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. Author manuscript; available in PMC: 2023 Sep 1.
Published in final edited form as: Pediatr Emerg Care. 2022 Mar 4;38(9):e1503–e1507. doi: 10.1097/PEC.0000000000002664

Assault-Related Concussion in a Pediatric Population

Margaret J Means *, Rachel K Myers †,‡,§,||, Christina L Master ‡,§,, Kristy B Arbogast †,‡,§, Joel A Fein †,‡,§,||, Daniel J Corwin †,‡,§
PMCID: PMC10062197  NIHMSID: NIHMS1880905  PMID: 36040470

Abstract

Objectives:

The aim of this study was to compare demographic characteristics, medical care, and outcomes among patients with assault-related concussion (ARC) versus sports and recreation–related concussion (SRC).

Methods:

We conducted a retrospective chart review of 124 patients (62 ARC, 62 SRC) aged 8 to 17 years presenting to the care network of a large tertiary care pediatric hospital between July 1, 2012, and June 30, 2014 with a concussion diagnosis at time of presentation. We abstracted patient demographics, initial medical care visit characteristics, and outcome data, and compared proportions using χ2 testing and Fisher exact test and medians using Wilcoxon rank sum test.

Results:

Patients with ARC were more likely to be Black, publicly insured, and present first for care to the emergency department. Significantly fewer patients with ARC received visio-vestibular testing at initial visit (27% vs 74%, P < 0.001). During recovery, the total number of reported physical, cognitive, emotional, and sleep symptoms did not differ between groups; however, more than twice as many patients with ARC reported decline in grades postinjury compared with patients with SRC (47% vs 20%, P = 0.012). There were trends toward prolonged symptom recovery and time to physician clearance for full return to activities among patients with ARC compared with SRC.

Conclusions:

This study highlights potential disparities in the initial evaluation and outcomes of pediatric concussion patients based on mechanism of injury. Patients with ARC were less likely to receive a concussion-specific diagnostic evaluation and reported a greater impact on educational outcomes, suggesting differences in concussion diagnosis and management among assault-injured patients. Further examination in larger populations with prospective studies is needed to address potential inequities in concussion care and outcomes among patients with ARC.

Keywords: concussion, assault-related concussion, mild traumatic brain injury, concussion mechanism

Traumatic brain injury (TBI) is a serious and growing public health concern, accounting for a substantial number of emergency department (ED) visits, hospitalizations, and deaths in the United States.1–3 Recorded incidence of TBI increased by 54% from 2006 to 2014 to a rate of 801.9 per 100,000 population, with children accounting for nearly 30% of cases.1

Concussion, a form of mild TBI, requires special attention among children and adolescents due to the possible impact on the developing brain. Much of the current research and policy efforts predominantly focus on concussions sustained in sports and recreation. However, studies suggest that up to 30% of pediatric concussions occur from mechanisms unrelated to sports and recreation, such as assaults, falls, and motor vehicle collisions.4 The incidence of concussion resulting from assault is similar to that of concussion from motor vehicle crashes, which have been found to have prolonged recovery compared with concussion from sports.5–7 Over 30% of pediatric concussion patients report persistent postconcussion symptoms greater than 28 days after injury.5 Factors other than mechanism of injury that are associated with prolonged symptom duration include history of prior concussion, psychiatric and neurological comorbidities, female sex, learning difficulties, initial vestibular and ocular motor impairments, and family or social stressors.8–11

Concussion from assault injury may be unique based on the factors that bring the patient to care, including the injury pattern, the setting of clinical care, and associated emotional and psychological factors that could influence physical recovery. However, it remains unknown how injury mechanism may contribute to differences in assessment, recovery timelines, and clinical outcomes among children and adolescents. The objective of this study was to compare demographic characteristics, medical care received, and functional outcomes, including school performance and time to symptom resolution, among patients with assault-related concussion (ARC) compared with sports and recreation–related concussion (SRC).

METHODS

Study Design and Patient Population

We conducted a retrospective cohort study using the patient sample described by Haarbauer-Krupa et al4 in their investigation of mechanism of injury of pediatric and adolescent concussion. This sample included 1625 patients aged 0 to 17 years who presented for care after head injury within a large tertiary care pediatric network (including the ED, urgent care, primary care, or specialty care center) with initial visit between July 1, 2012, and June 30, 2014. Included patients were those who received a concussion diagnosis at time of presentation as defined by International Classification of Diseases, Ninth Edition (ICD-9) diagnosis codes indicative of concussion (800.02, 800.09, 800.52, 800.59, 801.02, 801.09, 801.39, 801.52, 801.56, 801.59, 803.02, 803.52, 803.59, 804.02, 804.09, 804.52, 850, 850.0, 850.1, 850.10, 850.11, 850.5, 850.9).12 Exclusion criteria included accompanying moderate or severe TBI as defined by an attached ICD-9 code, including the following key phrases: neuroimaging with cerebral contusion, laceration, subarachnoid, subdural, epidural, other and unspecified intracranial hemorrhage, and moderate or prolonged loss of consciousness within 2 weeks of the initial concussion visit. We excluded patients with clinically important injuries to body regions other than the brain, identified with ICD-9 codes corresponding to other injuries on the same day as the initial concussion visit.12 We also excluded patients who were diagnosed with a subsequent concussion before full recovery. Mechanism of injury was coded as defined by Haarbauer-Krupa et al4; briefly, 2 trained data abstractors reviewed the electronic health record (EHR) describing a child’s activity at Means et al the time of injury and used a structured coding system to define SRC and other external causes of injury, including falls, motor vehicle collisions, being unintentionally struck by a person or object, bicycle-related, and assault.

For our study, we included patients aged 8 to 17 years from the described data set. This age range was chosen to differentiate victims of assault from younger victims of abusive head trauma. A total of 66 patients with ARC (not including those with both ARC and SRC) were identified from the original sample and included in the current study’s sample. Four patients from the ARC cohort met the exclusion criteria (reinjury before full recovery) and were excluded, leaving 62 patients in the ARC group. Sixty-two patients aged 8 to 17 years with SRC (based on reviewer chart abstraction and not including those with both SRC and ARC) were chosen at random from the 913 patients with SRC aged 8 to 17 years from the original sample to make the SRC cohort for this analysis (Fig. 1). This study was approved by our institutional review board.

FIGURE 1.

FIGURE 1.

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Methods: cohort selection.

Data Abstracted

The following had been previously abstracted by Haarbauer-Krupa et al4 for the initial cohort: patient demographics as recorded in EHR (including sex, age, ethnicity, race, insurance coverage), number of days from date of injury to date of first clinical visit within the health network, and injury mechanism. Using the cohort described previously, we abstracted the following additional data from the EHR: premorbid neuropsychiatric conditions as documented in either provider notes or the patients’ EHR problem list (including migraine, anxiety, and depression), initial medical care visit characteristics (including documentation of visio-vestibular testing), initial symptoms, symptoms at follow-up visits, time to symptom resolution, and number of symptoms asked and documented by the treating provider at each visit. Concussion symptoms were categorized based on the Postconcussion Symptom Scale,13,14 which includes the following: 10 physical symptoms, 4 cognitive symptoms, 4 emotional symptoms, and 4 sleep symptoms. We recorded the documentation of presence or absence of these 22 symptoms for each clinical visit. We also abstracted the following outcomes: documentation of self-reported effect of injury on grades, provision of school accommodations by the treating provider (eg, extra time on assignments, half days, tutoring), specialist referral (including neurology, neuropsychology, psychiatry, concussion program, sleep medicine), prescription of therapies (including vestibular or physical), number of follow-up visits, and time until provider-documented symptom resolution. Not all subjects had documentation of all outcome data; therefore, the degree of missingness was documented and compared between the ARC and SRC group. Data were stored and managed using Research Electronic Data Capture (REDCap) tools hosted at our institution.15

Statistical Analysis

We summarized standard descriptive statistics for categorical variables stratified by ARC and SRC groups. We formulated bivariate comparisons between the ARC and SRC groups using χ2 testing or Fisher exact test for proportions, applied Student t test for means, and Wilcoxon rank sum test for medians where appropriate. We conducted logistic regression to account for initial visit location when comparing rates of visio-vestibular testing. We conducted logistic regression to account for known factors associated with prolonged recovery (sex, prior concussion history, premorbid conditions, and initial symptom burden) when comparing percentage of patients with symptoms beyond 28 days. Time until symptom resolution was compared graphically between the cohorts using a Kaplan-Meier estimate. Analyses were conducted using Stata version 14.2 (College Station, TX).

RESULTS

Demographics

Demographic data are presented in Table 1. Patients with ARC were more likely to be Black (56% vs 6%, P < 0.001), publicly insured (37% vs 13%, P = 0.002), present initially to the ED (66% vs 29%, P < 0.001), and present sooner after injury (1 day [interquartile range (IQR), 0, 6] vs 3 days [IQR, 1, 6], P = 0.027) compared with patients with SRC. There were no significant differences in age, sex, history of concussion, or presence of premorbid conditions, including anxiety, depression, and migraines, between the 2 groups.

TABLE 1.

Demographics of Subjects With SRC Versus ARC

Demographic ARC (N = 62) SRC (N = 62) P
Age, median (IQR), y 14.3(12.2, 16.1) 13.6 (11.9, 15.2) 0.506
Male, n (%) 45 (73%) 37 (60%) 0.129
Race/ethnicity <0.001
 Non-Hispanic Black, n (%) 35 (56%) 4 (6%)
 Non-Hispanic White, n (%) 22 (35%) 49 (79%)
 Hispanic, n (%) 2 (3%) 4 (6%)
 Non-Hispanic other/multiple race/unknown, n (%) 3 (5%) 5 (8%)
Insurance 0.002
 Medicaid, n (%) 23 (37%) 8(13%)
 Private, n (%) 35 (56%) 52 (84%)
 Self-pay, n (%) 4 (6%) 2 (3%)
Initial visit location <0.001
 Emergency department/urgent care, n (%) 41 (66%) 18(29%)
 Primary care, n (%) 20 (32%) 42 (68%)
 Specialty clinic, n (%) 1 (2%) 2 (3%)
Days from injury to initial visit, median (IQR) 1 (0,6) 3(1,6) 0.027
History of concussion, n (%) 10(16%) 12(19%) 0.638
Premorbid conditions, n (%) 21 (34%) 12(19%) 0.067
 Depression 4 (6%) 0 (0%) 0.119
 Anxiety 4 (6%) 2 (3%) 0.680
 Migraine headaches 4 (6%) 3 (5%) 1.000
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Values in boldface are statistically significant.

Symptoms and Visio-Vestibular Testing

At initial visit, based on available documentation, patients with ARC reported fewer physical symptoms compared with patients with SRC (median 1 [IQR, 1, 2] vs median 2 [IQR, 1, 3], P = 0.049). We observed no differences in cognitive, emotional, or sleep symptoms documented at initial visit, and total symptom burden did not differ between groups at initial visit or across their recovery (Table 2). There was no significant difference in overall number of symptoms inquired about and documented at the initial visit between patients with ARC and patients with SRC (Table 2).

TABLE 2.

Comparison of Symptoms (Symptoms Inquired About and Documented at Initial Visit, Total Initial Symptom Burden, and Maximum Number of Symptoms Reported During Recovery) and VVE Testing Between SRC and ARC Groups

ARC SRC P
Total overall symptoms asked, median (IQR) 5 (4, 8) 6.5 (5, 9) 0.109
Total physical symptoms asked, median (IQR) 4 (3, 5) 4.5 (3, 6) 0.052
Total cognitive symptoms asked, median (IQR) 1(1,2) 1 (0, 2) 0.848
Total emotional symptoms asked, median (IQR) 0 (0, 1) 0 (0, 0) 0.338
Total sleep symptoms asked, median (IQR) 0(0,1) 1 (0,1) 0.142
Total overall symptoms documented at initial visit, median (IQR) 2(1,4) 3 (2, 5) 0.114
Total physical symptoms at initial visit, median (IQR) 1 (1, 2) 2(1,3) 0.049
Total cognitive symptoms at initial visit, median (IQR) 0(0,1) 0(0,1) 0.983
Total emotional symptoms at initial visit, median (IQR) 0 (0, 0) 0 (0, 0) 0.501
Total sleep symptoms at initial visit, median (IQR) 0(0,1) 0(0,1) 0.348
Total overall symptoms documented at any point during recovery, median (IQR) 5 (2,10) 6(4,11) 0.318
Total physical symptoms at any point, median (IQR) 3 (2,5) 4 (3, 6) 0.207
Total cognitive symptoms at any point, median (IQR) 1 (0, 2) 1 (0, 2) 0.779
Total emotional symptoms at any point, median (IQR) 0 (0, 1) 0 (0, 1) 0.064
Total sleep symptoms at any point, median (IQR) 0 (0, 2) 1 (0, 2) 0.348
VVE performed, n (%) 17 (27%) 46 (74%) <0.001
VVE abnormal (of total performed), n (%) 10 (59%) 33 (82%) 0.328
Total no. abnormal VVE elements, median (IQR) 0 (0, 0) 1 (0, 3) <0.001
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Values in boldface are statistically significant.

VVE, visio-vestibular examination.

Fewer patients with ARC received visio-vestibular testing at their initial visit compared with patients with SRC (27% vs 74%, P < 0.001; unadjusted odds ratio [OR], 0.13; 95% confidence interval [CI], 0.059–0.29; Table 2). After adjusting for location of initial presentation (eg, ED, primary care, etc), the OR for patients with ARC receiving visio-vestibular testing was 0.21 (95% CI, 0.085–0.52). We observed no difference in the rate of abnormal visio-vestibular testing results between the groups, but more patients in the SRC group had at least 1 documented abnormal vestibular element (Table 2).

Outcomes

More than twice as many patients with ARC reported a decline in grades compared with patients with SRC (47% vs 20%, P = 0.012). There were no significant differences in time to return to school, time to symptom resolution, or time to full physician clearance (Supplemental Digital Content Table, http://links.lww.com/PEC/A884). There was a significant difference in data completeness for time to return to school, which was documented for 36 patients with ARC (58%) and 48 patients with SRC (77%) ( P = 0.021). Time to symptom resolution was documented for 36 patients with ARC (58%) and 44 patients with SRC (71%) ( P = 0.28), and time to full physician clearance was documented for 29 patients with ARC (47%) and 37 patients with SRC (60%) ( P = 0.15). We found no difference in rate of prolonged concussion symptoms after adjusting for factors known to be associated with prolonged symptoms (sex, concussion history, history of depression, history of anxiety, history of migraine headaches, and initial symptom burden) (OR, 1.7; 95% CI, 0.7–4.6) (Supplemental Digital Content Table, http://links.lww.com/PEC/A884). Although not statistically significant, there were trends toward longer time to symptom resolution among patients with ARC with a subpopulation having a more protracted course (Fig. 2). We found no difference in median number of follow-up visits, days from injury until final follow-up visit, specialist referral, or prescription of physical/vestibular therapy by concussion mechanism (Supplemental Digital Content Table, http://links.lww.com/PEC/A884).

FIGURE 2.

FIGURE 2.

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Survival curve of days until symptom resolution comparing SRC to ARC (P = 0.212).

DISCUSSION

This study, comparing visit characteristics and outcomes of children with ARC and SRC, revealed key differences in the demographics, clinical evaluation, and outcomes of the 2 patient groups.

We observed significant differences in the demographics and presentation locations between the 2 groups of patients. Children who experienced an ARC were more likely to be Black, consistent with previous studies that have found that minority patients are overrepresented among those diagnosed with ARC.4,16,17 Patients with ARC were more likely to have public insurance, suggesting lower socioeconomic status. Patients with ARC were also more likely to present to the ED. Previous studies have identified suboptimal rates of concussion diagnosis in the ED, with 1 study noting a 40.4% diagnostic rate of concussion in a population where 89.5% of patients met the criteria for the diagnosis of concussion.18 These differences highlight that patients with ARC are a demographically unique population and different from patients with SRC.

Patients with ARC were less likely to receive concussion-specific diagnostic evaluation at their initial visit. Significantly fewer patients with ARC received visio-vestibular testing compared with patients with SRC, even after accounting for differences in the location of initial clinical presentation. This is consistent with previous research that noted lower rates of visio-vestibular testing performed on initial visit to EDs among concussion patients injured by a nonsports mechanism.19 Visio-vestibular screening is a valuable tool to accurately identify patients with concussion,20,21 particularly among patients presenting with minimal symptoms.19 Furthermore, balance, vestibular, and oculomotor deficits contribute to morbidity from concussion and are associated with longer recovery times, making this testing important for prognostication and treatment.9,22–26 The discrepancy in performance of this diagnostic tool among patients with ARC may have implications in prompt recognition of concussion and recovery outcomes in this population.

In addition to differences in initial presentation and diagnostic evaluation, we observed differences in outcomes between patients with ARC and SRC. Assault-injured patients were more than twice as likely to report a decline in grades. Our results suggest that patients with ARC may be at greater risk for adverse effects on education than their SRC counterparts. This difference existed despite minimal difference in symptom burden, suggesting other causative factors. Although not statistically significant, we observed trends toward longer time to symptom resolution among patients with ARC compared with patients with SRC. Despite minimal differences in overall number of symptoms, the severity or longevity of symptoms may be greater among patients with ARC. This could be due to differences in care that these patients received or could represent fundamental differences in the pathophysiology of injury among these patients that is not well represented by symptom assessment. It is possible that there are other unrecognized factors that contribute to a specific subset of patients with ARC who experience a prolonged course of recovery. Within our sample, fewer patients with ARC completed follow-up until return to school, which could affect outcomes observed within this group and warrants further study.

Future research must investigate the discrepancy in diagnosis, treatment, and recovery as it pertains to mechanism of injury. Individual psychosocial differences may increase the complexity of concussion recovery across groups of patients. For example, experiencing assault is associated with posttraumatic stress symptoms27 and assault-injured youth commonly identify mental health support as an important postinjury recovery need.28 These co-occurring mental health needs may complicate or otherwise prolong recovery among patients with ARC compared with SRC. Further, community-or system-level factors may also contribute to differences in recovery outcomes by mechanism of injury, such as differential access to or awareness of resources and care to promote recovery. Future prospective studies should examine the contributions of socioeconomic status, clinical setting of presentation, and mechanism of injury in the differences between these populations.

There were several limitations to our study. First, as a retrospective chart review, the abstraction of data relied on the accuracy and completeness of documentation that was originally recorded for purposes other than research. Second, our study was limited to the network of a large tertiary care academic institution in a large city, so our results may not be generalizable to all populations. In addition, we included all patients who presented to care at least one time, resulting in some patients who did not seek any follow-up care within our health care institution and for whom we have no longitudinal outcome data. Not all patients completed follow-up to symptom resolution, and there could be relevant differences among the children who did or did not complete follow-up. The study was performed on a relatively small sample size, and as such, nonsignificant trends that were noted could prove to be statistically significant with larger sample sizes.

This study was the first to compare presentation, diagnostic evaluation, and outcomes among pediatric patients with SRC versus ARC. Patients with ARC are demographically different, are less likely to receive concussion-specific diagnostic evaluation, and are more likely to report a greater decline in school grades after injury. Awareness of the disparities experienced by this population can inform initial evaluation and management of these patients to ensure prompt diagnosis and treatment to optimize outcomes. Prospective studies are needed to further explore the source of these disparities and to develop interventions to improve diagnosis and treatment to enhance recovery among youth with ARC. In addition, examining impacts of psychosocial stress from assault as they impact recovery could further our understanding of the complexities of this population and help inform care.

Supplementary Material

Supplemental Digital Content

Footnotes

Disclosure: The author declares no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.pec-online.com).

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