Exploring Heterogeneity of Stepped Collaborative Care Treatment Response Trajectories after Adolescent Sports Injury Concussion

Abstract

Objective: Few clinical trials of posttraumatic interventions have utilized symptom trajectory modeling to explore heterogeneity of treatment responses. The goal of this investigation was to conduct a secondary analysis of a randomized clinical trial of stepped collaborative care for adolescents with sports and recreational related concussion and persistent symptoms of >1 month.

Method: Trajectory modeling was used to examine the impact of randomization to the intervention as well as demographic, clinical, and injury characteristics on adolescent post-concussive symptom trajectories. Two hundred male and female adolescents were assessed >1 month after a concussion, and then 3-, 6- and 12-months later with a standardized measure of concussive symptoms, the Health and Behavior Inventory (HBI). Multinomial logistic regression was used to compare the association between intervention, demographic, clinical and injury characteristics with trajectory group membership.

Results: Four post-concussive symptom trajectories emerged: recovery, remitting, low-persistent, and high-persistent. In adjusted analyses randomization to the intervention condition was associated with significantly greater odds of HBI recovery trajectory group membership (OR 3.29 95% CI 1.06–10.28). Female gender and prior concussion history were associated with significantly greater odds of high-persistent trajectory group membership relative to all other trajectories. Greater odds of high-persistent versus recovery group trajectory membership was observed for adolescents with a pre-injury history of anxiety and/or depressive disorders.

Conclusions: Stepped collaborative care was associated with an increased odds of recovery versus high-persistent post-concussive symptom trajectories, while readily identifiable baseline characteristics were associated high-persistent symptoms. Future post-concussive clinical trials and practice improvement efforts could incorporate these observations.

ACKNOWLEDGMENTS

We thank Clinical Research Coordinators Tierra Gogue-Garcia, Emily Holderness, Lauren Fay, Moira O’Connor Lenth, Lauren Stanek, and Michelina Tarasyuk for collecting participant data. Previous Study Coordinator Teah Hoopes organized data collection and IRB protocols. Care Managers Rebecca Parrish, LMFT and Katelyn Payne, LICSW provided collaborative care and CBT to the intervention participants. We thank the adolescents and families who participated in this research. We also thank Drs. Chris Feudtner, Keith Yeates, and Waylon Howard who served on our Data and Safety Monitoring Board.

DATA AVAILABILITY STATEMENT

Deidentified individual participant data will not be made available.

DISCLOSURE STATEMENT

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the National Institute of Child Health and Human Development, Grant number [1R01HD090230-01]. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the National Institute of Child Health and Human Development.

Notes on contributors

Robert J. Hilt

Robert J. Hilt is a University of Washington Professor of Psychiatry and Behavioral Sciences and a Psychiatrist at Seattle Children’s Hospital. Dr. Hilt is the Program Director for the Partnership Access Line, a child mental health consultation service for primary care providers in Washington, Wyoming, and Alaska. He is also the Program Director for the Medicaid Medication Second Opinion Programs of Wyoming, Washington and Alaska, and Multidisciplinary Team Psychiatric Consult Service in Wyoming for children in foster care.

Carolyn A. McCarty

Carolyn A. McCarty is a Research Professor in the Division of General Pediatrics, Department of Pediatrics at the University of Washington and an Adjunct Research Professor in the Department of Psychology. Dr. McCarty’s research program is devoted to understanding and promoting behavioral health among adolescents.

Frederick P. Rivara

Frederick P. Rivara MD, MPH is the holder of the Seattle Children’s Guild Association Endowed Chair in Pediatrics, Vice chair and Professor of Pediatrics and adjunct Professor of Epidemiology at the University of Washington.

Jin Wang

Jin Wang is a Research Consultant at the Harborview Injury Prevention and Research Center and Department of Pediatrics at the University of Washington. She has extensive experience in leading advanced statistical analyses.

Lyscha A. Marcynyszyn

Lyscha A. Marcynyszyn is a Research Manager at Seattle Children’s Research Institute’s Center for Child Health, Behavior, and Development. Dr. Marcynyszyn also serves as an inaugural member of the Communication and Community Engagement Committee for Seattle Children’s Health Equity, Diversity, and Inclusion Council. Her research interests include program evaluation, social determinants of health, and translating results into policy and action.

Sara P. D. Chrisman

Sara P. D. Chrisman is a pediatrician, Adolescent Medicine specialist. Dr. Chrisman and Associate Professor of Pediatrics and Adolescent Medicine at the University of Washington with a particular interest in the relationship between chronic illness or injury and emotional health. Her research is focused on decreasing the public health impact of concussion through preventive strategies including education and legislation, and novel treatment approaches.

Ashleigh M. Johnson

Ashleigh M. Johnson is a post-doctoral fellow at Seattle Children’s Research Institute’s Center for Child Health, Behavior, and Development. Her research interests include health education and health promotion among youth, with a focus on physical activity and concussions in sports.

Douglas F. Zatzick

Douglas F. Zatzick is a Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington as well as a member of the Core Research Faculty at the Harborview Injury Prevention and Research Center. Dr. Zatzick’s research interests focus on pragmatically oriented clinical trials targeting PTSD and related comorbidities in populations who have experienced traumatic injuries.