Association of concussion/brain injury symptoms and diagnosis with mental and social well-being in 2020 National Health Interview Survey (NHIS) children

ABSTRACT

Background

Population-based data regarding the associations between prior concussion or brain injury symptoms/diagnosis and mental/social well-being is lacking for U.S. children.

Methods

Associations between prior concussion or brain injury symptoms/diagnosis (reported by parents of children ages 5–17 from the 2020 National Health Interview Survey) and current mental/social well-being were determined in multivariable models.

Results

Amongst 2020 US children, 8.7% and 5.3% had previous symptoms and diagnosis of concussion/brain injury, respectively. 23% of children with symptoms were never checked for a concussion/brain injury, with younger children at higher risk of not getting checked after symptomatic head trauma. Prior concussion or brain injury symptoms/diagnosis was associated with a higher likelihood of current depressive symptoms (odds ratio [OR] = 1.60; 95% CI = 1.21–2.14; p < 0.001), anxiety (OR = 2.07; 95% CI = 1.52–2.82; p < 0.001), difficulty making friends (OR = 1.57; 95% = 1.06–2.33; p = 0.03), use of medications for mental/social/behavioral issues (OR = 1.69; CI = 1.21–2.36; p = 0.002), and mental health therapy/counseling (OR = 1.52; 95% CI = 1.13–2.04; p = 0.006).

Conclusion

U.S. children with prior concussion or brain injury symptoms/diagnosis have a higher rate of mental and social disturbances and a more frequent need for mental health services. Nearly one-quarter of children with significant symptoms after head trauma are never checked for a concussion/brain injury; routine concussion evaluation after head trauma should be emphasized especially in younger children.

KEYWORDS:

• Concussion
• traumatic brain injury
• depression
• anxiety
• mental health
• children

Introduction

Concussions/brain injuries are common in the pediatric population, with a 2020 study showing roughly 6.8% of children under the age of 17 having had a concussion/brain injury diagnosis or concussive symptoms during their lifetime (1). The short term and long-term sequelae of head trauma in children can be significant. Concussions/brain injury in children may be more severe than adults, as the trauma can disturb neuronal development (2). These brain changes can have a significant impact on a child’s mental and social well-being.

While studies have examined the long-term effects of concussions/brain injuries in adults, limited studies have examined these effects in children. In general, persistent post-concussive/post-brain injury symptoms can include headaches, fatigue, trouble thinking, dizziness, insomnia, difficulty concentrating, and memory difficulty (3,4) Children experience similar post-concussive/post-brain injury symptoms including headache, dizziness, fatigue, depressive symptoms, anxiety, light sensitivity, memory difficulty, worse psychosocial functioning, and trouble concentrating (5), with studies suggesting that symptoms can persist for years in some children (6,7). There are also studies suggesting a higher susceptibility to mental health disturbances in some adolescent post-concussive/post-brain injury patients (8,9). Much, but not all (10,11), of this knowledge has resulted from follow up of children diagnosed with concussions in referral clinics. One limitation of this analytic approach is that it excludes individuals with head trauma who do not seek care or are misdiagnosed, which may be more common in medically underserved populations.

To avoid this limitation, we studied the connection between past head trauma and current mental and social well-being with children included in the 2020 National Health Interview Survey (NHIS). By using this sample, we are more likely to capture the impact of head trauma in a broader population of children, not simply children presenting for care. Also, NHIS is designed to provide nationally representative population estimates and conclusions, not just for an individual clinic or community. Here, our primary objective was to use NHIS data to examine the associations between prior concussion/brain injury symptoms and/or concussion (or brain injury) diagnosis with mental and social being in a representative sample of United States children ages 5 to 17.

Materials and methods

NHIS (National Health Interview Survey) is a representative cross-sectional survey of the civilian noninstitutionalized population of the United States. Households participating in the survey were chosen through a scientific method with the goal of obtaining a diverse sample from which conclusions about the full US population can be drawn. Survey data were collected through in-person interviews or telephone interviews (depending on the COVID-19 situation) designed to give estimates on inferences for the entire U.S. population. After a brief survey with a household respondent was used to collect basic data on all members residing in the household, one sample child was randomly selected from households in which children age 17 or younger were present. Information regarding this child was then gathered from a parent (93.4% in 2019 survey) or another adult knowledgeable about the child’s healthcare (6.6%). Informed verbal consent was obtained from survey participants. Data were collected, deidentified, and made available through the National Center for Health Statistics. As NHIS data are publicly available and lack identifiers, no institutional review board approval was required. The datasets were derived from sources in the public domain at https://www.cdc.gov/nchs/nhis/2020nhis.htm. Children ages 5 to 17 were assessed in the current study.

Assessing history of concussion/brain injury symptoms and concussion/brain injury diagnosis

On the child’s behalf, parents/other adult respondents were asked 3 questions assessing if the child had ever had symptoms suggestive of a concussion/brain injury. Specifically, adult respondents were asked if, as a result of a blow or jolt to the head, the child: (1) was knocked out or lost consciousness, (2) was dazed or had a gap in his or her memory, or (3) had headaches, vomiting, blurred vision, or changes in mood or behavior. If necessary, interviewers could state ‘Please think about all head injuries, for example, from playing sports, car accidents, falls, or being hit by something or someone.’ Symptom data were classified as missing if 2 or 3 of the symptom questions were graded as missing, not ascertained, or don’t know, and no positive symptoms were described (n = 3).

Adult respondents were also asked if the child had ever been checked for a concussion or brain injury by a doctor, nurse, athletic trainer, or other health professional. No further questions were asked to distinguish between concussions/mild traumatic brain injury (TBI) or moderate/severe TBI. Respondents replying ‘yes’ were then asked if they were told the child had a concussion or brain injury by a doctor, nurse, athletic trainer, or other health professional. Children not checked for a concussion/brain injury, or checked but not said to have a concussion, were classified as not having a concussion/brain injury. If the question regarding being checked for a concussion/brain injury was graded as refused, not ascertained, don’t know or missing (n = 57), or if the child was checked for a concussion/brain injury but the follow-up question regarding diagnosis was graded as not ascertained or don’t know (n = 6), then concussion/brain injury diagnosis data were classified as missing/unknown. Description of the overlap between children with head trauma symptoms, being checked for a concussion/brain injury, and diagnosis of a concussion/brain injury is displayed in Figure 1.

Figure 1. Venn diagram showing the overlap of concussion/brain injury symptoms, check, and diagnosis in 2020 national health interview survey children ages 5–17.

Concussion/brain injury symptoms included reported vomiting, memory loss, vision loss, or loss of consciousness after a blow to the head). Check for, or diagnosis of, concussions consisted of an evaluation for a concussion by a health professional. Analyses were completed on children ages 5–17 with complete data on symptoms, check for a concussion, and concussion diagnosis (if checked).

A final analytic predictor variable was then created to classify children as having concussion/brain injury symptoms and/or a diagnosis (cases) or neither symptoms nor a concussion/brain injury diagnosis (controls). Children with missing concussion/brain injury symptom data were classified as having or not having prior concussion/brain injury symptoms/diagnosis based solely on their concussion/brain injury diagnosis status, while children missing diagnosis data were classified based solely on their symptom data. Children missing both symptom and diagnosis data were excluded (n = 29).

Assessment of current mental health and mental health treatment

Parents/adult respondents were asked several questions about the current mental and social well-being of the child, with this paper focusing on the frequency of depressive symptoms, anxiety, the child’s ability to make friends, and mental health treatment. Adult respondents were asked :1) how often the child feels very sad or depressed, (possible responses being ‘daily,’ ‘weekly,’ ‘monthly,’ ‘a few times a year,’ ‘never,’ ‘refused,’ ‘not ascertained,’ ‘don’t know’) 2) how often the child seems anxious, nervous, or worried, (possible responses being the same as above) and 3) does the child have difficulty making friends (possible responses being ‘no difficulty,’ ‘some difficulty,’ a lot of difficulty,’ ‘cannot do at all,’ ‘refused,’ ‘not ascertained,’ ‘don’t know)? Respondents were also asked questions regarding mental health treatment, including: 1) during the past 12 months, did the child receive counseling or therapy from a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker, and 2) during the past 12 months, did the child take any prescription medication to help with their emotions, concentration, behavior, or mental health? As a follow-up to the mental health counseling/therapy question, adult respondents were also asked if this treatment was delayed or not received due to cost.

Children were classified as having any depressive symptoms or any anxiety if respondents reported said the child experienced depressive symptoms/anxiety a few times a year or more. Additionally, children were classified as having any difficulty making friends if respondents said the child had some or a lot of difficulty, or could not make friends at all. If questions regarding anxiety, depressive symptoms, or the ability to make friends were marked as refused, not ascertained, don’t know, or missing, responses were classified as missing. Children with missing data for all 3 outcome measures were excluded from the study population.

Given the relatively high frequency of these outcome measures (≥30% for any depression or any anxiety, and ≥ 10% for any difficulty making friends) in the population, we also examined higher levels of depressive symptoms, anxiety, and difficulty making friends as outcomes. Children were classified as having higher levels of depressive symptoms/anxiety if adult respondents reported the child experiencing the issues daily or weekly. Likewise, children were classified as having greater difficulty making friends if they were said to have a lot of difficulty or could not make friends at all.

Assessment of covariates

Data were collected on the age (5–17), race (white, black, Asian, and other) and sex (male and female) of the child. Household region was classified as Northeast, South, Midwest, and West. Household income data was reported as numeric values and classified as below the 2020 poverty line for a family of 4 (as defined at for 2020 by the U.S. Department of Health and Human Services) (12), above the poverty line but below the 2020 median household income ($26,201 to $67,521), or above the 2020 median household income. Children with missing parent education (high school or below and college or above) (n = 2) and health insurance coverage (covered or not covered) (n = 13) data were not included in the multivariable logistic regression models. Children with missing race data (n = 350) were included in the multivariable logistic regression models with ‘missing’ considered as its own category. No missing data were observed for other covariates. Covariates were chosen based on previous associations and clinical relevance (13–15).

Statistical approach

NHIS study weightings were designed to account for the sampling probability and response rates across a broad range of sociodemographic features. Study weights were applied for all analyses, such that outcomes from individuals’ data were transformed into findings representative of all US children. In exploratory analyses, very few children below the age 5 had parent-reported symptoms of depression, anxiety, or difficulty making friends, and were therefore excluded from study analyses (Figure 2). A Venn diagram was created to illustrate the overlap of concussion/brain injury symptoms, evaluation for a concussion/brain injury, and a concussion/brain injury diagnosis amongst children with complete data for all these measures (Figure 1). Pairwise comparisons of outcome measures were assessed using chi squared tests. The associations of concussion/brain injury symptoms and/or concussion/brain injury diagnosis (primary exposure variable) with study outcomes were evaluated in separate multivariable logistic regression models. Primary outcome measures were as follows: (1) any frequency/level of depressive symptoms, anxiety or difficulty making friends, (2) mental health counseling or therapy, and (3) prescription medicine for mental health or behavioral issues. A higher frequency/level of depressive symptoms, anxiety or difficulty making friends were evaluated secondary outcomes. To address potential bias, sensitivity analyses in which children who had delayed counseling/therapy or none at all due to cost were analyzed together with those having received these services. All multivariable models included age, sex, race, family income, parent education, household region, and health insurance coverage as covariates. No sample size calculations were conducted, as sample size was already established through the size of the NHIS Survey sample.

Figure 2. Flow chart describing the selection of 2020 national health interview survey (NHIS) children included and excluded from the final analytic sample.

Results

Study data were analyzed for a total of 4,269 children ages 5–17 years with available data on concussive/brain injury symptoms and/or concussion/brain injury diagnosis (at any prior timepoint), and outcome data regarding the current frequency of one or more of the 4 study outcomes: depressive symptoms, anxiety, difficulty making friends, recent use of medications for emotional, concentration, behavioral, or mental health issues, and recent usage of therapy or counseling for mental health (Figure 2). All interviews were completed in 2020, but no associations were seen between month of interview (January–March vs. April–December) and any of the study outcomes.

Using the NHIS survey weights, we compared the population of United States children with and without a history of prior concussion/brain injury symptoms and/or concussion/brain injury diagnosis. Roughly half (49.4%) of the children with prior concussion/brain injury symptoms/diagnosis were ages 14–17 years as compared to only 29.9% of children with neither symptoms nor a concussion/brain injury diagnosis (Table 1). The majority of children in the prior concussion/brain injury symptom/diagnosis group were male (58.0%) while there were equal numbers of boys and girls amongst children with neither symptoms nor a concussion/brain injury diagnosis (50.1% and 49.9%, respectively). Both groups were largely Caucasian (86.7% and 71.3%, respectively).

Table 1. Description of children ages 5–17 in the 2020 national health interview study (NHIS) with and without symptomatic head trauma or a diagnosed concussion/brain injury.

	Concussion/Brain Injury symptoms/diagnosis		No concussion/brain injury symptoms or diagnosis
	N (%)*	95% CI	N (%)*	95% CI
Age
5–9 years	1,074(21.2)	(750, 1,399)	18,929(39.6)	(17,359, 20499)
10–13 years	1,485(29.3)	(1,097, 1,874)	14,553(30.5)	(13,262, 15843)
14–17 years	2,501(49.4)	(2,081, 2,921)	14,293(29.9)	(13,102, 15485)
Male Sex	2,931(57.9)	(2,424, 3,437)	23,931(50.1)	(22,216, 25665)
Race^**
White (only)	4,090(80.8)	(3,476, 4,705)	30,867(64.6)	(28,770, 32964)
Black (only)	270(5.3)	(126, 413)	7,125(14.9)	(6,036, 8,214)
Asian (only)	85(1.7)	(19, 150)	2,263(4.7)	(1,875, 2,652)
Hispanic ethnicity	1012(20.0)	(694, 1,330)	12,387(25.9)	(10,802, 13972)
Household income^***
Below poverty line	575(11.4)	(371, 778)	6,208(13.0)	(5,292, 7,124)
Above poverty/below median	1,440(28.5)	(1,073, 1,807)	15,666 (32.8)	(14,259, 17072)
Above median	3,046(60.2)	(2,547, 3,545)	25,906(54.2)	(23,914, 27899)
Mental Health
Any level of anxiety in last year	3,476(68.6)	(2,919, 4,032)	22,316(46.9)	(20,608, 24024)
Any level of depression in last year	2,267(44.8)	(1,818, 2,716)	14,200(29.8)	(12,855, 15544)
Any difficulty making friends	852(16.8)	(560, 1,144)	4,951(10.4)	(4,287, 5,614)
Mental health medications****	905(17.9)	(658, 1,151)	4,171(8.7)	(3,566, 4,775)
Therapy/counseling for mental health****	996(19.8)	(753, 1240)	5, 558(11.6)	(4,865, 6,252)

CI- 95% confidence interval.

*All numbers shown in thousands.

**Children with race categorized responses as other, multiple different races, not ascertained, refused, or ‘don’t know’ where not included in this table.

***2020 federal poverty line assessed for a family of 4. Percentage above median family income is slightly above 50%, reflecting that current analyses only assessed households with children.

****In the past 12 months.

In population estimates judged from the 4,236 NHIS children with complete symptom and concussion/brain injury history data (representative of 52.8 million US Children ages 5–17), in the 2020 U.S. population, 4.6 million (8.7%) children age 5–17 years experienced prior concussion/brain injury symptoms, 6.4 million children (12.2%) had been checked for a concussion, and 2.6 million (5.0%) children had a history of a concussion/brain injury diagnosis (Figure 1). Out of 6.4 million children checked for a concussion, 3.4 million (53%) had reported having head trauma symptoms. Also, out of these 6.4 million children checked for a concussion, 2.6 million (41.3%) had a concussion/brain injury diagnosis (Figure 1), including 16.4% of children without NHIS reported-head trauma symptoms and 63.4% of children with symptoms. Younger age was associated with having a lower likelihood of being checked for a concussion/brain injury in the setting of symptomatic head trauma (Table 2). In children without NHIS-reported symptoms, females, African-Americans and Asians, Hispanics, uninsured children, and children of less educated parents were less likely to be evaluated for a concussion/brain injury.

Table 2. Factors associated with being checked for a concussion/brain injury amongst 2020 national health interview survey children ages 5–17 with or without NHIS-reported previous symptomatic head trauma.

	Reported symptomatic head trauma		No NHIS-reported symptomatic head trauma
Variable	Odds ratio (CI)	P-value	Odds ratio (CI)	P-value
Age (per one year older)	1.13 (1.03, 1.25)	.01	1.02 (.98, 1.07)	.31
Sex (Female vs. Male)	1.18 (.57, 2.43)	.65	.51 (.36, .74)	<0.001
Race*
Black vs. White	.80 (.22, 2.94)	.74	.44 (.21, .90)	.03
Asian vs. White	.59 (.11, 3.31)	.55	.15 (.05, .44)	<0.001
Ethnicity (Hispanic vs. not Hispanic)	2.38 (.98, 5.76)	.06	.57 (.35, .95)	.03
Region
Midwest vs. Northeast	.52 (.19, 1.46)	.21	.98 (.60, 1.60)	.95
South vs. Northeast	.62 (.22, 1.77)	.37	.96 (.59, 1.54)	.85
West vs. Northeast	1.36 (.47, 3.91)	.57	1.13 (.68, 1.88)	.63
No insurance coverage	.32 (.06, 1.62)	.17	.20 (.04, .93)	.04
Parent Education (High school or less vs. College or above)	1.92 (.80, 4.61)	.14	2.02 (1.21, 3.37)	.007
Household Income
Below poverty vs. above median	.74 (.25, 2.15)	.57	1.10 (.54, 2.25)	.79
Below median/above poverty vs. above median	.82 (.28, 2.39)	.71	1.11 (.57, 2.17)	.75

Odds ratios derived from multivariable regression models including each of the above variables as covariates.

CI = 95% Confidence interval.

*Children with missing answers for race were included in the regression, but are not shown in this table.

Less than one-third (29.8%) of children with neither symptoms nor a concussion/brain injury diagnosis described current depressive symptoms at any frequency (a few times a year or more); any level of depressive symptoms were more frequent in children with prior concussion/brain injury symptoms (44.8%, p < 0.001) or a concussion/brain injury diagnosis (47.0%, p < 0.001). Similarly, 47.0% of children with neither symptoms nor a concussion/brain injury diagnosis had any levels of anxiety (a few times a year or more), with more prevalent anxiety (at any level) noted in children with prior concussion/brain injury symptoms (69.1%, p < 0.001) or diagnosis (69.7%, p < 0.001). 10.38% of children with neither symptoms nor a concussion/brain injury diagnosis described any level of current difficulty making friends, with a greater prevalence noted in children with a history of concussion/brain injury symptoms (16.7%, p = 0.01) or diagnosis (18.0%, p = 0.02). Additionally, 8.73% of children with neither symptoms nor a concussion/brain injury diagnosis took medications for emotions, concentration, behavior, and/or mental health uses in the past 12 months; as opposed to 18.4% and 20.2% of children with prior concussive/brain injury symptoms or diagnosis, respectively (p < 0.001 for both).

Multivariable models were constructed to determine the association of prior concussion/brain injury symptoms and/or concussion/brain injury diagnosis (5.1 million children −9.7% of the population) with study outcomes (depressive symptoms, anxiety, difficulty making friends). In fully adjusted multivariable analyses, prior concussion/brain injury symptoms/diagnosis was associated with higher odds of any level of prevalent depressive symptoms (odds ratio [OR] = 1.60, 95% CI 1.21 to 2.13, p = 0.001), anxiety (OR = 2.07, 95% CI = 1.52 to 2.82, p < 0.001), and difficulty making friends (OR = 1.57, 95% = 1.06 to 2.33), p = 0.03) (Table 3). In models examining the association of prior concussion/brain injury symptoms/diagnosis with more frequent/severe outcomes, prior concussion/brain injury symptoms/diagnosis was associated with a greater likelihood of frequent depressive symptoms (OR = 1.97, 95% CI = 1.13 to 3.43, p = 0.002), frequent anxiety (OR = 2.44, 95% CI = 1.77 to 3.37, p < 0.001), mental health therapy/counseling from a mental health professional (OR = 1.52, CI = 1.13 to 2.04, p = 0.006) and mental health medication use (OR = 1.69, 95% CI = 1.21 to 2.36, p = 0.002), but not difficulty making friends (OR = 1.75, 95% CI = 0.79 to 3.86, p = 0.17) (Table 4). Age, race, ethnicity, household region, health insurance coverage, parental education, and family income were also associated with at least one of the 3 studied outcome measures (Table 3 and 4). For mental health treatment outcomes (medication use; therapy/counseling), similar results were noted in sensitivity analyses in which the outcomes included children with counseling/therapy delayed or not received due to cost. No differences in any study outcomes between children with concussion brain/injury symptoms but no diagnosis and children with a diagnosis of concussion/brain injury (p > 0.1 for all).

Table 3. Association of concussion/brain injury symptoms/diagnosis with mental/social well-being in 2020 national health interview survey children ages 5–17.

	Anxiety		Depression		Difficulty Making Friends
Variable	Odds ratio (CI)	p	Odds ratio (CI)	p	Odds ratio (CI)	p
Prior concussion/brain injury symptoms/diagnosis	2.07 (1.52, 2.82)	<.001	1.60 (1.21, 2.13)	.001	1.57 (1.06, 2.33)	.03
Age (Per one year older)	1.04 (1.02, 1.07)	<.001	1.07 (1.05, 1.10)	<.001	1.03 (1.00, 1.07)	.05
Sex (Female vs. Male)	1.40 (1.19, 1.65)	<.001	1.67 (1.40, 1.99)	<.001	0.87 (.69, 1.08)	.21
Race
Black vs. White	0.41 (.31, .54)	<.001	0.48 (.35, .67)	<.001	0.81 (.51, 1.29)	.38
Asian vs. White	0.54 (.39, .74)	<.001	0.60 (.41, .87)	.007	0.53 (.28, 1.00)	.05
Ethnicity (Hispanic vs. not Hispanic)	1.65 (1.28, 2.12)	<.001	1.68 (1.30, 2.17)	<.001	0.97 (.70, 1.34)	.87
Region
Midwest vs. Northeast	1.50 (1.10, 2.06)	.01	1.30 (.91, 1.85)	.14	0.89 (.61, 1.32)	.57
South vs. Northeast	1.03 (.79, 1.34)	.84	1.07 (.78, 1.46)	.70	0.85 (.59, 1.23)	.39
West vs. Northeast	1.05 (.79, 1.40)	.73	1.20 (.86, 1.68)	.28	0.96 (.63, 1.46)	.85
Health Insurance - (not covered vs. covered)	0.59 (.40, .88)	.01	0.96 (.60, 1.53)	.85	0.66 (.33, 1.32)	.24
Parent education (high school or less vs. any college)	0.67 (.53, .84)	<.001	0.82 (.62, 1.07)	.14	0.78 (.54, 1.14)	.19
Total Family Income
Below poverty vs. above median	0.86 (.64, 1.15)	.31	1.03 (.75, 1.43)	.84	2.28 (1.55, 3.35)	<.001
Below median/above poverty vs. below poverty	0.93 (.76, 1.13)	.46	1.37 (1.11, 1.70)	.003	1.35 (.98, 1.86)	.07

Odds ratios derived from multivariable regression models including each of the above variables as covariates.

Table 4. Association of concussion/brain injury symptoms/diagnosis with high levels of mental/social distress in 2020 national health interview survey children ages 5–17.

	Anxiety		Depression		Difficulty Making Friends		Mental health therapy/counseling*		Took medication for mental health*
Variable	Odds ratio (CI)	p	Odds ratio (CI)	p	Odds ratio (CI)	p	Odds ratio (CI)	p	Odds ratio (CI)	p
Prior concussion/brain injury symptoms/diagnosis	2.44 (1.77, 3.37)	<.001	1.97 (1.13, 3.43)	.002	1.75 (.79, 3.86)	.17	1.52 (1.13, 2.04)	.006	1.69 (1.21, 2.36)	.002
Age (per one year older)	1.01 (.98, 1.04)	.60	1.03 (.98, 1.08)	.22	1.09 (1.03, 1.15)	.004	1.06 (1.03, 1.10)	<.001	1.09 (1.06, 1.13)	<.001
Sex (Female vs. Male)	1.25 (.99, 1.57)	.06	1.52 (1.05, 2.22)	.03	0.61 (.34, 1.09)	.09	1.15 (.90, 1.46)	.26	0.69 (.53, .91)	.008
Race**
Black vs. White	0.40 (.24, .68)	.001	0.56 (.25, 1.26)	.17	0.93 (.34, 2.52)	.89	0.53 (.33, .84)	.007	0.30 (.17, .54)	<.001
Asian vs. White	0.30 (.15, .58)	<.001	0.63 (.27, 1.46)	.28	0.60 (.17, 2.12)	.43	0.19 (.09, .39)	<.001	0.18 (.07, .44)	<.001
Ethnicity (Hispanic vs. Not Hispanic	1.17 (.81, 1.68)	.41	1.25 (.75, 2.09)	.40	0.89 (.45, 1.78)	.45	1.31 (.89, 1.93)	.18	1.88 (1.24, 2.84)	.003
Region
Midwest vs. Northeast	.98 (.68, 1.40)	.89	1.80 (.93, 3.49)	.08	1.55 (.73, 3.32)	.26	1.07 (.74, 1.54)	.72	1.34 (.86, 2.08)	.20
South vs. Northeast	0.74 (.55, 1.00)	.05	1.27 (.71, 2.27)	.43	0.96 (.48, 1.93)	.91	0.82 (.60, 1.13)	.23	1.15 (.78, 1.70)	.47
West vs. Northeast	0.98 (.70, 1.37)	.89	1.61 (.85, 3.09)	.14	2.02 (.90, 4.54)	.09	0.91 (.65, 1.28)	.59	0.81 (.50, 1.30)	.38
Health Insurance Coverage (Not covered vs covered)	0.38 (.20, .73)	.004	0.48 (.22, 1.02)	.06	0.53 (.13, 2.15)	.37	0.25 (.11, .56)	.001	0.48 (.21, 1.08)	.08
Parent Education (High school or less vs. any college)	0.69 (.50, .94)	.02	0.49 (.30, .78)	.003	.95 (.51, 1.76)	.87	0.93 (.66, 1.31)	.67	0.84 (.58, 1.21)	.34
Total Family Income
Below poverty vs. above median	1.35 (.91, 1.99)	.14	1.95 (1.06, 3.60)	.03	2.90 (1.31, 6.43)	.009	1.91 (1.29, 2.83)	.001	3.28 (2.16, 4.99)	<.001
Below median/above poverty vs. above median	1.22 (.93, 1.59)	.15	2.04 (1.32, 3.16)	.001	0.71 (.92, 3.15)	.09	1.46 (1.11, 1.91)	.007	1.47 (1.09, 2.00)	.01

CI-95% confidence interval.

High levels of mental/social distress evaluated in for several outcomes in separate multivariable logistic models, including: anxiety or depression weekly or daily, having a large amount of difficulty making friends or not being able to make friends at all, mental health counseling, or taking medications for emotions/concentration/behavior/mental health.

*Considered within the past 12 months.

**Children with other race or missing answers for race were included in the regression, but are not shown in this table.

Discussion

Based on 2020 NHIS data, a significant proportion of U.S. children were reported to have a previous concussion/brain injury diagnosis (5.3%), with even more reported to have symptoms suggestive of a concussion/brain injury following a blow to the head (8.6%). Over a quarter of children reported to have suggestive symptoms following a blow to the head were never checked for a concussion. Notably, younger children were less likely to be checked for a concussion, with no other factors predictive (income, parental education, gender, race). A history of both concussive/brain injury symptoms and concussion/brain injury diagnosis had similar, significant effects on current mental and social health including (1) depressive symptoms, (2) anxiety, (3) use of medication for concentration, mental health, behavior, or emotions, and (4) therapy/counseling for mental health. While our cross-sectional study design cannot demonstrate causality, these findings suggest that, when comparing children with and without prior concussion symptoms/diagnosis derived from a population-based evaluation of children, prior concussive/brain injury symptoms/diagnosis may contribute to a higher risk of prevalent mental health, social, and/or behavioral difficulties in children.

Our findings support the idea that prior traumatic head injuries are associated with ongoing depressive symptoms and anxiety. As compared to a variety of control groups, higher rates of depression and anxiety have been noted in children with head trauma identified from population cohorts or kids presenting to hospitals or clinics with concussive/brain injury symptoms. Like other population-based studies (11,16–19), our study used children without head trauma as controls (17,19,20) though clinic-based studies have also found higher rates of depression and anxiety in children with head trauma as compared to more specific control groups, i.e. children with orthopedic injuries (19). While our study likely captured children with a broad range of head trauma severity, clinic-based studies focused on those admitted for head trauma (10,21,22) – likely severe cases. While studies are fairly universal in finding associations with head trauma and depressive symptoms/anxiety in the first 6 months after concussions (19,20,21–23), associations with long-term anxiety and depression have shown mixed results (10,17). In our study, the duration of time between the head trauma(s) and the assessment of the outcomes is unknown, suggesting that associations may be derived from individuals with recent trauma, remote trauma, or a combination of the two.

Further suggesting that the impact of head trauma is clinically significant, we found associations between prior concussion/brain injury symptoms/diagnosis with ongoing mental health treatment, including therapy/counseling and use of medications. Our findings support prior work showing a higher rate of psychiatric diagnosis, medication use, and service utilization in children with mild traumatic brain injury as compared to those without traumatic brain injury over a three-year period of follow up (24). Psychiatric disorders may persist in a fair number of children with one study of 46 children finding 22 with at least one DSM-IV diagnosis a year after their diagnosis (6). Appropriate treatment via medications or therapy/counseling is likely important as studies have identified a higher rate self-harm, psychiatric hospitalization, suicide rates in children and young adults with prior concussions or traumatic brain injury (6,18,19,25,26). We only found that 26.1% percent of children with depressive symptoms/anxiety were getting treatment through therapy or medication, suggesting that mental health problems might be undertreated, contributing to a higher risk of self-harm and suicide (27–29).

We also found associations between prior concussion/brain injury symptoms/diagnosis and difficulty making friends. This finding agrees with a prior study which found more difficulty with friendships in children with moderate or severe head injuries as compared to uninjured controls (10). In this study, the prevalence of friendship difficulty was high (44%) even in children more than two years out from their injury (10). Several compelling reasons have been suggested for why children with a history of head trauma may have difficulty developing and maintaining friendships including social withdrawal, hyperactivity, and hard time communicating and upholding conversations, trouble recognizing feelings and thoughts, greater sensitivity and self-centeredness, and rage attacks (7,10,30–32). Although we did not find associations between concussion/brain injury symptoms/diagnosis and severe difficulty making friends, our analyses may have been underpowered, with only 2.3% of all children reported to have severe difficulty (or total inability) making friends, as compared to 10.7% of children having any difficulty. Given past evidence that friendships allow for children to develop essential skills such as communication, cooperation, problem solving, controlling/processing emotions, and social cognition (33,34) our findings further highlight the need for therapies to address this challenge in children experiencing head trauma.

In our study, we evaluated mental and social outcomes not just in children diagnosed with a concussion, but also children with concussion/brain injury symptoms. This decision was based on our finding that associations between both prior symptoms and diagnosis with current mental and social outcomes were quite similar (Figure 3a-c), and that a significant proportion of children with suggestive symptoms were not checked for a concussion/brain injury (23%). Notably, the question regarding concussion/brain injury symptoms implied both a blow to the head and another major finding such as loss of consciousness, memory loss, vision loss, mood change, and/or vomiting, all of which would suggest a possible concussion/brain injury per consensus diagnosis guidelines (35). While symptoms alone are not sufficient to diagnose a concussion, it is concerning that so many children (especially younger children) with a previous blow to the head leading to substantial associated symptoms were not checked for concussions. These findings also highlight the importance of population-based studies which, unlike clinic-based studies, are well-suited for capturing symptomatic head trauma which does not lead to medical care.

Figure 3. Frequency of depressive symptoms, anxiety frequency, and level of difficulty making friends reported in 2020 national health interview survey children ages 5–17 with symptomatic head trauma, a diagnosed concussion/brain injury, or unaffected controls.

Data are shown for frequency of depressive symptoms (a), frequency of anxiety (b), and level of difficulty making friends (c). Unaffected controls included children with neither symptomatic head trauma nor a concussion diagnosis. The symptomatic head trauma and concussion/brain injury diagnosis groups were not mutually exclusive.

Sixteen percent of US children checked for a concussion/brain injury did not report symptoms following head trauma per the NHIS questions, though they likely incurred head trauma. These findings suggest that symptoms outside those queried in NHIS may be sufficient for diagnosing a concussion/brain injury. We found several risk factors associated with a lower likelihood of being checked for a concussion/brain injury in the absence of previous symptomatic head trauma (as judged by the NHIS questions). Many of these factors (female gender, Black/Asian race, Hispanic ethnicity) have been reported to have a lower frequency of diagnosed consussions in NHIS (1); though it remains unclear whether they represent risk factors for head trauma (as might be suspected for male gender) or inequities in access to care (as might be suspected for lack of insurance or less parental education).

Limitations of our study included its cross-sectional design which made the time between the head trauma and the mental health/social assessment unknown. Thus, it is unclear whether our associations are capturing a much larger effect in children who have had recent trauma (diluted out by smaller/null associations in children with more distant trauma), or whether they reflect children with associations in both recent and distant trauma. Prior studies have also demonstrated more frequent reporting of more recent, severe trauma (36), as parents/reporters might not have been aware of or did not remember milder injuries, which would bias our findings toward positive associations. Also, agreement between parent and child reporting is good, but not perfect, and could have introduced error (37). Furthermore, the distribution of the severity of brain injury is unknown, as parents were asked about diagnoses of concussion or brain injury, with no follow-up questions to gauge the severity of the TBI. There might have also been inaccuracies of the mental and social outcomes of the child, due to parents/reporters not accurately understanding the child’s mental and social state. Our study analyzed the 2020 NHIS data, the first to ask about traumatic brain injury in children, though the results of the survey could have been impacted by COVID-19 adjusted interview format. Specifically, in-person interviews held before the pandemic may have differed from post-pandemic interviews held over the phone. Finally, our study used a control group with neither symptoms nor diagnosis of a concussion, unlike other case control studies which compared head trauma to other injuries or health events. Therefore, it is not clear whether brain injury is causing a worsened mental health, as opposed to secondary emotional effects.

Our findings support the growing notion that childhood head trauma can have substantial repercussions. A unique aspect of our work is that it was derived from population-based data designed to be representative of the U.S population. As such, our work can be used to understand the effect of concussions in the entire U.S. population, and not just for specific communities or clinical centers. Specific takeaways from our study are the need to ensure that all children experiencing head trauma are evaluated for a concussion/brain injury, even in the absence of significant concussion/brain injury symptoms (vomiting, loss of consciousness, mood change, vision loss, and memory loss), due to the detrimental effects of a second head trauma and also the need to ensure that children and their families have proper resources to address the mental and social repercussions head trauma might produce. Future population-based studies are needed which follow children, mental health, and the occurrence of traumatic brain injury (and repeat injury) prospectively to better understand the repercussions of TBI on mental health in children.

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Funding

The author(s) reported there is no funding associated with the work featured in this article.