Some children and adolescents who continue to report symptoms weeks and months after suffering a concussion may be exaggerating or feigning symptoms in order to get out of schoolwork or sports or for other reasons unrelated to their injury, says a new study in the journal Pediatrics.
Asked to take a computerized test designed to evaluate response validity and complete a graded symptom scale, 23 out of 191 patients aged 8 to 17 years seen for neuropsychological evaluation after mild traumatic brain injury (mTBI) failed the validity test, and those that did self-reported significantly more postconcussive symptoms than those that passed. The results were comparable to those seen in adult studies.
Based on data explored in a previous study (Kirkwood MW, et al, 2010) neuropsychologists attributed the children's failure on the validity test to a desire to get out of schoolwork or sports, to direct psychological factors (e.g. somatization - the tendency to experience and communicate psychological distress in the form of physical symptoms), or to indirect causes (e.g. depression leading to a "plea for help").
Lead author Michael Kirkwood, a neuropsychololgist in the concussion program at Children's Hospital Colorado, said that the study's findings further complicate management of mTBI in youth by pediatricians and other primary care providers, many of whom already feel they lack the training or tools to adequately care for such patients, because they "do not routinely use objective methodology to detect" children exaggerating or feigning some of their symptoms.
Kirkwood worries that if such exaggeration or feigning goes undetected, "less than optimal treatment recommendations may occur." For instance, he writes, "if a child exaggerates memory problems after mTBI because of anxiety-related issues and such exaggeration remains undetected, then health care personnel might assume the injury reflects more severe neurologic injury and make statements to this effect to the family and unnecessary recommendations for cognitive rehabilitation or academic remediation, which could [cause unnecessary harm]."
"In contrast, if the exaggeration is detected, reasurrance from a brain injury perspective and treatments that are targeted at the true underlying [cause of injury](e.g. cognitive behavioral anxiety intervention) can follow, which in turn are apt to minimize inefficient use of limited health care resources and improve the child's long-term health," Kirkwood says.
Neuropsychologists: "uniquely positioned"
The study, Kirkwood said, also serves to highlight the "importance of incorporating clinical neuropsychologists into mTBI patient care, particularly when symptoms or functional complaints persist beyond the first days to weeks post-injury, when most children would be expected to have recovered naturally."
Kirkwood believes that, because neuropsychologists are trained both in the neurologic principles of brain injury and the psychological principles of emotion and behavior, they are "uniquely positioned to understand both the injury and noninjury factors that may be contributing to persistent symptomatology."
In particular, Kirkwood says, pediatric neuropsychologists, who have additional specialized expertise in child development, family and school systems, and developmental conditions that can influence post-injury management (eg, attentional or learning difficulties) are "especially well-suited to add to the care of youth who have persistent complaints."
Computerized neuropsychological tests: validity measures already embedded
"Neuropsychologists have long been aware of the contribution of incentive and motivation on the outcome of test results, whether with adults or children," notes Dr. Rosemarie Scolaro Moser, a sports concussion neuropsychologist not involved in the study.
"With the implementation of compturized neuropyschological concussion testing, validity measures are now embedded into the concussion tests themselves. Interestingly, this study did not include such testing, which can provide indications of questionable validity of patient test results, even before the concussion, such as with 'sandbagging' baseline tests."
"It is important that those health care professionals who are interpreting post-concussion testing be knowledgeable of detecting cognitive test results that don't make sense or that decline over time as red flags for factors other than the concussion which may be interfering with recovery," says Dr. Moser.
She recommends that whenever there is the possibility of secondary gain, effort should be assessed, which can be done in a variety of ways: by formal effort testing, by examination of cognitive test results patterns, by assessment of psychological factors, and/or by qualitative examination of the child's course of recovery.
The current study "reinforces that message, as well as the message that, in the management of post-concussion symptoms, a neuropsychological consultation is highly recommended, as it is the neuropsychologist who can best interpret cognitive, emotional, and motivational factors."
As neuropsychologists, says Moser, "we know that whenever symptoms do not improve and the recovery period is longer than expected, the possibility of emotional/psychological factors affecting symptoms should be considered. Thus, it is not surprising that presence of anxiety in this particular study was associated with incidence of failure on the motivation test."
Advice for parents and youth athletes
Moser cautions parents, however, not to read too much into the current study. "Although 12% failed the effort test, that meant 88% did not, so it can be presumed that the large majority were reporting valid symptoms. Furthermore," Moser says, "failing an effort test may not necessarily indicate outright malingering or faking that is intentional. It does, however, signal to the health care professional that psychological factors need to be assessed and managed, and that counseling may be in order."
"In our sports concussion practice, it is not uncommon to find that a youth who becomes 'ill' can be quite impressionable and anxious when he or she believes his or her brain has been hurt. It is important that the doctor not reinforce the sick role or unnecessarily frighten the youth who may be susceptible to developing irrational beliefs about his or her health. If the child becomes over-focused on health issues and fearful of re-injury, the recovery process can be a confused one and symptom magnification may occur. These young students' assessment of their own symptoms can become distorted and unrealistic."
She acknowledges that there are some student-athletes who may "consciously play the system so that they may stay out of school longer and receive more accommodations," and that there are "parents who may be anxious and overprotective and hamper the recovery process. However, for the most part, the students we treat prefer not to be kept out of school and tend to fight any prescriptions for rest or academic accommodations. Post-concussion recovery and staying out of school also means staying out of social experiences, after-school activities, travel, and sports. Very few students enjoy such restrictions for very long, unless there are significant, valid post-concussion symptoms or significant emotional concerns, either of which need treatment, whether or not effort testing is valid," Moser says.
"In the end, with youth, it is important to err on the side of caution, be wise to incentives, and not casually dismiss post-concussion complaints," Moser recommends.
Kirkwood MW, Peterson RL, Connery AK, Daker DA, Grubenhoff JA. Postconcussion Symptom Exaggeration After Pediatric Mild Traumatic Brain Injury. Pediatrics 2014;133(4). doi: 10.1542/peds.2013-3195 (epublished March 10, 2014).
Kirkwood MW, Kirk JW, Blaha RZ, Wilson P. Noncredible effort during pediatric neuro- psychological exam: a case series and lit- erature review. Child Neuropsychol. 2010;16 (6):604-618