Article Text

Mental health after paediatric concussion: a systematic review and meta-analysis
  1. Alice Gornall1,2,
  2. Michael Takagi1,2,3,
  3. Thilanka Morawakage2,
  4. Xiaomin Liu2,
  5. Vicki Anderson2,3,4
  1. 1 Psychological Sciences, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
  2. 2 Brain and Mind Research, Clinical Sciences Theme, Murdoch Children's Research Institute, Parkville, Victoria, Australia
  3. 3 Psychology, The University of Melbourne, Melbourne School of Psychological Sciences, Melbourne, Victoria, Australia
  4. 4 Psychology Service, The Royal Children’s Hospital, Mebourne, Victoria, Australia
  1. Correspondence to Professor Vicki Anderson, Brain and Mind Research, Murdoch Children's Research Institute Clinical Sciences Theme, Parkville, VIC 3052, Australia; vicki.anderson{at}


Objective This systematic review and meta-analysis sought to rigorously examine mental health outcomes following paediatric concussion. To date, heterogeneous findings and methodologies have limited clinicians’ and researchers’ ability to meaningfully synthesise existing literature. In this context, there is a need to clarify mental health outcomes in a homogeneous sample, controlling for key methodological differences and applying a consistent definition of concussion across studies.

Design Systematic review and meta-analysis.

Data sources We searched Medline, Embase, PsycINFO, CINAHL, SportDiscus, Scopus and PubMed.

Eligibility Peer-reviewed studies published between 1980 and June 2020 that prospectively examined mental health outcomes after paediatric concussion, defined as per the Berlin Consensus Statement on Concussion in Sport.

Results Sixty-nine articles characterising 60 unique samples met inclusion criteria, representing 89 114 children with concussion. Forty articles (33 studies) contributed to a random effects meta-analysis of internalising (withdrawal, anxiety, depression, post-traumatic stress), externalising (conduct problems, aggression, attention, hyperactivity) and total mental health difficulties across three time points post-injury (acute, persisting and chronic). Overall, children with concussion (n=6819) experienced significantly higher levels of internalising (g=0.41–0.46), externalising (g=0.25–0.46) and overall mental health difficulties compared with controls (g=0.18–0.49; n=56 271), with effects decreasing over time.

Summary/conclusions Our review highlights that mental health is central to concussion recovery. Assessment, prevention and intervention of mental health status should be integrated into standard follow-up procedures. Further research is needed to clarify the mechanisms underlying observed relationships between mental health, post-concussion symptoms and other psychosocial factors. Results suggest that concussion may both precipitate and exacerbate mental health difficulties, thus impacting delayed recovery and psychosocial outcomes.

  • concussion
  • psychology
  • meta-analysis
  • sports medicine
  • paediatrics

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  • Twitter @VickiAn28323584

  • Contributors AG designed the search strategy, conducted the systematic searches, completed title, abstract and full-text screening, completed quality analysis, conducted meta-analyses and qualitative synthesis, and drafted the manuscript. TM co-screened title and abstracts for this review. XL co-conducted the full-text review. MT completed quality analysis consensus and critically revised the manuscript for important intellectual content. VA contributed to the conception of this study and critically revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Funding This research was supported by the Victorian Government Operational Infrastructure Scheme. MT is funded by a research grant from the Royal Children’s Hospital Foundation. VA is funded by an Australian National Health and Medical Research Council Senior Practitioner Fellowship. This research was conducted as part of AG’s PhD research which is supported by the Australian Government Research Training Scheme.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.