Concussions are a common injury among children and adolescents, with an estimated 1.1-1.9 million youth experiencing one annually. Recovery from a concussion typically occurs within a few weeks of injury. However, a subset of youth experience persistent post-concussive symptoms (PPCS) which have a significant impact on their physical and emotional well-being. Corinne Catarozoli, PhD, a pediatric psychologist at NewYork-Presbyterian and Weill Cornell Medicine and Co-Director of Behavioral Health Integration and Innovation within the Department of Pediatrics at Weill Cornell Medicine, is interested in the psychological impact PPCS has on youth.
“Concussion is a condition that has an interesting intersection of physical symptoms, cognitive symptoms, and psychological symptoms,” she says. “What we have found is that the psychological symptoms can really prolong recovery from concussion.”
Dr. Catarozoli recently collaborated on a paper published in Cognitive and Behavioral Practice examining PPCS and how cognitive-behavioral therapy (CBT), a widely used evidence-based therapeutic approach for many conditions, can be applied to youth with PPCS. “We’ve used CBT for a long time to treat anxiety in youth, depression in youth, and a whole host of mental health concerns,” she says. “But it’s not usually on the forefront of our mind when thinking about treating a medical issue like concussion. However, it’s extremely relevant and can be pretty easily adapted to target PPCS.”
We’ve used CBT for a long time to treat anxiety in youth, depression in youth, and a whole host of mental health concerns. But it’s not usually on the forefront of our mind when thinking about treating a medical issue like concussion. However, it’s extremely relevant and can be pretty easily adapted to target PPCS.
— Dr. Corinne Catarozoli
Applying CBT to PPCS
In the paper, Dr. Catarozoli and her colleagues highlight the benefits of CBT and the adaptations necessary to apply it in youth with PPCS and their families. CBT is often used for individuals who experience faulty or unhelpful ways of thinking, learned patterns of unhelpful behavior, and/or maladaptive coping strategies. Avoidance is a common behavior exhibited by youth with PPCS and can be targeted by CBT. “Kids are nervous to go back to school or sports, so they stay home and hang back and avoid for quite a long time,” Dr. Catarozoli says. “This exacerbates their symptoms. They start to become deconditioned. They start to become sensitive to somatic or physical sensations and get nervous anytime they experience any little ache or pain and worry that it means something is horribly wrong. It really fuels this pain-stress cycle and a pain-avoidance cycle.”
The typical course of CBT in an outpatient setting is around eight to 12 sessions. Dr. Catarozoli says that for PPCS, it’s more abbreviated. “In the context of concussion, we usually take three or four sessions to teach these basic skills, have some follow up and some troubleshooting,” she says. “Kids do quite well, even with this brief treatment model. And we’re seeing that when we’re targeting a specific condition, like concussion, a briefer treatment is more accessible to families, more palatable, and just as effective.”
In the context of concussion, we usually take three or four sessions to teach these basic skills, have some follow up and some troubleshooting. Kids do quite well, even with this brief treatment model. And we’re seeing that when we’re targeting a specific condition, like concussion, a briefer treatment is more accessible to families, more palatable, and just as effective.
— Dr. Corinne Catarozoli
To effectively apply CBT in the setting of PPCS, Dr. Catarozoli highlighted that adaptations need to be made to ensure the approach transfers well. The adaptation of CBT for PPCS outlined in the article involves a combination of family psychoeducation, relaxation skills, cognitive techniques, and behavioral interventions.
Psychoeducation
Psychoeducation is a cornerstone of CBT. Dr. Catarozoli says that PPCS psychoeducation starts with learning about the pain-stress connection. “Many aren’t aware of the role that anxiety plays in this and instead operate under a common medical frame of wait until you’re better to go back to your activities,” she says. “If a child has the flu, we say wait until you’re fever free for 24 hours to go back to school. However, following a concussion, while we want to see some clinical improvement before going back, we also don’t want them to wait too long. We want kids to start resuming their activities, to start going back to school, start gradually getting back into sports and socializing despite the pain. I sometimes say to families, ‘School is medicine. We can’t wait to feel better to go back to school. Going back to school is in fact what is going to make you feel better.’”
This can be a tough concept for kids and their parents to understand and embrace. “We do a lot of education around this and supporting parents in facilitating activity in school reentry,” says Dr. Catarozoli.”
Relaxation Techniques
Another cornerstone of CBT is the use of relaxation techniques, such as mindfulness, diaphragmatic breathing, progressive muscle relaxation, and guided imagery. “All these strategies help activate the parasympathetic nervous system response, the calming response or the brakes as I call it, versus the gas pedal,” says Dr. Catarozoli. “We know that these are good behavioral strategies that are helpful in managing anxiety and pain.”
Cognitive Techniques
The next CBT component for PPCS targets faulty thoughts, beliefs, and interpretations of concussion symptoms and recovery. “These typically target worries that children develop, such as ‘I have something wrong with my brain,’ ‘my brain’s never going to be normal again,’ ‘catching up on all this work is impossible,’ and ‘my concussion messed me up forever,’” says Dr. Catarozoli. “All these catastrophic thoughts about recovery we address the way we would with any other anxiety disorder. We teach the kids to check their thoughts, to challenge them, and to reframe them to be a little bit more rational, more logical, and more based on the facts.”
All these catastrophic thoughts about recovery we address the way we would with any other anxiety disorder. We teach the kids to check their thoughts, to challenge them, and to reframe them to be a little bit more rational, more logical, and more based on the facts.
— Dr. Corinne Catarozoli
Behavioral Interventions
A final component, and possibly the most impactful one, is behavioral interventions. Using an exposure therapy approach, Dr. Catarozoli works with the youth to create a hierarchy of tasks that would elicit anxiety, from the least to the most, and then do activities to expose themselves to the tasks. “We come up with graded tasks of gradual school reentry,” she says. “For example, going for one meeting with your guidance counselor, going in for two classes, for a half day, a half day plus lunch, and gradually working up to a full day. We also help them understand that they might develop symptoms or get a headache and that’s okay – their brain is not used to all this activity.”
This allows them to challenge their fears and gain some evidence and confidence that these kinds of activities aren’t dangerous or harmful.
— Dr. Corinne Catarozoli
Many of the children experience hypervigilance or fears around physical sensations. “It sounds crazy, but in the office we’ll actually have them hit their head on something and show them it’s okay, nothing bad happens,” says Dr. Catarozoli. “This allows them to challenge their fears and gain some evidence and confidence that these kinds of activities aren’t dangerous or harmful.”
The Role of Parents in Treatment
CBT for PPCS is successful when parents are fully participating in all the strategies. “Parents need to prompt their kids to practice their relaxation strategies, help them identify what sounds like a worry thought and how to restructure it,” says Dr. Catarozoli. “They certainly facilitate school resumption and getting back into other activities.”
Parents, understandably, want to support their children, but pushing them to be uncomfortable can be difficult. “We work with parents a lot on not accommodating, meaning not allowing a child to avoid getting back into these activities because of their fears,” she says. “We also support the parents and managing their own anxiety. If parents are anxious and nervous about their child going back to school or sports, the child is going to pick up on it. We want a parent to be giving a vote of confidence and that can take some coaching to help facilitate.”
Keys to Successful Adaptation
Adapting CBT for PPCS might seem difficult to some mental health providers who do not treat patients with concussions on a regular basis. However, Dr. Catarozoli asserts that they don’t need to have experience with a specific medical condition to use CBT to treat it; rather they should lean into their psychiatric training and use that to their advantage. “This is just adapting all of the core strategies you already know and deliver all the time for a slightly different treatment target,” she says. “I’m not a concussion expert. I’m a CBT expert and that’s what really makes you qualified to do this.”
Dr. Catarozoli also says that being flexible is key to the success of this intervention. “Working in a medical clinic, it’s fast-paced and appointments are briefer,” she says. “This is not your typical 45-minute session. It requires pivoting at times based on if somebody needs to go have an MRI or another procedure. Having a flexible mindset in how you adapt this treatment is critical.”
Embracing a Multidisciplinary Approach to Recovery
At NewYork-Presbyterian and Weill Cornell Medicine, pediatric psychologists are integrated across all medical subspecialty groups. “We’ve been integrated with neurology, so this means if a child comes in to see one of our neurologists for a concussion, they automatically have access to visits with a pediatric psychologist, and pediatric psychology is embedded into the team approach,” says Dr. Catarozoli.
Rather than having to refer a family out to a specialty psychology or psychiatry clinic where there’s limited capacity and it requires the family to go somewhere new, to go through a whole other intake process, they can be seen in the same place, oftentimes on the same day or even in the same visit as their physician in the concussion clinic. It’s a one-stop shop where we’re putting their mental health on par with their physical health.
— Dr. Corinne Catarozoli
This approach to integrated care removes some of the barriers that kids and their families might face when seeking psychiatric help separately. “It’s one of the best ways to reach patients,” she says. “Rather than having to refer a family out to a specialty psychology or psychiatry clinic where there’s limited capacity and it requires the family to go somewhere new, to go through a whole other intake process, they can be seen in the same place, oftentimes on the same day or even in the same visit as their physician in the concussion clinic. It’s a one-stop shop where we’re putting their mental health on par with their physical health.”
