Management of post-concussion emotional changes

Why do these changes happen?

In short, a concussion causes brain cells to be temporarily damaged.  Thankfully, these brain cells will heal!  Until they heal, communication between brain cells is more difficult.  This difficulty results in concussion symptoms because the brain is having to work harder, with injured connections and less energy, trying to perform its usual numerous actions.   This very helpful blog post explains exactly what happens in the brain that causes emotional changes: What happens to your brain?

How else could this symptom manifest?

• Cries more easily
• Short tempered
• Apathetic, like “like a bump on a log”
• Feeling overwhelmed
• More fidgety and distracted

Are there any helpful medications/supplements?

“Fortunately, your brain can repair and heal itself! It is valuable to remember that your brain can be retrained. Networks between neurons can be reshaped, rebuilt, and strengthened.”  With time, care, and occasionally with medications and natural health products, quality of life and symptoms will get better.  Though this list is not extensive, these are a few medications/supplements to discuss with your concussion provider that may be helpful for your child’s emotional changes:

• Omega-3’s (while not targeted to a specific symptom, helpful in overall concussion recovery)
• Multivitamin (If lacking a well-balanced diet, a daily multivitamin is important since good nutrition is essential for healing. Also, it’s important to have adequate Vitamin D levels at baseline as Vitamin D deficiency can lead to prolonged recovery - More info on Vitamin D. )
• Magnesium
• Antidepressant medications

The FDA does not regulate Natural Health Products (NHP’s) in the same way as prescription medications and therefore when choosing a NHP it is important to consider interactions with other NHP’s and medications, whether the product has undergone 3rd party testing (like that done by Consumer Lab), and the number of ingredients in each product.   The companies we typically trust, because they conduct 3rd party testing and have fewer added ingredients include:  Metagenics, Pure Encapsulations, Nordic Naturals, Barleans, Kirkland Signature, NatureMade, and Neurobiologix. 

What else can we do?

1. Encourage your child to listen to his/her body. If he/she is feeling very tired, taking breaks more often will be helpful.  Listening to his/her body, rather than “pushing through” an activity despite feeling more and more fatigued, will greatly help recovery.  An easy rule of thumb is not let their emotionality reach a number >5/10.  So, if for example they start their day rating their  feeling of being overwhelmed as a 2/10 and being in the school environment causes it to go up to a 4/10, it’s okay to keep pushing; however, if those symptoms reach a level 5 or greater, we recommend they stop and take a break. 
2. Feeling more emotional after a concussion can be both frustrating and worrisome, but it is very normal! Encouraging the child to talk about how he/she is feeling can be very helpful.  For the teen who just “doesn’t want to talk about it anymore!!,” you can post a symptom checklist somewhere in the home.  Ask them to complete it everyday and the parent can review the scores to watch for symptom improvement.  If symptoms seem to either not be improving, or worsening, establishing care with a counselor can often be very helpful.
3. Encouraging the child/teen to journal their feelings, though it sounds silly, is often really helpful. This is particularly helpful for worry and anxiety.  We explain it to them this way: “I want you to get a notepad and each night before bed set a timer for 5 minutes (or whatever duration they find helpful) and write down everything you are thinking and worrying about.  It doesn’t need to be in complete sentences and should be stream of consciousness.  I envision it sounding something like, “dinner tonight was gross… I can’t believe I did so bad on that chemistry test, why can’t I remember anything… what if I never get better…. I am so tired, but I can’t sleep… I want to be normal again,”  Then, when done with journaling, do whatever with the entry that makes you feel good.  If you are worried someone will read it, tear out the page and tear it up and throw it away.””  When emotions are high, sometimes we can really benefit from just getting the thoughts out of our brain, even momentarily. 
4. Exercise! To ask a student who regularly plays soccer for 1 hour/day 5 days a week to stop all exercise during concussion recovery is not helpful.  This does not mean he/she should continue to scrimmage or play in games, but continuing to do light, non-contact exercise, as long as it is not worsening symptoms, is helpful (when certain parameters have been met).  Exercise helps maintain the regular routine, keep him/her in shape for return to sports when well, improve mental health, and promotes good sleep.  
5. Stay connected with friends and teammates. Removing a child/teen from contact with their peers, when they already feel “not normal” due to their concussion, makes them feel even less “normal.”  Obviously, parents need to decide which activities seem reasonable – Having a friend over to hang out at his/her home would be better than meeting up at the movie theatre or shopping area.  Staying connected with friends and teammates helps promote mental health.
6. It’s very important to make sure they avoid alcohol and drugs. Often, the pleasure center of the brain can be affected in a concussion, and this puts kids at great risk of using and becoming addicted to substances.  And the impact of these substances can be as much as “5 times greater than what it would be to another kid,” which predisposes them to immediate addiction. “Most kids get into using those substances because it makes them feel good about themselves, and when you're not feeling good about yourself it seems pretty natural to head towards it.”
7. If symptoms of depression and/or anxiety become worse or debilitating, referral to a specialist to discuss medications can be helpful (psychiatry and/or neurology). This is usually not necessary, but when needed, we like to get the child support quickly. 
8. Though parents know our children so well, we can’t read their minds. To complicate things, their concussion symptoms are often not obvious us, unless they are specifically verbalized outload.  Because of this, it can be easy to doubt that they truly feel the symptoms they are reporting.  It is so important that we validate them, letting them know that that we believe them. Then, it is important to encourage them that these concussion symptoms will resolve and that they will return to normal.

Most children recover from a concussion in 3-4 weeks, and during that time, symptoms typically improve very gradually.  If this is not the observed trend, or symptoms are worsening, it is very important to talk to your concussion provider. 

References:  https://www.cdc.gov/traumaticbraininjury/pdf/pediatricmtbiguidelineeducationaltools/2018-mTBI_Recovery-508.pdf

https://www.brainline.org/video/emotional-and-behavioral-changes-children-after-brain-injury

https://www.concussionalliance.org/what-happens-to-your-brain