CHOC Children’s Grand Rounds Video: Cognitive Side to Mental Health and the Psychology Behind Concussions

A concussion or mild traumatic brain injury is defined as a transient neurologic change resulting from a biomechanical impact to the head. Given this broad definition, it is not surprising that concussion represents the most common type of traumatic brain injury (TBI). Concussions can be complicated and multifaceted, as patients usually present with various combinations of neurologic, cognitive and psychiatric symptoms, Drs. Sharief Taraman and Jonathan Romain said in a recent grand rounds presentation at CHOC Children’s.

Adolescents represent a commonly seen subgroup within the concussion population, most notably because of their frequent involvement in sports and higher-risk activities. Additionally, when injuries do occur at the high school and college level, the impact velocities tend to be at a higher rate than is seen in younger athletes, potentially resulting in more pronounced concussions. Further complicating the situation is that adolescents tend to have busy schedules and multiple responsibilities throughout the school year (when most concussions occur). Thus, when a concussion is sustained, the student athlete not only needs to deal with the immediate symptoms of the injury, but also the potential for academic and social derailment during the recovery process. Combine these issues with a strong body of literature suggesting adolescents tend to have slower resolution than do adults, and you have the recipe for a very bumpy recovery.

The doctors explain that cognitive symptoms manifest as slower processing speed, feeling foggy, and occasional forgetting or transient confusion.  Psychiatric symptoms often include irritability, liability and sadness. A child may have one or many of these symptoms, although more often these symptoms overlap. The patient and their family may not recognize how persistent symptoms of headache and dizziness, for example, can contribute to memory problems and difficulty concentrating, irritability, and feelings of depression and hopelessness. Children with prolonged symptoms also can feel isolated from their peers while they are sitting out of play and school.

Learn more about CHOC’s Concussion Program.

View previous grand rounds videos.

Stroke in Pediatric Patients: Occurrence, Intervention and Beyond

By Dr. Sharief Taraman

Many might picture a stroke patient as middle aged or elderly, but

Dr. Sharief Taraman, CHOC Children's pediatric neurologist
Dr. Sharief Taraman, CHOC Children’s pediatric neurologist

the reality is that the ailment occurs across the lifespan.

A stroke affects one in every 3,500 live births and six to 13 per 100,000 children per year.  At CHOC Children’s, that translates to one or two patients per month outside the newborn period.

Among many risk factors, the largest for stroke in children include cardiac disease (19 percent); coagulation disorders (14 percent); and dehydration (11 percent). Multiple risk factors are present in up to 25 percent of pediatric stroke patients.

Atherosclerosis and modifiable risk factors that dominate adult stroke mechanism and treatment were nearly non-existent in pediatric stroke. However, in the past decade and a half, traditional cardiovascular risk factors for stroke in people ages 15 to 34 have been steadily increasing.

Placental diseases can cause perinatal arterial stroke, and perinatal stroke accounts for a large proportion of pediatric stroke morbidity. The first week of life carries the most risk for stroke and the majority of survivors have lifelong morbidity, most typically, hemiparetic cerebral palsy. Cognitive or behavioral disorders and epilepsy are also common.

Acute ischemic stroke (AIS) lesions are often multifocal, even in the absence of overt cardiac disease, which lends support to proximal embolic source. Many neonates with AIS have risk factors and presentations that overlap with hypoxic ischemic encephalopathy, and the two can co-occur.

Delayed diagnosis

Despite these occurrences and the inherent dangers, a lack of awareness prevails and diagnosis of childhood stroke is often significantly delayed. One study found up to a 28-hour delay in seeking medical attention from the onset of symptoms and a 7.2 hour delay after presentation before any brain imaging occurred (Lenn, et al, 2002).

Further complicating matters is that presentation can be subtle, varied and non-specific, and often occurs in the setting of a systemic illness. One study found the median time to diagnose AIS in neonates was 87.9 hours and 24.8 hours in children (Mackay, et al 2009). Another study saw that 19 of 45 children with a stroke did not receive a correct diagnosis until 15 hours after initial presentation, and in some cases, up to three months afterward (DeVeber, et all 2006).

Also, many other diseases mimic a stroke: A fifth of children presenting for evaluation of suspected acute stroke have a “stroke mimic,” rather than an actual stroke (Shelhaas, Pediatrics, 2006). Stroke mimics include migraines and delirium, as well as seizure and tumor.

Intervention

High-powered clinical trials that guide adult stroke management – including antiplatelet and anticoagulant strategies; chemical and mechanical thrombolysis; stroke unit care; and many others – do not yet exist for children.

Of 687 children enrolled in the International Pediatric Stroke Study (2011), 15 patients received tissue plasminogen activator (tPA): nine underwent intravenous tPA and six underwent intra-arterial tPA. The median time to treatment from onset was 3.3 hours for intravenous alteplase and 4.5 hours for intra-arterial alteplase.

Of those patients, four had intracranial hemorrhage (non-symptomatic); one died from brainstem stroke; one died from massive stroke with herniation; one was discharged without deficits; and 12 were discharged with neurological deficits.

Intravenous tissue plasminogen activator (tPA) needs more study for safety, dosing and efficacy before it can be fully applied to pediatric patients. Dosing in children cannot be extrapolated from adult data or existing pediatric data.

Limited pediatric safety and effectiveness data also exists around neurointerventional techniques like intra-arterial tPA and mechanical thromboectomy. Early intervention results in better outcomes, though success rates depend heavily on the operator’s experience.

Rehabilitation, recurrence

Similar to the adult stroke population, rehabilitation is multifaceted and comprises neuropsychology; developmental monitoring; educational intervention; and physical, occupational, and speech therapies. Most of the functional recovery occurs in the first two to three months. The quality of functional recovery is better in the pediatric population; however, the prognosis worsens as the lesion size increases.

The risk of recurrence following a stroke is up to 25 percent and highest in the first three months of onset. The lowest risk of recurrence is in perinatal and cryptogenic stroke.

Like any other condition, prevention of pediatric stroke is important and many patients will be placed on antiplatelet or anticoagulation. Interestingly, children with some, few or no vaccinations are shown to be at risk of stroke seven times higher than those who received all or most vaccinations.

CHOC has a collaborative team with protocols in place to recognize and treat pediatric stroke aggressively. Learn more about the CHOC Children’s Neuroscience Institute.

2015 CHOC Children’s – UC Irvine Child Health Research Awards

We are pleased to announce that we just completed another round of the CHOC Children’s – UC Irvine Child Health Research Awards, our annual call for proposals that enhance research collaborations between CHOC and UC Irvine and further the Mission, Vision and strategic aims of the CHOC-UCI Child Health Research Strategic Plan. Intended to support research and collaboration in targeted areas of research excellence that align research strengths for focused growth and maximal translational impact, our call this year specifically solicited applications for two funding mechanisms, Pilot Collaborative Research Awards and Clinician Investigator Awards.

Child Health Research Award - UC Irvine Infographic

Pilot Collaborative Research Awards are intended to provide funds for collaborative projects in need of initial start-up funding to enable procurement of other independent support. These awards are designed to promote novel, translational research efforts that coalesce talented clinicians and researchers from CHOC and UC Irvine. Projects bring investigators from multiple disciplines from CHOC and UC Irvine together to identify targets for improved diagnosis, prevention, or treatment of a pediatric health problem relevant to the goals of the CHOC-UCI Child Health Research Strategic Plan.

Clinician Investigator Awards are intended to provide funds for clinician-investigator initiated projects in need of funding to advance study into a clinically relevant and important topic that has a high likelihood of impacting clinical practice and the positive experience of pediatric/ adolescent patients and their families. Priorities are given to proposals that are closely aligned with the research themes identified in the CHOC – UCI Child Health Research Strategic Plan. Projects identify targets for improved diagnosis, prevention, or treatment of a pediatric health problem relevant to the goals of the CHOC-UCI Child Health Research Strategic Plan. Collaborations between CHOC and UCI faculty are strongly encouraged, but not required.

This year we received 18 proposals, an increase of 13% over last year, covering a wide range of topics and specialties. After external academic peer reviews and committee discussions, we decided to fund 6 projects, 3 Pilot Collaborative Research Awards and 3 Clinician Investigator Awards.

Congratulations to the well-deserving recipients of the 2015 awards! They are listed below, in order of award type and Principle Investigator’s last name.

 

Pilot Collaborative Research Awards.

Principal Investigator: Dr. Gurpreet Ahuja

Collaborators: Drs. Nguyen PhamKevin Huoh, Naveen Bhandarkar, Carolyn Coughlan, Joon You

Project Title: NIR Imaging of Pediatric Sinuses

 

Principal Investigator: Dr. Tami John

Collaborators: Drs. Lilibeth Torno, Daniela Bota, Grace Mucci, Mary Zupanc, Jack Lin

Project Title: Cognitive Training to Promote Neuroplasticity and Neural Re-circuitry in Chemotherapy

Associated Cognitive Impairment

 

Principal Investigator: Dr. Calvin Li

Collaborators: Drs. John Weiss, Hong Yin, William Loudon

Project Title: A Tunable Engineered Tissue Graft Model for Repair of Traumatic Brain Injury

 

Clinician Investigator Awards

Principal Investigator: Dr. Antonio Arrieta

Collaborators: Drs. Katrine Whiteson, David Michalik

Project Title: Addressing the Fear Factor in Neonatal Serious Bacterial Infections: Distinguishing E Coli From Bacteremia, Urinary Tract Infection, and Bacteremic Urinary Tract Infection in Infants <28 Days vs. >28 Days to 90 Days Old by Pairing E. Coli Genome Analysis with Clinical Data

 

Principal Investigator: Dr. Joanne Starr

Collaborators: Drs. Richard Gates, Sharief Taraman, Mary Zupanc, Paul Yost, Michele Domico, Juliette Hunt, Tammy Yoon, Kimberley Lakes

Project Title: Seizures and Neurodevelopmental Outcomes in Mild Hypothermic Cardiopulmonary Bypass

 

Principal Investigators: Dr. Sharief Taraman and Ruth McCarty

Collaborators: Drs. William Loudon, Frank Hsu

Project Title: The Use of Traditional Chinese Medicine (TCM) as a Complementary Treatment of Pediatric and Young Adults with Post-Concussive Syndrome

Mental Health Effects of Concussions on Adolescents and Teens

By Jonathan E. Roman, Ph.D. and Sharief Taraman, M.D.
Pediatric News

A concussion or mild traumatic brain injury is defined as a transient neurologic change resulting from a biomechanical impact to the head. Given this broad definition, it is not surprising that concussion represents the most common type of traumatic brain injury (TBI). Concussions can be complicated and multifaceted, as patients usually present with various combinations of neurologic, cognitive and psychiatric Concussion Effectssymptoms.

Fortunately, these injuries tend to have a more favorable outcome than do more severe brain injuries, with the vast majority of patients returning to usual functioning within days to weeks, with time and a guided return-to-activity plan. However, there is a subset of patients whose symptoms persist into what has been loosely defined as postconcussive syndrome. These individuals tend to be the greatest challenge for clinicians, and usually benefit from a multidisciplinary team approach, including neurologists, neuropsychologists, physical therapists, and speech pathologists.

Adolescents represent a commonly seen subgroup within the concussion population, most notably because of their frequent involvement in sports and higher-risk activities. Additionally, when injuries do occur at the high school and college level, the impact velocities tend to be at a higher rate than is seen in younger athletes, potentially resulting in more pronounced concussions. Further complicating the situation is that adolescents tend to have busy schedules and multiple responsibilities throughout the school year (when most concussions occur). Thus, when a concussion is sustained, the student athlete not only needs to deal with the immediate symptoms of the injury, but also the potential for academic and social derailment during the recovery process. Combine these issues with a strong body of literature suggesting adolescents tend to have slower resolution than do adults, and you have the recipe for a very bumpy recovery.

Neurologic symptoms usually present as headache, light and noise sensitivity, dizziness, and balance issues. Cognitive symptoms manifest as slower processing speed, feeling foggy, and occasional forgetting or transient confusion. Psychiatric symptoms often include irritability, lability and sadness. A child may have one or many of these symptoms, although more often these symptoms overlap. The patient and their family may not recognize how persistent symptoms of headache and dizziness, for example, can contributeConcussions Teens to memory problems and difficulty concentrating, irritability, and feelings of depression and hopelessness. Children with prolonged symptoms also can feel isolated from their peers while they are sitting out of play and school.

The treatment strategy for managing the emotional and mental health needs of the adolescent concussion patient is dictated by the underlying etiology. It is reasonable to suspect that irritability, a short fuse, and frequent crying during the first few days following injury are a direct result of neurologic disruption, which are not amenable to reason and behavioral interventions. In these cases, the best treatment is to educate the family that this is a transient neurologic state, while ensuring that the patient is protected from environmental stressors. One analogy that parents and patients find helpful is “weathering the storm,” and with time, these symptoms tend to abate. The key here is to normalize the recovery process and provide parents with a realistic recovery trajectory.

The more challenging patient is the child whose symptoms persist for weeks or develop over time, or, even more complicated, the child who had preexisting known or unknown mental health issues. A common theme in working with TBI patients is that brain injuries tend to exacerbate preexisting conditions. In these cases, good history taking is the foundation for good mental health management.

Key questions include: Is there a preexisting history of learning disability and/or attention-deficit/hyperactivity disorder (ADHD)? Are there preexisting or current family stressors? Has the child ever been in therapy before? How much school has the child missed? How has the school responded to the child missing tests and assignments? Is the child being pressured by teachers or coaches to return to activity? The answer to these and other questions will dictate how mental health issues should be addressed.

As a pediatrician, a release to talk with the school can clear up many of the return-to-activity stressors or may help to better understand the contribution of preexisting learning struggles or ADHD. Again, it is particularly important to have an awareness of premorbid history, as head injuries tend to exacerbate or accentuate preexisting symptoms. The full utility of the multidisciplinary team is accentuated in these situations, and a referral to a psychologist familiar with concussion is often the next step. Short-term medication management also may be considered, with additional referral to a psychiatrist for long-term management as necessary.Concussions Teens

Although fairly uncommon, the circumstances of a concussion can result in posttraumatic stress disorder (PTSD) or acute stress disorder, particularly when considering that concussions do not have to result in loss of consciousness during the event. It is important to at least screen for PTSD in situations in which there is the strong potential for this (in other words, an event that involved threatened death or serious injury to self or other, was the result of an assault, and resulted in intense fear or horror). Some symptoms to look for include intense psychological distress, recurrent distressing recollection, and frequent nightmares of the event, flashbacks, hypervigilance, and exaggerated startle response, and feelings of detachment from others. If these symptoms are present, a mental health evaluation and treatment would be the next logical step.

Concussion is a relatively common occurrence in adolescence and has received increased interest in recent years. It is important for pediatricians to be aware of the neurologic, cognitive, and psychiatric/emotional symptoms of concussion and how these symptoms often overlap. The management of mental health issues in concussion depends on the stage of recovery, the impact of the concussion on academic and social functions, whether preexisting issues exist, and the circumstances of the injury. In certain situations, mental health symptoms can be headed off in the pediatrician’s office, while more complicated and protracted recoveries necessitate a multidisciplinary team that includes mental health professionals.

Dr. Romain is a neuropsychologist at the Children’s Hospital of Orange County, Calif., and was the primary author of this commentary. He provides neuropsychological evaluations at the CHOC multidisciplinary concussion clinic. Dr. Taraman is a pediatric neurologist at the hospital. Dr. Romain and Dr. Taraman said they have no relevant financial disclosures.

Originally published on Sept. 3, 2014 in Pediatric News. Republished onto the CHOC Docs Blog with permission from Pediatric News.

Dr Mary Zupanc and Dr Sharief Taraman Talk About Infantile Spasms

Taraman and Zupanc

Dr. Mary Zupanc, chief of neurology and the director of CHOC’s comprehensive epilepsy program, and Dr. Sharief Taraman, who leads the CHOC Concussion Program, recently stopped by CHOC Radio to talk about an upcoming conference no pediatrician should miss.

From sleep disorders to epilepsy, there are a wide range of neurological conditions that can easily escape diagnosis by a general practitioner. Sadly, the delay in diagnosis and proper treatment can negatively impact a patient’s outcome.

Dr. Zupanc and Dr. Taraman share a recent case study involving infantile spasms. These can present in a subtle way and yet are very serious. Knowing what to ask parents and what to look for during an examination are key factors that can lead to the right diagnosis.

Listen in to this segment of CHOC Radio for more about this case and the conference, “Neurology Problems Pediatricians Shouldn’t Miss.”

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