Hostname: page-component-cd9895bd7-dk4vv Total loading time: 0 Render date: 2024-12-23T00:34:56.888Z Has data issue: false hasContentIssue false
  • English
  • Français

Predictors of Post-concussive Symptoms in Young Children: Injury versus Non-injury Related Factors

Published online by Cambridge University Press:  13 September 2016

Coco O. Bernard ,
Jennie A. Ponsford ,
Audrey McKinlay ,
Dean McKenzie  and
David Krieser
Coco O. Bernard*
Affiliation:
School of Psychological Sciences, Monash University, Melbourne, Australia
Jennie A. Ponsford
Affiliation:
School of Psychological Sciences, Monash University, Melbourne, Australia
Audrey McKinlay
Affiliation:
Melbourne School of Psychological Sciences, The University of Melbourne, Australia
Dean McKenzie
Affiliation:
Epworth HealthCare and School of Public Health and Preventive Medicine, Melbourne, Australia
David Krieser
Affiliation:
Sunshine Hospital Emergency Department, Melbourne, Australia
*
Correspondence and reprint requests to: Coco O. Bernard, Doctorate of Clinical Neuropsychology (candidate), School of Psychological Sciences, Monash University, Clayton, Australia 3800. E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives: A notable minority of children will experience persistent post-concussive symptoms (PCS) following mild traumatic brain injury (mTBI), likely maintained by a combination of injury and non-injury related factors. Adopting a prospective longitudinal design, this study aimed to investigate the relative influence of child, family, and injury factors on both acute and persistent PCS in young children. Methods: Participants were 101 children aged 2–12 who presented to an Emergency Department, with either mTBI or minor bodily trauma (control). PCS were assessed at time of injury, 1 week, and 1, 2, and 3 months post-injury. Predictors included injury and demographic variables, premorbid child behavior, sleep hygiene, and parental stress. Random effects ordinal logistic regression models were used to analyze the relative influence of these predictors on PCS at early (acute – 1 week) and late (1–3 month) post-injury phases. Results: Presence of mTBI was a stronger predictor of PCS in the early [odds ratio (OR)=18.2] compared with late (OR=7.3) post-injury phase. Older age at injury and pre-existing learning difficulties were significant predictors of PCS beyond 1 month post-injury. Family factors, including higher levels of parental stress, higher socio-economic status, and being of Anglo-Saxon descent, consistently predicted greater PCS. Conclusions: Injury characteristics were significantly associated with PCS for 3 months following mTBI but the association weakened over time. On the other hand, pre-existing child and family factors displayed an increasingly strong association with PCS over time. Follow-up for these “at-risk” children which also addresses family stress may minimize longer-term complications. (JINS, 2016, 22, 793–803)

Keywords

Mild traumatic brain injuryConcussionPost concussive symptomsChildPredictorsChildPediatricBehavior
Type
Research Articles
Information
Journal of the International Neuropsychological Society , Volume 22 , Issue 8 , September 2016 , pp. 793 - 803
Copyright
Copyright © The International Neuropsychological Society 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

Abidin, R. (1983). Parental stress index (3rd ed.). Lutz, FL: Psychological Assessment Resources, Inc.Google Scholar
Anderson, V., Catroppa, C., Morse, S., Haritou, F., & Rosenfeld, J. (2001). Outcome from mild head injury in young children: A prospective study. Journal of Clinical and Experimental Neuropsychology, 23(6), 705–717. doi:10.1076/jcen.23.6.705.1015 Google Scholar
Anderson, V., Godfrey, C., Rosenfeld, J.V., & Catroppa, C. (2012). Predictors of cognitive function and recovery 10 years after traumatic brain injury in young children. Pediatrics, 129(2), e254–e261. doi:10.1542/peds.2011-0311 Google Scholar
Anderson, V., & Yeates, K. (1997). Pediatric Head Injury: Developmental Implications Introduction from the symposium organizers. Journal of the International Neuropsychological Society, 3(6), 553–554.Google Scholar
Araujo, G.C., Antonini, T.N., Monahan, K., Gelfius, C., Klamar, K., Potts, M., & Bodin, D. (2014). The relationship between suboptimal effort and post-concussion symptoms in children and adolescents with mild traumatic brain injury. The Clinical Neuropsychologist, 28(5), 786–801. doi:10.1080/13854046.2014.896415 Google Scholar
Ayr, L., Yeates, K., Taylor, H., & Browne, M. (2009). Dimensions of postconcussive symptoms in children with mild traumatic brain injuries. Journal of the International Neuropsychological Society, 15(1), 19–30. doi:10.1017/S1355617708090188 Google Scholar
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. Pediatrics, 167(2), 156–161. doi:10.1001/jamapediatrics.2013.434 Google Scholar
Babikian, T., McArthur, D., & Asarnow, R. (2013). Predictors of 1-month and 1-year neurocognitive functioning from the UCLA longitudinal mild, uncomplicated, pediatric traumatic brain injury study. Journal of the International Neuropsychological Society, 19(2), 145–154. doi:10.1017/S135561771200104X Google Scholar
Barlow, K., Crawford, S., Stevenson, A., Sandhu, S.S., Belanger, F., & Dewey, D. (2010). Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics, 126(2), 374–381. doi:10.1542/peds.2009-0925 Google Scholar
Bigler, E. (2008). Neuropsychology and clinical neuroscience of persistent post-concussive syndrome. Journal of the International Neuropsychological Society, 14(1), 1–22. doi:10.1017/s135561770808017x Google Scholar
Bracken, B., & Keith, L. (2004). Clinical assessment of behaviour. Lutz, FL: Psychological Assessment Resources, Inc.Google Scholar
Brooks, B.L., Kadoura, B., Turley, B., Crawford, S., Mikrogianakis, A., & Barlow, K.M. (2014). Perception of recovery after pediatric mild traumatic brain injury is influenced by the “good old days” bias: Tangible implications for clinical practice and outcomes research. Archives of Clinical Neuropsychology, 29(2), 186–193. doi:10.1093/arclin/act083 Google Scholar
Carroll, L., Cassidy, J., Holm, L., Kraus, J., & Coronado, V. (2004). Methodological issues and research recommendations for mild traumatic brain injury: The WHO Collaborating Centre Task Force on mild traumatic brain injury. Journal of Rehabilitation Medicine, 43, 113–125. doi:10.1080/16501960410023877 Google Scholar
Carroll, L., Cassidy, J., Peloso, P., Borg, J., von Holst, H., Holm, L., & Pepin, M. (2004). Prognosis for mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on mild traumatic brain injury. Journal of Rehabilitation Medicine, 43(Suppl), 84–105.Google Scholar
Chan, L.G., & Feinstein, A. (2015). Persistent sleep disturbances independently predict poorer functional and social outcomes 1 year after mild traumatic brain injury. Journal of Head Trauma Rehabilitation November/December, 30(6), E67–E75.Google Scholar
Connery, A.K., Peterson, R.L., Baker, D.A., & Kirkwood, M.W. (2016). The impact of pediatric neuropsychological consultation in mild traumatic brain injury: A model for providing feedback after invalid performance. The Clinical Neuropsychologist, 30, 579–598. doi:10.1080/13854046.2016.1177596 Google Scholar
Cronbach, L. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16(3), 297–334.Google Scholar
Crowe, L., Catroppa, C., Babl, F.E., Rosenfeld, J., & Anderson, V. (2012). Timing of traumatic brain injury in childhood and intellectual outcomes. Journal of Pediatric Psychology, 37(7), 745–754. doi:10.1093/jpepsy/jss070 Google Scholar
Gagnon, I., Swaine, B.R., Friedman, D., & Forget, R. (2005). Exploring children’s self-efficacy related to physical activity performance after a mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 20, 436–449.Google Scholar
Ganesalingam, K., Yeates, K.O., Ginn, M.S., Taylor, H., Dietrich, A., Nuss, K., & Wright, M. (2008). Family burden and parental distress following mild traumatic brain injury in children and its relationship to post-concussive symptoms. Journal of Pediatric Psychology, 33(6), 621–629. doi:10.1093/jpepsy/jsm133 Google Scholar
Gibbons, R.D., Hedeker, D., Elkin, I., Waternaux, C., Kraemer, H.C., Greenhouse, J.B., & Watkins, J.T. (1993). Some conceptual and statistical issues in analysis of longitudinal psychiatric data: Application to the nimh treatment of depression collaborative research program dataset. Archives of General Psychiatry, 50(9), 739–750. doi:10.1001/archpsyc.1993.01820210073009 Google Scholar
Gioia, G., Collins, M., & Isquith, P.K. (2008). Improving identification and diagnosis of mild traumatic brain injury with evidence: Psychometric support for the acute concussion evaluation. The Journal of Head Trauma Rehabilitation, 23(4), 230–242. doi:10.1097/01.HTR.0000327255.38881.ca Google Scholar
Gioia, G., Schneider, J., Vaughan, C., & Isquith, P. (2009). Which symptom assessments and approaches are uniquely appropriate for paediatric concussion? British Journal of Sports Medicine, 43(Suppl. 1), i13–i22. doi:10.1136/bjsm.2009.058255.Google Scholar
Giza, C.C., & Hovda, D.A. (2001). The neurometabolic cascade of concussion. Journal of Athletic Training (National Athletic Trainers’ Association), 36(3), 228–235.Google Scholar
Giza, C.C., & Hovda, D.A. (2014). The new neurometabolic cascade of concussion. Neurosurgery, 75(Suppl. 4), S24–S33. doi:10.1227/NEU.0000000000000505 Google Scholar
Goodlin-Jones, B., Sitnick, S., Tang, K., Liu, J., & Anders, T. (2008). The children’s sleep habits questionnaire in toddlers and preschool children. Journal of Developmental and Behavioral Pediatrics, 29(2), 82–88. doi:10.1097/DBP.0b013e318163c39a Google Scholar
Gronwall, D., Wrightson, P., & McGinn, V. (1997). Effect of mild head injury during the preschool years. Journal of the International Neuropsychological Society, 3(6), 592–597.CrossRefGoogle ScholarPubMed
Grubenhoff, J.A., Currie, D., Comstock, R.D., Juarez-Colunga, E., Bajaj, L., & Kirkwood, M.W. (2016). Psychological factors associated with delayed symptom resolution in children with concussion. The Journal of Pediatrics, 174, 27–32. doi:10.1016/j.jpeds.2016.03.027 Google Scholar
Guo, S., & Fraser, M.W. (2015). Propensity score analysis: Statistical methods and applications (2nd ed.). Thousand Oaks, CA: Sage.Google Scholar
Hajek, C.A., Yeates, K.O., Taylor, H., Bangert, B., Dietrich, A., Nuss, K.E., & Wright, M. (2011). Agreement between parents and children on ratings of post-concussive symptoms following mild traumatic brain injury. Child Neuropsychology, 17(1), 17–33. doi:10.1080/09297049.2010.495058 Google Scholar
Hosmer, D., Lemeshow, S., & Sturdivant, R. (2013). Applied logistic regression (3rd ed.). Hoboken, NJ: Wiley.Google Scholar
Keenan, H., Runyan, D., & Nocera, M. (2006). Longitudinal follow-up of families and young children with traumatic brain injury. Pediatrics, 117(4), 1291–1297. doi:10.1542/peds.2005-1883 Google Scholar
Kirkwood, M., Peterson, R.L., Connery, A.K., Baker, D.A., & Grubenhoff, J. (2014). Postconcussive symptom exaggeration after pediatric mild traumatic brain injury. Pediatrics, 133(4), 643–650. doi:10.1542/peds.2013-3195 Google Scholar
Kirkwood, M., Yeates, K., Taylor, H., Randolph, C., McCrea, M., & Anderson, V. (2008). Management of pediatric mild traumatic brain injury: A neuropsychological review from injury through recovery. The Clinical Neuropsychologist, 22(5), 769–800. doi:10.1080/13854040701543700 CrossRefGoogle ScholarPubMed
Koepsell, T.D., Rivara, F.P., Vavilala, M.S., Wang, J., Temkin, N., Jaffe, K.M., & Durbin, D.R. (2011). Incidence and descriptive epidemiologic features of traumatic brain injury in King County, Washington. Pediatrics, 128(5), 946–954. doi:10.1542/peds.2010-2259 Google Scholar
Kolb, B. (1999). Synaptic plasticity and the organization of behaviour after early and late brain injury. Canadian Journal of Experimental Psychology, 53(1), 62–76. doi:10.1037/h0087300 Google Scholar
Kolb, B., & Teskey, G. (2012). Age, experience, injury, and the changing brain. Developmental Psychobiology, 54(3), 311–325. doi:10.1002/dev.20515 Google Scholar
Kraus, J., Hsu, P., Schaffer, K., Vaca, F., Ayers, K., Kennedy, F., & Afifi, A.A. (2009). Preinjury factors and 3-month outcomes following emergency department diagnosis of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 24(5), 344–354.CrossRefGoogle ScholarPubMed
Lloyd, J., Wilson, M.L., Tenovuo, O., & Saarijarvi, S. (2015). Outcomes from mild and moderate traumatic brain injuries among children and adolescents: A systematic review of studies from 2008-2013. Brain Injury, 29(5), 539–549. doi:10.3109/02699052.2014.1002003 Google Scholar
MacFarlane, M.P., & Glenn, T.C. (2015). Neurochemical cascade of concussion. Brain Injury, 29(2), 139–153. doi:10.3109/02699052.2014.965208 Google Scholar
McKinlay, A., Dalrymple-Alford, J., Norwood, L., & Fergusson, D. (2002). Long term psychosocial outcomes after mild head injury in early childhood. Journal of Neurology, Neurosurgery, & Psychiatry, 73(3), 281–288. doi:10.1136/jnnp.73.3.281 Google Scholar
McKinlay, A., Ligteringen, V., & Than, M. (2014). A comparison of concussive symptoms reported by parents for preschool versus school-aged children. The Journal of Head Trauma Rehabilitation, 29(3), 233–238. doi:10.1097/HTR.0b013e3182a2dd7f Google Scholar
McNally, K.A., Bangert, B., Dietrich, A., Nuss, K., Rusin, J., Wright, M., & Yeates, K.O. (2013). Injury versus noninjury factors as predictors of postconcussive symptoms following mild traumatic brain injury in children. Neuropsychology, 27(1), 1–12. doi:10.1037/a0031370 CrossRefGoogle ScholarPubMed
Melo, J.R.T., Lemos-Junior, L.P., Reis, R.C., Araujo, A.O., Menezes, C.W., Santos, G.P., & Oliveira-Filho, J. (2010). Do children with Glasgow 13/14 could be identified as mild traumatic brain injury? Arquivos de Neuro-Psiquiatria, 68(3), 381–384. doi:10.1590/S0004-282X2010000300010 CrossRefGoogle ScholarPubMed
Mittenberg, W., Wittner, M.S., & Miller, L.J. (1997). Postconcussion syndrome occurs in children. Neuropsychology, 11(3), 447–452.Google Scholar
Nelson, L.D., Tarima, S., LaRoche, A.A., Hammeke, T.A., Barr, W.B., Guskiewicz, K., & McCrea, M.A. (2016). Preinjury somatization symptoms contribute to clinical recovery after sport-related concussion. Neurology, 86(20), 1856–1863. doi:10.1212/wnl.0000000000002679 Google Scholar
Oddy, M. (1993). Head injury during childhood. Neuropsychological Rehabilitation, 3(4), 301–320. doi:10.1080/09602019308401444 Google Scholar
Olsson, K.A., Lloyd, O.T., LeBrocque, R.M., McKinlay, L., Anderson, V.A., & Kenardy, J.A. (2013). Predictors of child post-concussion symptoms at 6 and 18 months following mild traumatic brain injury. Brain Injury, 27(2), 145–157. doi:10.3109/02699052.2012.729286 Google Scholar
Osberg, J.S., Baker, S.P., & Long, W. (1996). Pediatric trauma: Impact on work and family finances. Pediatrics, 98(5), 890–897.CrossRefGoogle ScholarPubMed
Owens, J.A., Spirito, A., & McGuinn, M. (2000). The Children’s Sleep Habits Questionnaire (CSHQ): Psychometric properties of a survey instrument for school-aged children. Sleep: Journal of Sleep and Sleep Disorders Research, 23(8), 1–9.Google Scholar
Ponsford, J., Cameron, P., Fitzgerald, M., Grant, M., Mikocka-Walus, A., & Schonberger, M. (2012). Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. Neuropsychology, 26(3), 304–313. doi:10.1037/a0027888 Google Scholar
Ponsford, J., Willmott, C., Rothwell, A., Cameron, P., Ayton, G., Nelms, R., & Ng, K. (1999). Cognitive and behavioral outcome following mild traumatic head injury in children. Journal of Head Trauma Rehabilitation, 14, 360–372.Google Scholar
Prigatano, G., & Gray, J. (2007). Parental concerns and distress after paediatric traumatic brain injury: A qualitative study. Brain Injury, 21(7), 721–729. doi:10.1080/02699050701481605 Google Scholar
Rivara, J., Jaffe, K., Polissar, N., Fay, G., Liao, S., & Martin, K. (1996). Predictors of family functioning and change 3 years after traumatic brain injury in children. Archives of Physical Medicine and Rehabilitation, 77(8), 754–764. doi:10.1016/s0003-9993(96)90253-1 Google Scholar
Sady, M.D., Vaughan, C.G., & Gioia, G.A. (2014). Psychometric characteristics of the Postconcussion Symptom Inventory in children and adolescents. Archives of Clinical Neuropsychology, 29(4), 348–363. doi:10.1093/arclin/acu014 Google Scholar
Saltapidas, H., & Ponsford, J. (2007). The influence of cultural background on motivation for and participation in rehabilitation and outcome following traumatic brain injury. The Journal of Head Trauma Rehabilitation, 22(2), 132–139. doi:10.1097/01.HTR.0000265101.75177.8d Google Scholar
Satz, P. (1993). Brain reserve capacity on symptom onset after brain injury: A formulation and review of evidence for threshold theory. Neuropsychology, 7(3), 273–295. doi:10.1037/0894-4105.7.3.273 Google Scholar
Satz, P., Zaucha, K., McCleary, C., Light, R., Asarnow, R., & Becker, D. (1997). Mild head injury in children and adolescents: A review of studies (1970-1995). Psychological Bulletin, 122, 107–131.CrossRefGoogle ScholarPubMed
Scott, C., McKinlay, A., McLellan, T., Britt, E., Grace, R., & MacFarlane, M. (2015). A comparison of adult outcomes for males compared to females following pediatric traumatic brain injury. Neuropsychology, 29(4), 501–508. doi:10.1037/neu0000074 Google Scholar
Shores, E., Lammel, A., Hullick, C., Sheedy, J., Flynn, M., Levick, W., & Batchelor, J. (2008). The diagnostic accuracy of the Revised Westmead PTA Scale as an adjunct to the Glasgow Coma Scale in the early identification of cognitive impairment in patients with mild traumatic brain injury. Journal of Neurology, Neurosurgery, & Psychiatry, 79(10), 1100–1106. doi:10.1136/jnnp.2007.132571 CrossRefGoogle Scholar
Stavinoha, P., Butcher, B., & Spurgin, A. (2012). Premorbid functional considerations in pediatric concussion. In J.N. Apps & K.D. Walter (Eds.), Paediatrics and adolescent concussion: Diagnosis, management and outcomes (pp. 135–149). New York: Springer Science+Business Media.Google Scholar
Tabachnick, B.G., & Fidell, L.S. (2013). Using multivariate statistics (6th ed.). Boston, MA: Allyn & Bacon/Pearson Education.Google Scholar
Taylor, H., & Alden, J. (1997). Age-related differences in outcomes following childhood brain insults: An introduction and overview. Journal of the International Neuropsychological Society, 3(6), 555–567. doi:10.1017/S1355617797005559 Google Scholar
Taylor, H., Dietrich, A., Nuss, K., Wright, M., Rusin, J., Bangert, B., & Yeates, K. (2010). Post-concussive symptoms in children with mild traumatic brain injury. Neuropsychology, 24(2), 148–159. doi:10.1037/a0018112 Google Scholar
Taylor, H., Drotar, D., Wade, S., Yeates, K., Stancin, T., & Klein, S. (1995). Recovery from traumatic brain injury in children: The importance of the family. Traumatic head injury in children (pp. 188–216). New York, NY: Oxford University Press.Google Scholar
Taylor, H., Yeates, K., Wade, S., Drotar, D., Stancin, T., & Burant, C. (2001). Bidirectional child-family influences on outcomes of traumatic brain injury in children. Journal of the International Neuropsychological Society, 7(6), 755–767. doi:10.1017/S1355617701766118 Google Scholar
Theadom, A., Cropley, M., Parmar, P., Barker-Collo, S., Starkey, N., Jones, K., & Feigin, V.L. (2015). Sleep difficulties one year following mild traumatic brain injury in a population-based study. Sleep Medicine, 16(8), 926–932. doi:10.1016/j.sleep.2015.04.013 Google Scholar
Wade, S., Cassedy, A., Walz, N., Taylor, H., Stancin, T., & Yeates, K. (2011). The relationship of parental warm responsiveness and negativity to emerging behavior problems following traumatic brain injury in young children. Developmental Psychology, 47(1), 119–133. doi:10.1037/a0021028 Google Scholar
Wade, S., Taylor, H., Yeates, K., Drotar, D., Stancin, T., Minich, N., & Schluchter, M. (2006). Long-term parental and family adaptation following pediatric brain injury. Journal of Pediatric Psychology, 31(10), 1072–1083. doi:10.1093/jpepsy/jsj077 Google Scholar
Whelan-Goodinson, R., Ponsford, J.L., Schonberger, M., & Johnston, L. (2010). Predictors of psychiatric disorders following traumatic brain injury. The Journal of Head Trauma Rehabilitation, 25(5), 320–329. doi:10.1097/HTR.0b013e3181c8f8e7 Google Scholar
Wilde, E., McCauley, S., Hunter, J., Bigler, E., Chu, Z., Wang, Z., & Levin, H. (2008). Diffusion tensor imaging of acute mild traumatic brain injury in adolescents. Neurology, 70(12), 948–955. doi:10.1212/01.wnl.0000305961.68029.54 Google Scholar
Winkler, R., & Taylor, N. (2015). Do children and adolescents with mild traumatic brain injury and persistent symptoms benefit from treatment? A systematic review. Journal of Head Trauma Rehabilitation, 30(5), 324–333. doi:10.1097/HTR.0000000000000114 Google Scholar
Woodrome, S.E., Yeates, K.O., Taylor, H., Rusin, J., Bangert, B., Dietrich, A., & Wright, M. (2011). Coping strategies as a predictor of post-concussive symptoms in children with mild traumatic brain injury versus mild orthopedic injury. Journal of the International Neuropsychological Society, 17(2), 317–326. doi:10.1017/S1355617710001700 Google Scholar
Yeates, K., Taylor, H., Rusin, J., Bangert, B., Dietrich, A., Nuss, K., & Wright, M. (2012). Premorbid child and family functioning as predictors of post-concussive symptoms in children with mild traumatic brain injuries. International Journal of Developmental Neuroscience, 30(3), 231–237. doi:10.1016/j.ijdevneu.2011.05.008 Google Scholar
Yeates, K., Taylor, H., Walz, N., Stancin, T., & Wade, S. (2010). The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children. Neuropsychology, 24(3), 345–356. doi:10.1037/a0018387 Google Scholar
Yeates, K., Taylor, H., Woodrome, S., Wade, S.L., Stancin, T., & Drotar, D. (2002). Race as a moderator of parent and family outcomes following pediatric traumatic brain injury. Journal of Pediatric Psychology, 27(4), 393–403. doi:10.1093/jpepsy/27.4.393 Google Scholar
Yeates, K.O., Taylor, H.G., Barry, C.T., Drotar, D., Wade, S.L., & Stancin, T. (2001). Neurobehavioral symptoms in childhood closed-head injuries: Changes in prevalence and correlates during the first year postinjury. Journal of Pediatric Psychology, 26(2), 79–91. doi:10.1093/jpepsy/26.2.79 CrossRefGoogle ScholarPubMed
Zemek, R., Barrowman, N., Freedman, S.B., Gravel, J., Gagnon, I., McGahern, C., & Osmond, M.H. (2016). Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. Journal of the American Medical Association, 315(10), 1014–1025. doi:10.1001/jama.2016.1203 Google Scholar
Zemek, R., Farion, K.J., Sampson, M., & McGahern, C. (2016). Prognosticators of persistent symptoms following pediatric concussion. JAMA Pediatrics, 167(3), 259–265. doi:0.1001/2013.jamapediatrics.216 Google Scholar