "1941-0921", "PMID" : "23016082", "abstract" : "Prolonged symptoms after concussion are called post-concussion syndrome (PCS), which is a controversial disorder with a wide differential diagnosis.", "author" : [ { "dropping-particle" : "", "family" : "Leddy", "given" : "John J", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sandhu", "given" : "Harkeet", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Sodhi", "given" : "Vikram", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Baker", "given" : "John G", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" }, { "dropping-particle" : "", "family" : "Willer", "given" : "Barry", "non-dropping-particle" : "", "parse-names" : false, "suffix" : "" } ], "container-title" : "Sports health", "id" : "ITEM-1", "issue" : "2", "issued" : { "date-parts" : [ [ "2012", "3" ] ] }, "page" : "147-54", "title" : "Rehabilitation of Concussion and Post-concussion Syndrome.", "type" : "article-journal", "volume" : "4" }, "uris" : [ "" ] } ], "mendeley" : { "formattedCitation" : "(Leddy, Sandhu, Sodhi, Baker, & Willer, 2012)", "plainTextFormattedCitation" : "(Leddy, Sandhu, Sodhi, Baker, & Willer, 2012)", "previouslyFormattedCitation" : "(Leddy, Sandhu, Sodhi, Baker, & Willer, 2012)" }, "properties" : { "noteIndex" : 0 }, "schema" : "" }(Leddy, Sandhu, Sodhi, Baker, & Willer, 2012). The families interviewed did not experience the phenomena of concussion and of depression as two distinct conditions; therefore, there may have been an expectation that provision of services would align and treat these together. Symptoms of concussion and depression overlap, yet both result in decreased engagement in meaningful activities. An approach to intervention directed at the combination of these conditions might be more effective than treating the depression in isolation and may lead to earlier recovery and re-engagement in daily life. An intervention study examining this question with an active rehabilitation approach is another highly needed area of research and a multi-site trial is currently underway across Canada. ConclusionThe goal of this research was to understand more about depression after concussion in youth and how it may complicate their recoveries. This thesis confirms and adds to the growing body of evidence that there is a tangible risk of depression in youth after concussion. Predictors of elevated symptoms of depression included high post-concussive symptom scores and admission to hospital. Exploring the lives of children and families as they experienced the challenges of activity restrictions, emotional symptoms and their interactions with health care provided insight into how health care providers might better support children and families during recovery from concussion. ReferencesADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY Bay, E., & Covassin, T. (2012). Chronic Stress, Somatic and Depressive Symptoms Following Mild to Moderate Traumatic Brain Injury. Archives of Psychiatric Nursing, 26(6), 477–486. doi:10.1016/j.apnu.2012.06.002Boelen, P. a., Van De Schoot, R., Van Den Hout, M. a., De Keijser, J., & Van Den Bout, J. (2010). 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J., Sandhu, H., Sodhi, V., Baker, J. G., & Willer, B. (2012). Rehabilitation of Concussion and Post-concussion Syndrome. Sports Health, 4(2), 147–54. doi:10.1177/1941738111433673Macmillan, H. L., Patterson, C. J. S., & Wathen, C. N. (2005). Screening for depression in primary care?: Task Force on Preventive Health Care. Screening, 172(1), 33–35. doi:10.1503/cmaj.1030823Meehan, W. P., Mannix, R. C., Stracciolini, A., Elbin, R. J., & Collins, M. W. (2013). Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. The Journal of Pediatrics, 163(3), 721–5. doi:10.1016/j.jpeds.2013.03.012Merry, S., Hetrick, S., Cox, G., Brudevold-Iversen, T., Bir, J., & McDowell, H. (2011). Psychological and educational interventions for preventing depression in children and adolescents. The Cochrane Library, (12). Retrieved from , L., Ekeland, E., Hagen, K., & Heian. (2009). 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A systematic review of psychological treatments for mild traumatic brain injury: an update on the evidence. Journal of Clinical and Experimental Neuropsychology, 31(1), 20–38. doi:10.1080/13803390801978849Wade, S. L., Carey, J., & Wolfe, C. R. (2006). An online family intervention to reduce parental distress following pediatric brain injury. Journal of Consulting and Clinical Psychology, 74(3), 445–454. doi:10.1037/0022-006X.74.3.445Williams, S. J. (2000). Chronic illness as biographical disruption or biographical disruption as chronic illness? Reflections on a core concept, 22(1), 40–67. doi:10.1111/1467-9566.00191Zemek, R. L., Duval, S., & DeMatteo, C. (2014). Guidelines for diagnosing and managing pediatric concussion. Toronto, Ontario.Zuckerbrot, R. a, Cheung, A. H., Jensen, P. S., Stein, R. E. K., & Laraque, D. (2007). Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics, 120(5), e1299–e1312. doi:10.1542/peds.2007-1144 Appendix A-Approval LetterAppendix B- Parent Consent FormInformation and Consent Form: Development of Depression after Concussion:Which Children are at Risk?Principal Investigator:Kathy Stazyk, BHScOTReg(Ont), McMaster UniversitySupervisor:Dr. Cheryl Missiuna, Ph.D., OTReg(Ont), McMaster UniversityDear Parents/Guardians:We would like to invite you to take part in a study to understand changes in mood in children who are recovering from concussion.WHY ARE WE DOING THIS STUDY?Mood changes or depressive symptoms can develop after life stresses and injuries. These changes are thought to be more frequent after brain injury and can often prevent a child from returning to school and sports. We need a better understanding about mood changes after concussion so that we can intervene early to prevent or lessen the impact of this on participation.WHAT BENEFIT IS THIS TO YOU AND YOUR CHILD?There are no direct benefits from participating; however, the information shared by your family helps us to understand the strengths and challenges that are experienced when a child is recovering from concussion and the added impact of changes in mood and emotions.WHAT RISKS ARE INVOLVED IN THIS STUDY?The risk of participating in interviews is low, although it may be stressful to talk about the experiences that families and children have had since the concussion occurred. WHAT DO YOU NEED TO DO?If you choose to take part in this study you will be contacted to set up an interview which will be scheduled at your convenience at your home if you like, or an agreed upon location that is comfortable for you sharing personal information. You will need to sign these consent forms and give them to the investigator before the interview begins. The interview will take about an hour and can include yourself and your child together or separately with their assent. The questions will ask about the impact of concussion and mood changes on your family and on your son/daughter, what things have been helpful and what has been most challenging in this recovery period. The interview will be audio recorded to help with collecting and analyzing the information. At this appointment you will also be asked to complete a brief questionnaire about your child’s moods and feelings over the previous two weeks.IF I DO NOT WANT TO TAKE PART IN THE STUDY, ARE THERE OTHER CHOICES?Even if you agree to participate in the study, you and your child's participation is voluntary and you may withdraw from the study at any time. There is no obligation for you or your child to answer any questions or to participate in any aspect of this project. WILL MY INFORMATION BE KEPT CONFIDENTIAL?All personal data will be kept strictly confidential and all information will be coded so that your name is not associated with your answers. Only the researchers will have access to the data. No personal information regarding your child or family will be identified in publication of the results of this study.WHAT ELSE DO YOU NEED TO KNOW? This study has been reviewed by the Hamilton Health Sciences/McMaster Faculty of Health Sciences Research Ethics Board (HHS/FHS REB). The REB is responsible for ensuring that participants are informed of the risks associated with the research, and that participants are free to decide if participation is right for them. If you have any questions about your rights as a research participant, please call The Office of the Chair, Hamilton Integrated Research Ethics Board (HIREB) at 905.521.2100 x 42013.If you would like to receive more information about the study please contact Kathy Stazyk at 289-208-1139 or by email: stazyk@mcmaster.ca or Dr. Cheryl Missiuna at 905-525-9140 ext 27842 or by email: missiuna@mcmaster.ca.Thank you for your participation!Kathy StazykCheryl MissiunaMcMaster UniversityMcMaster UniversityINFORMED CONSENT – Depressive Symptoms after ConcussionParental/Guardian Statement:I am the parent or legal guardian of the child named below, who is under the age of 18 yearsParent’s Consent and Signature Yes please sign us up!I give my personal consent and give consent for my child, _____________________, to take part in this study where an occupational therapist will interview myself and my child (with their assent) about their experiences with recovery from concussion.No, thank-you.Signature of Parent/Guardian: _________________________ Date: _______________Print name: ________________________________________I have explained this study and believe that it has been understood and the participant is voluntarily and knowlingly giving informed consent.______________________ ____________________________SignatureDate_________________________Person obtaining consentAppendix C- Youth Assent FormYOUTH ASSENT FORM: Development of Depression after Concussion: Which children are at risk?UNDERSTANDING KIDS LIKE YOU!WHY ARE WE DOING THIS STUDY?We are doing this research study to find out more about kids moods and feelings after they have had a concussion injury. We are asking kids who are having long lasting symptoms and may be very sad or depressed about this to tell us more about their everyday lives.If I AM IN THE STUDY, WHAT WILL HAPPEN TO ME?The person reading this with you will want to ask you questions about your feelings after concussion and what it has been like for you. We are also talking to your parents about these things too. You will also be asked to answer a short questionnaire about your moods and feelings for the past 2 weeks.Will I BE HURT IF I AM IN THE STUDY?Many children like to tell their story, however if at any point you feel uncomfortable, all you have to do is say that you would like to stop.WHAT IF I DON’T WANT TO ANSWER ONE OF THE QUESTIONS?You can skip any of the questions that make you uncomfortable. If you don’t understand a question, you can ask the person from the study to explain it to you.HOW WILL THE STUDY HELP ME?The information you share with us helps us understand more about how kids your age feel after having a concussion and about getting better from it. It helps us to help kids like you to have positive experiences in the future.DO I HAVE TO BE IN THIS STUDY?You don’t have to be in this study if you don’t want to. People take part in studies like this one because they want to –they think it is interesting and important. Nobody will make you be a part of a study if you don’t want to and you can leave the study if you decide you no longer want to take part.WHAT HAPPENS AFTER THE STUDY? When we are finished this study we will write a report about what was learned. This report will not include your name or that you were in the study.WHAT IF I HAVE QUESTIONS?You can ask questions if you do not understand the study. You can also call or email us if you have questions later:Kathy Stazyk, Person in charge of the study……………….email:stazyk@mcmaster.ca tel: 289-208-1139ASSENTIf you would like to be in this study, please print/write your name. If you decide that you don’t want to be in the study, even after you have started, all you have to do is let someone know.I,______________________________(Print your name) would like to be in this research study._______________________________ (Date of assent)I have explained this study and believe that _____________________ has understood it.________________________________________(Name of person who obtained assent)________________________________________ (Signature and Date)Appendix D- Interview GuideInterview Guide/Child: Development of Depression after Concussion: Which children are at risk?471170114935Introduction: Thank you for agreeing to be interviewed. I am interested in your experiences with concussion recovery and in particular with the depressive symptoms that are a part of that. I am hoping that the information I gather will help to identify those children who may be at risk for depression and provide support for offering specific help to those families00Introduction: Thank you for agreeing to be interviewed. I am interested in your experiences with concussion recovery and in particular with the depressive symptoms that are a part of that. I am hoping that the information I gather will help to identify those children who may be at risk for depression and provide support for offering specific help to those familiesMain QuestionAdditional QuestionsClarifying questionsTell me the story about yourconcussion.Type of PC symptomsLength of time of PC symptoms# of concussionsCan you expand on this?Can you give me examples?Can you tell me anything else?Tell me about the mood changes you have experienced since your concussion.Probe for symptoms, timingProbe any perceptions of precipitating eventsProbe feelings, thoughts and beliefsCan you expand on this?Can you give me examples?Can you tell me anything else?Tell me about the impact of this on you?Probe prior functioningProbe productivity, self-care and leisure (school, friends etc)Can you expand on this?Can you give me examples?Can you tell me anything else?What has it been like for your family?Probe for family dynamics, interactions (changes in these)Probe for productivity, leisure issues (time off work, change in activity patterns)Can you expand on this?Can you give me examples?Can you tell me anything else?What are the things that have been helpful or challenging throughout this whole experience?Probe for course of careProbe for individual strengthsCan you expand on this?Can you give me examples?Can you tell me anything else?ConclusionIs there anything else you would like to add that you haven’t shared with me yet?AppendixAppendix E- Post-Concussion Symptom Inventory (PCSI) ................
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