OBJECTIVES:

To evaluate parent-child agreement on postconcussion symptom severity within 48 hours of injury and examine the comparative predictive power of a clinical prediction rule when using parent or child symptom reporting.

METHODS:

Both patients and parents quantified preinjury and current symptoms using the Postconcussion Symptom Inventory (PCSI) in the pediatric emergency department. Two-way mixed, absolute measure intraclass correlation coefficients were calculated to evaluate the agreement between patient and parent reports. A multiple logistic regression was run with 9 items to determine the predictive power of the Predicting and Preventing Postconcussive Problems in Pediatrics clinical prediction rule when using the child-reported PCSI. Delong’s receiver operating characteristic curve analysis was used to compare the area under the curve (AUC) for the child-report models versus previously published parent-report models.

RESULTS:

Overall parent-child agreement for the total PCSI score was fair (intraclass correlation coefficient = 0.66). Parent-child agreement was greater for (1) postinjury (versus preinjury) ratings, (2) physical (versus emotional) symptoms, and (3) older (versus younger) children. Applying the clinical prediction rule by using the child-reported PCSI maintained similar predictive power to parent-reported PCSI (child AUC = 0.70 [95% confidence interval: 0.67–0.72]; parent AUC = 0.71 [95% confidence interval: 0.68–0.74]; P = .23).

CONCLUSIONS:

Overall parent-child agreement on postconcussion symptoms is fair but varies according to several factors. The findings for physical symptoms and the clinical prediction rule have high agreement; information in these domains are likely to be similar regardless of whether they are provided by either the parent or child. Younger children and emotional symptoms show poorer agreement; interviewing both the child and the parent would provide more comprehensive information in these instances.

What’s Known on This Subject:

Fair to moderate parent-child agreement on concussion symptom severity has been reported at several weeks post injury, and a clinical prediction rule for stratifying pediatric persistent postconcussion symptom risk has been established by using parent-reported symptom checklists.

What This Study Adds:

Our results suggest that parent-child agreement was greater for (1) current postconcussion symptoms, (2) physical symptoms, and (3) older children. The clinical prediction rule, using the child-reported Postconcussion Symptom Inventory, maintained similar predictive power to the original rule.

Given the paucity of validated, objective biomarkers (eg, advanced neuroimaging and fluid) to measure clinical and physiologic recovery after a concussion,1  clinicians continue to rely on self-report scales to diagnose and monitor postinjury status.2,3  However, measuring self-reported symptoms introduces several inherent challenges. Postconcussion symptoms are known only by patients themselves, and direct assessment of the patient perspective is necessary to understand the concussion. With children, the measurement challenge is compounded by varying levels of developmental ability and comprehension of general health concepts.4  Additionally, because a concussion can influence mental status,5  children and adolescents may not recognize the presence or severity of concussion symptoms. A parental proxy report has thus been advocated to complement the postinjury symptom reports obtained from children to aid in the diagnostic process.

In addition to a concussion diagnosis, symptom reports may provide prognostic information that allows for the identifying of concussed children most at risk for experiencing persistent symptoms several weeks after injury. Studies reveal that dizziness,6,7  migraine symptoms,8  and overall symptom burden9,10  are predictive of persistent postconcussion symptoms (PPCSs). To help clinicians acutely identify children and adolescents at risk for prolonged recovery, the Predicting and Preventing Postconcussive Problems in Pediatrics (5P) study was created to derive and validate a clinical risk score to stratify PPCS risk in children and youth.11  Although this clinical prediction rule has a moderate ability to predict PPCS risk and is more accurate than physician opinion alone,11  the postconcussion symptom scores used in this model were obtained from parent reports.

Most experts now agree that parent-reported outcomes cannot be recognized as an unfailingly accurate characterization of children’s subjective experiences. Expert recommendations state that although “parents can provide a useful perspective on their children’s health status, proxy-report items inherently require the respondent to make inferences about another person’s subjective experience,”12  which may not be equivalent. Tools used to ascertain both child and parent proxy information, such as the Postconcussion Symptom Inventory (PCSI),13,14  may serve as a potential solution to these challenges.

Understanding parent-child agreement on postconcussion symptom reports is critical to an appropriate injury diagnosis and streamlining the concussion diagnostic process. Fair agreement in parent and patient postconcussion symptoms has been reported, with studies underscoring the importance of obtaining both perspectives,13,15,16  and agreement varies on the basis of the symptom cluster (ie, physical, cognitive, fatigue, and emotional) and age of the child being evaluated.13,15  However, these studies were conducted several weeks after injury; parent-child agreement on symptom reporting is unknown in the acute phases of injury. Therefore, our primary purpose in this article was to determine parent-child agreement regarding the severity of postconcussion symptoms within 48 hours of injury, with a focus on potential differences based on age group and symptom clusters. Because postconcussion symptoms are not only a critical component of postconcussion diagnosis but also postconcussion prognosis, evaluating the effect of parent-child agreement on concussion outcomes, such as persistent symptoms, is needed. The 5P clinical prediction rule developed by using parent reports is able to discriminate PPCS risk, but whether this ability is maintained when child reports are used is unknown. Therefore, a secondary purpose was to examine the comparative predictive power of a previously derived clinical prediction rule11  when using child-reported symptoms.

This was a planned secondary analysis of a data set collected in the derivation phase of the 5P study.11,14  The 5P study was a prospective multicenter cohort study that recruited participants in 9 Canadian pediatric emergency departments (PEDs), members of the Pediatric Emergency Research Canada network. A total of 2006 children were enrolled in the derivation phase between August 2013 and September 2014. Eligible patients were aged 5 to 17.99 years, presented to a participating PED with a head injury that occurred within the preceding 48 hours, and met criteria for a diagnosis of concussion as per the 2012 Zurich consensus statement. Details about patient selection and general procedures have been published previously.11,14  Our study was approved by the research ethics board of each participating institution, and written consent and assent were obtained from all participants and their parents as appropriate.

At the PED, both patients and parents quantified preinjury and current symptoms using the PCSI15,17  and provided information on their history and general levels of functioning. In our previous studies, we developed a clinical prediction rule for PPCSs in children and adolescents,11,14  in which PPCSs were classified as 3 new or worsening symptoms lasting at least 4 weeks after a concussion (International Statistical Classification of Diseases and Related Health Problems, 10th Revision definition18 ). Because the child PCSI has 3 separation versions, the initial clinical prediction rule for PPCSs used the parent PCSI reports to avoid differences in symptoms listed and response scaling present across the 3 versions for children of different age groups. Nine factors assessed in the PED were found to predict PPCSs at 28 days in children and adolescents by using parent reports. We sought to compare the predictive power of this previously derived and validated clinical rule with the predictive power of a model using child PCSI reports.

The PCSI is a set of symptom scales for parents (20-item, 7-point Guttman scale) and developmentally specific self-report forms for children aged 5 to 7 (5-item, 3-point scale), children aged 8 to 12 (17-item, 3-point scale), and 13- to 18-year-olds (19-item, 7-point scale). The symptoms are loaded onto 4 different factors (ie, clusters), which include physical, cognitive, emotional, and fatigue domains.15  A summary question is also included to rate, on a scale of 0 to 4, what degree the child is acting differently from before the injury. This question encompasses a holistic view of recovery after a concussion and reflects the kind of question primary care providers not using specific symptom scales would rely on. Patients and parents completed the PCSI in PEDs using the standard PCSI administration procedures and instructions. In this study, we used the most up to date PCSI version at the time study enrollment began in August 2013. A newer iteration of the PCSI that appends the symptom “sleep more” into the 13- to 18-year-old assessment has been subsequently developed; however, this item was not evaluated in the PCSI version used in this study. The PCSI is a commonly used symptom scale and is a recommended common data element according to the National Institute of Neurological Disorders and Stroke and the US Department of Defense.19 

The means and SDs for each item on the scale were computed overall and by age group. Item scores for the 5 to 7 and 8 to 12 age groups, whose responses were on a 0 to 2 rating, were scaled by a factor of 3 to allow comparisons across age groups and with parent scores. Summary statistics were computed for the total PCSI score, factors (physical, fatigue, emotional, and cognitive), and the “feels different” summary question for each age group. Items, factors, and overall scores were examined by using the reported preinjury, postinjury, and an adjusted score, the latter of which is defined as the difference between the preinjury score and postinjury score.

Parent-Child PCSI Report Agreement

To assess agreement between child and parent reports, 2-way mixed, absolute measure intraclass correlation coefficients (ICCs) were calculated. ICCs were computed for all items, factors, and overall scores reported for preinjury, postinjury, and adjusted scores for all age groups. ICCs could only be calculated for those items in which both parent and child items were available. We considered ICC < 0.50 as poor, 0.50 < ICC < 0.75 as fair, 0.75 < ICC < 0.90 as moderate, and ICC > 0.90 as excellent.20 

Prediction Model Comparing Parent and Child PCSI Report

The 5P rule11  was reevaluated by using child reports for PCSI items included in the original rule. Therefore, a multiple logistic regression was performed with 9 items: age group, sex, duration of previous concussion, personal history of migraine headaches, Balance Error Scoring System tandem stance errors, answers questions slowly (Acute Concussion Evaluation), headache (child PCSI), sensitivity to noise (child PCSI), and fatigue (child PCSI). Missingness was handled via listwise deletion. Adjusted odds ratios and the respective 95% confidence intervals (CIs) were calculated. Validation was evaluated with a correlated receiver operating characteristic (ROC) analysis. Delong’s ROC analysis was also used to compare the child PCSI report model with the parent-report model and a model with physician prediction alone. Analyses were performed by using SPSS Statistics versions 21 and 23 (IBM SPSS Statistics, IBM Corporation) and R version 3.0.2. Two-sided P values <.05 were considered statistically significant.

A total of 2006 children and adolescents participated in this study. Descriptive characteristics of the sample are presented in Table 1.

TABLE 1

Baseline Characteristics (N = 2006)

CharacteristicDerivation Sample Used for This Study (N = 2006)
Age, y, median (IQR) 11.8 (8.9–14.6) 
 5–7, n (%) 377 (18.8) 
 8–12, n (%) 845 (42.1) 
 13–18, n (%) 784 (39.1) 
Female sex, n (%) 765 (38.1) 
Hours between PED visit and injury, median (IQR) 2.8 (1.4–11.1) 
Previous No. concussions, n (%)  
 0 1532 (76.4) 
 1 292 (14.6) 
 2 105 (5.2) 
 3+ 65 (3.2) 
Longest symptom duration of previous concussion, wk, n (%)  
 <1 201 (10.0) 
 1–4 170 (8.5) 
 5+ 86 (4.3) 
Migraine, n (%) 242 (12.1) 
Learning disabilities, n (%) 179 (8.9) 
ADD or ADHD, n (%) 190 (9.5) 
Other developmental disorder, n (%) 70 (3.5) 
Anxiety, n (%) 153 (7.6) 
Depression, n (%) 45 (2.2) 
Loss of consciousness, n (%) 239 (11.9) 
Duration, min, median (IQR) 0.5 (0.2–1.0) 
Seizure, n (%) 38 (1.9) 
Mechanism of injury, n (%)  
 Sports and recreational play 1349 (67.2) 
  Football 171 (8.5) 
  Hockey 87 (4.3) 
  Skiing or snowboarding 79 (3.9) 
  Soccer 63 (3.1) 
  Basketball 15 (0.7) 
  Other 1591 (79.3) 
 Non–sport-related injury or fall 495 (24.7) 
 Motor vehicle collision 36 (1.8) 
 Assault 22 (1.1) 
 Other 98 (4.9) 
Helmet use, n (%) 522 (26.0) 
Mouth guard use, n (%) 302 (15.1) 
CharacteristicDerivation Sample Used for This Study (N = 2006)
Age, y, median (IQR) 11.8 (8.9–14.6) 
 5–7, n (%) 377 (18.8) 
 8–12, n (%) 845 (42.1) 
 13–18, n (%) 784 (39.1) 
Female sex, n (%) 765 (38.1) 
Hours between PED visit and injury, median (IQR) 2.8 (1.4–11.1) 
Previous No. concussions, n (%)  
 0 1532 (76.4) 
 1 292 (14.6) 
 2 105 (5.2) 
 3+ 65 (3.2) 
Longest symptom duration of previous concussion, wk, n (%)  
 <1 201 (10.0) 
 1–4 170 (8.5) 
 5+ 86 (4.3) 
Migraine, n (%) 242 (12.1) 
Learning disabilities, n (%) 179 (8.9) 
ADD or ADHD, n (%) 190 (9.5) 
Other developmental disorder, n (%) 70 (3.5) 
Anxiety, n (%) 153 (7.6) 
Depression, n (%) 45 (2.2) 
Loss of consciousness, n (%) 239 (11.9) 
Duration, min, median (IQR) 0.5 (0.2–1.0) 
Seizure, n (%) 38 (1.9) 
Mechanism of injury, n (%)  
 Sports and recreational play 1349 (67.2) 
  Football 171 (8.5) 
  Hockey 87 (4.3) 
  Skiing or snowboarding 79 (3.9) 
  Soccer 63 (3.1) 
  Basketball 15 (0.7) 
  Other 1591 (79.3) 
 Non–sport-related injury or fall 495 (24.7) 
 Motor vehicle collision 36 (1.8) 
 Assault 22 (1.1) 
 Other 98 (4.9) 
Helmet use, n (%) 522 (26.0) 
Mouth guard use, n (%) 302 (15.1) 

ADD, attention-deficit disorder; ADHD, attention-deficit/hyperactivity disorder; IQR, interquartile range.

Descriptive statistics for child and parent PCSI reports are shown in Table 2 (child) and Table 3 (parent). Mean preinjury scores (scaled) for the child PCSI ranged from 0.06 (answers questions more slowly) to 0.48 (headache). The mean child PCSI postconcussion scores (scaled) ranged from 0.99 (irritable) to 4.02 (headache). The largest mean difference in child PCSI scores could be found for the item headache (mean difference score = 3.53). The “feels different” child summary score, which was only used to assess postinjury, ranged from 1.47 (5–7-year-old version) to 2.19 (13–18-year-old version). Parent mean item preinjury scores ranged from 0.06 (dizziness) to 0.39 (difficulty concentrating), and postconcussion scores (scaled) ranged from 0.88 (nervous) to 4.05 (headache). The largest mean difference adjusted score was for the item headache (mean adjusted score = 3.39). The “feels different” parental summary score, which only assessed postinjury, ranged from 1.70 (8–12-year-old version) to 1.83 (13–18-year-old version).

TABLE 2

Mean Preinjury, Postinjury, and Adjusted PCSI Scores as Reported by the Patient (Child)

Prescore Mean (SD)Postscore Mean (SD)Adjusted Score (Prescore and Postscore Difference) Mean (SD)
Age 5–7aAge 8–12aAge 13–18TotalAge 5–7aAge 8–12aAge 13–18TotalAge 5–7aAge 8–12aAge 13–18Total
Headache 0.33 (1.01) 0.60 (1.39) 0.42 (1.04) 0.48 (1.20) 3.44 (2.39) 4.24 (2.02) 4.02 (1.63) 4.02 (1.63) 3.12 (2.52) 3.64 (2.36) 3.60 (1.83) 3.53 (2.20) 
Nausea 0.19 (0.83) 0.20 (0.84) 0.10 (0.50) 0.16 (0.72) 2.62 (2.55) 2.46 (2.25) 2.30 (2.04) 2.29 (2.04) 2.43 (2.66) 2.25 (2.31) 2.19 (2.04) 2.26 (2.28) 
Balance — 0.12 (0.70) 0.11 (0.51) 0.12 (0.62) — 2.14 (2.12) 2.08 (1.98) 2.11 (2.06) — 2.02 (2.18) 1.97 (1.95) 2.00 (2.07) 
Dizziness 0.10 (0.62) 0.11 (0.66) 0.09 (0.45) 0.10 (0.58) 1.85 (2.18) 3.07 (2.24) 2.89 (1.93) 2.77 (2.16) 1.75 (2.21) 2.96 (2.28) 2.80 (1.96) 2.68 (2.19) 
Fatigue — 0.35 (1.12) 0.41 (1.01) 0.38 (1.07) — 3.57 (2.32) 3.32 (2.06) 3.44 (2.20) — 3.22 (2.51) 2.91 (2.10) 3.07 (2.32) 
Drowsy — 0.23 (0.90) 0.19 (0.66) 0.21 (0.79) — 3.17 (2.34) 2.79 (2.13) 2.99 (2.24) — 2.94 (2.44) 2.60 (2.11) 2.77 (2.29) 
Sensitivity to light — 0.20 (0.84) 0.14 (0.61) 0.17 (0.74) — 1.70 (2.19) 2.25 (2.17) 1.97 (2.20) — 1.51 (2.18) 2.11 (2.14) 1.80 (2.18) 
Sensitivity to noise — 0.27 (1.04) 0.18 (0.72) 0.23 (0.90) — 1.60 (2.16) 2.06 (2.10) 1.81 (2.13) — 1.32 (2.12) 1.88 (2.06) 1.59 (2.11) 
Irritable 0.27 (1.00) 0.24 (0.88) 0.38 (1.07) 0.30 (0.98) 0.62 (1.39) 0.81 (1.64) 1.36 (1.89) 0.99 (1.73) 0.35 (1.55) 0.58 (1.69) 0.98 (1.81) 0.69 (1.73) 
Sad — 0.19 (0.85) 0.16 (0.73) 0.18 (0.79) — 1.27 (1.94) 0.98 (1.64) 1.13 (1.81) — 1.08 (1.97) 0.82 (1.54) 0.95 (1.77) 
Nervous — 0.31 (1.05) 0.35 (0.98) 0.33 (1.02) — 1.55 (2.03) 1.03 (1.60) 1.30 (1.86) — 1.25 (2.03) 0.67 (1.55) 0.97 (1.94) 
More emotional — — 0.23 (0.84) 0.23 (0.84) — — 1.16 (1.79) 1.16 (1.79) — — 0.93 (1.70) 0.93 (1.70) 
Feeling mentally foggy — — 0.09 (0.47) 0.09 (0.47) — — 2.11 (1.99) 2.11 (1.99) — — 2.02 (1.97) 2.02 (1.97) 
Difficulty concentrating 0.54 (1.43) 0.43 (1.21) 0.39 (1.05) 0.44 (1.19) 1.30 (2.00) 1.67 (2.05) 2.21 (2.02) 1.81 (2.06) 0.76 (2.07) 1.24 (2.05) 1.82 (1.92) 1.38 (2.04) 
Difficulty remembering — 0.24 (0.91) 0.22 (0.79) 0.23 (0.85) — 1.62 (2.12) 1.61 (1.96) 1.61 (2.05) — 1.38 (2.03) 1.39 (1.88) 1.38 (1.96) 
Blurry vision — 0.04 (0.36) 0.08 (0.42) 0.06 (0.39) — 1.56 (2.09) 1.54 (1.91) 1.55 (2.00) — 1.52 (2.08) 1.47 (1.90) 1.49 (1.99) 
Confused with directions or tasks — — 0.12 (0.60) 0.12 (0.60) — — 1.02 (1.61) 1.02 (1.61) — — 0.90 (1.54) 0.90 (1.54) 
Clumsy — — 0.33 (0.98) 0.33 (0.98) — — 1.51 (1.90) 1.51 (1.86) — — 1.19 (1.73) 1.19 (1.73) 
Answers questions more slowly — — 0.06 (0.36) 0.06 (0.36) — — 1.81 (1.89) 1.82 (1.89) — — 1.76 (1.87) 1.76 (1.87) 
Physical factor 0.62 (1.75) 1.65 (3.65) 1.45 (3.04) 1.38 (3.15) 7.89 (4.77) 19.00 (10.31) 18.64 (10.52) 16.79 (10.51) 7.27 (5.00) 17.36 (10.41) 17.19 (10.38) 15.42 (10.37) 
Fatigue factor — 0.57 (1.75) 0.60 (1.51) 0.58 (1.64) — 6.73 (4.25) 6.11 (3.89) 6.43 (4.09) — 6.15 (4.47) 5.51 (3.91) 5.84 (4.22) 
Emotional factor 0.27 (1.00) 0.73 (2.10) 1.13 (2.72) 0.80 (2.24) 0.62 (1.39) 3.63 (4.08) 4.53 (5.20) 3.43 (4.47) 0.35 (1.55) 2.90 (4.03) 3.41 (4.66) 2.62 (4.13) 
Cognitive factor 0.54 (1.43) 0.87 (2.35) 0.99 (2.59) 0.86 (2.32) 1.30 (2.00) 7.03 (6.27) 11.05 (8.71) 7.55 (7.70) 0.76 (2.07) 6.16 (6.16) 10.06 (8.37) 6.70 (7.44) 
Total PCSI score 1.43 (2.98) 3.82 (7.30) 4.17 (7.92) 3.51 (7.05) 9.81 (6.03) 36.37 (19.11) 40.32 (23.42) 32.98 (22.40) 8.38 (6.43) 32.55 (18.93) 36.15 (22.25) 29.47 (21.38) 
“Feels different” summary question — — — — 1.47 (1.47) 1.96 (1.33) 2.19 (1.16) 1.96 (1.32) — — — — 
Prescore Mean (SD)Postscore Mean (SD)Adjusted Score (Prescore and Postscore Difference) Mean (SD)
Age 5–7aAge 8–12aAge 13–18TotalAge 5–7aAge 8–12aAge 13–18TotalAge 5–7aAge 8–12aAge 13–18Total
Headache 0.33 (1.01) 0.60 (1.39) 0.42 (1.04) 0.48 (1.20) 3.44 (2.39) 4.24 (2.02) 4.02 (1.63) 4.02 (1.63) 3.12 (2.52) 3.64 (2.36) 3.60 (1.83) 3.53 (2.20) 
Nausea 0.19 (0.83) 0.20 (0.84) 0.10 (0.50) 0.16 (0.72) 2.62 (2.55) 2.46 (2.25) 2.30 (2.04) 2.29 (2.04) 2.43 (2.66) 2.25 (2.31) 2.19 (2.04) 2.26 (2.28) 
Balance — 0.12 (0.70) 0.11 (0.51) 0.12 (0.62) — 2.14 (2.12) 2.08 (1.98) 2.11 (2.06) — 2.02 (2.18) 1.97 (1.95) 2.00 (2.07) 
Dizziness 0.10 (0.62) 0.11 (0.66) 0.09 (0.45) 0.10 (0.58) 1.85 (2.18) 3.07 (2.24) 2.89 (1.93) 2.77 (2.16) 1.75 (2.21) 2.96 (2.28) 2.80 (1.96) 2.68 (2.19) 
Fatigue — 0.35 (1.12) 0.41 (1.01) 0.38 (1.07) — 3.57 (2.32) 3.32 (2.06) 3.44 (2.20) — 3.22 (2.51) 2.91 (2.10) 3.07 (2.32) 
Drowsy — 0.23 (0.90) 0.19 (0.66) 0.21 (0.79) — 3.17 (2.34) 2.79 (2.13) 2.99 (2.24) — 2.94 (2.44) 2.60 (2.11) 2.77 (2.29) 
Sensitivity to light — 0.20 (0.84) 0.14 (0.61) 0.17 (0.74) — 1.70 (2.19) 2.25 (2.17) 1.97 (2.20) — 1.51 (2.18) 2.11 (2.14) 1.80 (2.18) 
Sensitivity to noise — 0.27 (1.04) 0.18 (0.72) 0.23 (0.90) — 1.60 (2.16) 2.06 (2.10) 1.81 (2.13) — 1.32 (2.12) 1.88 (2.06) 1.59 (2.11) 
Irritable 0.27 (1.00) 0.24 (0.88) 0.38 (1.07) 0.30 (0.98) 0.62 (1.39) 0.81 (1.64) 1.36 (1.89) 0.99 (1.73) 0.35 (1.55) 0.58 (1.69) 0.98 (1.81) 0.69 (1.73) 
Sad — 0.19 (0.85) 0.16 (0.73) 0.18 (0.79) — 1.27 (1.94) 0.98 (1.64) 1.13 (1.81) — 1.08 (1.97) 0.82 (1.54) 0.95 (1.77) 
Nervous — 0.31 (1.05) 0.35 (0.98) 0.33 (1.02) — 1.55 (2.03) 1.03 (1.60) 1.30 (1.86) — 1.25 (2.03) 0.67 (1.55) 0.97 (1.94) 
More emotional — — 0.23 (0.84) 0.23 (0.84) — — 1.16 (1.79) 1.16 (1.79) — — 0.93 (1.70) 0.93 (1.70) 
Feeling mentally foggy — — 0.09 (0.47) 0.09 (0.47) — — 2.11 (1.99) 2.11 (1.99) — — 2.02 (1.97) 2.02 (1.97) 
Difficulty concentrating 0.54 (1.43) 0.43 (1.21) 0.39 (1.05) 0.44 (1.19) 1.30 (2.00) 1.67 (2.05) 2.21 (2.02) 1.81 (2.06) 0.76 (2.07) 1.24 (2.05) 1.82 (1.92) 1.38 (2.04) 
Difficulty remembering — 0.24 (0.91) 0.22 (0.79) 0.23 (0.85) — 1.62 (2.12) 1.61 (1.96) 1.61 (2.05) — 1.38 (2.03) 1.39 (1.88) 1.38 (1.96) 
Blurry vision — 0.04 (0.36) 0.08 (0.42) 0.06 (0.39) — 1.56 (2.09) 1.54 (1.91) 1.55 (2.00) — 1.52 (2.08) 1.47 (1.90) 1.49 (1.99) 
Confused with directions or tasks — — 0.12 (0.60) 0.12 (0.60) — — 1.02 (1.61) 1.02 (1.61) — — 0.90 (1.54) 0.90 (1.54) 
Clumsy — — 0.33 (0.98) 0.33 (0.98) — — 1.51 (1.90) 1.51 (1.86) — — 1.19 (1.73) 1.19 (1.73) 
Answers questions more slowly — — 0.06 (0.36) 0.06 (0.36) — — 1.81 (1.89) 1.82 (1.89) — — 1.76 (1.87) 1.76 (1.87) 
Physical factor 0.62 (1.75) 1.65 (3.65) 1.45 (3.04) 1.38 (3.15) 7.89 (4.77) 19.00 (10.31) 18.64 (10.52) 16.79 (10.51) 7.27 (5.00) 17.36 (10.41) 17.19 (10.38) 15.42 (10.37) 
Fatigue factor — 0.57 (1.75) 0.60 (1.51) 0.58 (1.64) — 6.73 (4.25) 6.11 (3.89) 6.43 (4.09) — 6.15 (4.47) 5.51 (3.91) 5.84 (4.22) 
Emotional factor 0.27 (1.00) 0.73 (2.10) 1.13 (2.72) 0.80 (2.24) 0.62 (1.39) 3.63 (4.08) 4.53 (5.20) 3.43 (4.47) 0.35 (1.55) 2.90 (4.03) 3.41 (4.66) 2.62 (4.13) 
Cognitive factor 0.54 (1.43) 0.87 (2.35) 0.99 (2.59) 0.86 (2.32) 1.30 (2.00) 7.03 (6.27) 11.05 (8.71) 7.55 (7.70) 0.76 (2.07) 6.16 (6.16) 10.06 (8.37) 6.70 (7.44) 
Total PCSI score 1.43 (2.98) 3.82 (7.30) 4.17 (7.92) 3.51 (7.05) 9.81 (6.03) 36.37 (19.11) 40.32 (23.42) 32.98 (22.40) 8.38 (6.43) 32.55 (18.93) 36.15 (22.25) 29.47 (21.38) 
“Feels different” summary question — — — — 1.47 (1.47) 1.96 (1.33) 2.19 (1.16) 1.96 (1.32) — — — — 

—, not applicable.

a

Responses on the 5–7- and 8–12-y-old versions of the PCSI have been scaled (multiplied by 3) to match the 0–6 rating scale used on the 13–18-y-old and parental versions.

TABLE 3

Mean Preinjury, Postinjury, and Adjusted PCSI Scores as Reported by the Parent

Prescore Mean (SD)Postscore Mean (SD)Difference Between Prescore and Postscore Means (SD)
Age 5–7Age 8–12Age 13–18TotalAge 5–7Age 8–12Age 13–18TotalAge 5–7Age 8–12Age 13–18Total
Headache 0.17 (0.60) 0.42 (1.03) 0.44 (1.09) 0.38 (1.00) 3.23 (2.06) 3.77 (1.91) 4.05 (1.78) 4.05 (1.78) 3.06 (2.14) 3.35 (2.06) 3.61 (1.97) 3.39 (2.05) 
Nausea 0.07 (0.43) 0.13 (0.62) 0.12 (0.57) 0.12 (0.57) 2.60 (2.45) 2.27 (2.22) 2.29 (2.18) 2.29 (2.18) 2.53 (2.47) 2.14 (2.23) 2.16 (2.17) 2.22 (2.26) 
Balance — 0.07 (0.47) 0.08 (0.49) 0.07 (0.48) — 1.41 (1.86) 1.75 (2.07) 1.47 (1.92) — 1.34 (1.84) 1.66 (2.07) 1.49 (1.95) 
Dizziness 0.01 (0.13) 0.05 (0.40) 0.10 (0.48) 0.06 (0.40) 1.70 (1.90) 2.59 (2.06) 2.87 (2.05) 2.52 (2.07) 1.69 (1.91) 2.53 (2.07) 2.77 (2.09) 2.46 (2.09) 
Fatigue — 0.16 (0.70) 0.25 (0.80) 0.20 (0.75) — 2.81 (2.11) 3.04 (2.17) 2.92 (2.14) — 2.65 (2.11) 2.79 (2.21) 2.72 (2.16) 
Drowsy — 0.07 (0.44) 0.14 (0.67) 0.11 (0.56) — 2.89 (2.12) 2.97 (2.18) 2.93 (2.15) — 2.81 (2.14) 2.83 (2.20) 2.82 (2.17) 
Sensitivity to light — 0.14 (0.64) 0.12 (0.60) 0.13 (0.62) — 1.28 (1.91) 2.06 (2.31) 1.65 (2.14) — 1.14 (1.90) 1.93 (2.29) 1.51 (2.13) 
Sensitivity to noise — 0.20 (0.79) 0.14 (0.62) 0.17 (0.72) — 1.17 (1.85) 1.90 (2.13) 1.51 (2.02) — 0.97 (1.71) 1.76 (2.13) 1.34 (1.96) 
Irritable 0.23 (0.73) 0.26 (0.85) 0.40 (1.05) 0.31 (0.91) 1.03 (1.71) 0.85 (1.58) 1.27 (1.90) 1.04 (1.74) 0.80 (1.73) 0.59 (1.49) 0.87 (1.77) 0.74 (1.65) 
Sad — 0.10 (0.56) 0.14 (0.69) 0.12 (0.63) — 1.43 (1.92) 1.26 (1.88) 1.35 (1.90) — 1.33 (1.92) 1.12 (1.85) 1.23 (1.89) 
Nervous — 0.24 (0.91) 0.22 (0.81) 0.23 (0.86) — 0.92 (1.63) 0.83 (1.61) 0.88 (1.62) — 0.68 (1.58) 0.61 (1.53) 0.64 (1.56) 
More emotional — — 0.23 (0.81) 0.23 (0.81) — — 1.39 (1.94) 1.39 (1.94) — — 1.17 (1.93) 1.17 (1.93) 
Feeling mentally foggy — — 0.09 (0.46) 0.09 (0.46) — — 2.08 (2.10) 2.08 (2.10) — — 2.00 (2.09) 2.00 (2.09) 
Difficulty concentrating 0.34 (0.95) 0.43 (1.14) 0.36 (0.99) 0.39 (1.05) 0.99 (1.63) 1.31 (1.81) 1.82 (2.04) 1.44 (1.89) 0.65 (1.47) 0.87 (1.65 () 1.45 (1.94) 1.05 (1.76) 
Difficulty remembering — 0.16 (0.69) 0.20 (0.75) 0.18 (0.72) — 1.00 (1.75) 1.43 (1.99) 1.12 (1.88) — 0.84 (1.65) 1.24 (1.89) 1.02 (1.78) 
Blurry vision — 0.08 (0.49) 0.10 (0.50) 0.09 (0.49) — 1.19 (1.84) 1.39 (1.94) 1.28 (1.89) — 1.11 (1.87) 1.29 (1.92) 1.20 (1.89) 
Confused with directions or tasks — — 0.14 (0.67) 0.14 (0.67) — — 0.98 (1.70) 0.98 (1.70) — — 0.84 (1.60) 0.84 (1.60) 
Clumsy — — 0.26 (0.85) 0.26 (0.85) — — 1.14 (1.78) 1.14 (1.78) — — 0.88 (1.64) 0.88 (1.64) 
Answers questions more slowly — — 0.06 (0.38) 0.06 (0.38) — — 1.61 (1.89) 1.61 (1.89) — — 1.55 (1.86) 1.55 (1.86) 
Physical factor 1.11 (2.27) 1.34 (3.17) 1.37 (2.90) 1.30 (2.91) 11.85 (7.89) 14.64 (9.21) 17.43 (10.33) 15.14 (9.63) 10.73 (7.90) 13.30 (9.18) 16.07 (10.35) 13.83 (9.60) 
Fatigue factor  0.31 (1.23) 0.54 (1.57) 0.42 (1.40) — 7.08 (5.28) 7.48 (5.38) 7.27 (5.33) — 6.77 (5.31) 6.94 (5.48) 6.85 (5.39) 
Emotional factor 0.94 (2.20) 0.98 (2.51) 0.99 (2.51) 0.98 (2.45) 5.54 (5.50) 4.87 (5.16) 4.75 (5.39) 4.96 (5.32) 4.59 (5.47) 3.89 (5.06) 3.76 (5.17) 3.98 (5.19) 
Cognitive factor 0.62 (1.64) 0.82 (2.26) 0.85 (2.51) 0.79 (2.25) 5.09 (6.25) 6.11 (6.86) 7.90 (7.61) 6.59 (7.12) 4.47 (6.01) 5.29 (6.61) 7.06 (7.35) 5.79 (6.86) 
Total PCSI score 2.87 (4.95) 3.45 (6.86) 3.75 (7.34) 3.45 (6.73) 30.35 (19.60) 32.70 (20.22) 37.56 (22.49) 34.06 (21.17) 27.47 (19.31) 29.25 (19.60) 33.83 (22.11) 30.62 (20.67) 
“Feels different” summary question — — — — 1.77 (1.32) 1.70 (1.26) 1.83 (1.29) 1.77 (1.28) — — — — 
Prescore Mean (SD)Postscore Mean (SD)Difference Between Prescore and Postscore Means (SD)
Age 5–7Age 8–12Age 13–18TotalAge 5–7Age 8–12Age 13–18TotalAge 5–7Age 8–12Age 13–18Total
Headache 0.17 (0.60) 0.42 (1.03) 0.44 (1.09) 0.38 (1.00) 3.23 (2.06) 3.77 (1.91) 4.05 (1.78) 4.05 (1.78) 3.06 (2.14) 3.35 (2.06) 3.61 (1.97) 3.39 (2.05) 
Nausea 0.07 (0.43) 0.13 (0.62) 0.12 (0.57) 0.12 (0.57) 2.60 (2.45) 2.27 (2.22) 2.29 (2.18) 2.29 (2.18) 2.53 (2.47) 2.14 (2.23) 2.16 (2.17) 2.22 (2.26) 
Balance — 0.07 (0.47) 0.08 (0.49) 0.07 (0.48) — 1.41 (1.86) 1.75 (2.07) 1.47 (1.92) — 1.34 (1.84) 1.66 (2.07) 1.49 (1.95) 
Dizziness 0.01 (0.13) 0.05 (0.40) 0.10 (0.48) 0.06 (0.40) 1.70 (1.90) 2.59 (2.06) 2.87 (2.05) 2.52 (2.07) 1.69 (1.91) 2.53 (2.07) 2.77 (2.09) 2.46 (2.09) 
Fatigue — 0.16 (0.70) 0.25 (0.80) 0.20 (0.75) — 2.81 (2.11) 3.04 (2.17) 2.92 (2.14) — 2.65 (2.11) 2.79 (2.21) 2.72 (2.16) 
Drowsy — 0.07 (0.44) 0.14 (0.67) 0.11 (0.56) — 2.89 (2.12) 2.97 (2.18) 2.93 (2.15) — 2.81 (2.14) 2.83 (2.20) 2.82 (2.17) 
Sensitivity to light — 0.14 (0.64) 0.12 (0.60) 0.13 (0.62) — 1.28 (1.91) 2.06 (2.31) 1.65 (2.14) — 1.14 (1.90) 1.93 (2.29) 1.51 (2.13) 
Sensitivity to noise — 0.20 (0.79) 0.14 (0.62) 0.17 (0.72) — 1.17 (1.85) 1.90 (2.13) 1.51 (2.02) — 0.97 (1.71) 1.76 (2.13) 1.34 (1.96) 
Irritable 0.23 (0.73) 0.26 (0.85) 0.40 (1.05) 0.31 (0.91) 1.03 (1.71) 0.85 (1.58) 1.27 (1.90) 1.04 (1.74) 0.80 (1.73) 0.59 (1.49) 0.87 (1.77) 0.74 (1.65) 
Sad — 0.10 (0.56) 0.14 (0.69) 0.12 (0.63) — 1.43 (1.92) 1.26 (1.88) 1.35 (1.90) — 1.33 (1.92) 1.12 (1.85) 1.23 (1.89) 
Nervous — 0.24 (0.91) 0.22 (0.81) 0.23 (0.86) — 0.92 (1.63) 0.83 (1.61) 0.88 (1.62) — 0.68 (1.58) 0.61 (1.53) 0.64 (1.56) 
More emotional — — 0.23 (0.81) 0.23 (0.81) — — 1.39 (1.94) 1.39 (1.94) — — 1.17 (1.93) 1.17 (1.93) 
Feeling mentally foggy — — 0.09 (0.46) 0.09 (0.46) — — 2.08 (2.10) 2.08 (2.10) — — 2.00 (2.09) 2.00 (2.09) 
Difficulty concentrating 0.34 (0.95) 0.43 (1.14) 0.36 (0.99) 0.39 (1.05) 0.99 (1.63) 1.31 (1.81) 1.82 (2.04) 1.44 (1.89) 0.65 (1.47) 0.87 (1.65 () 1.45 (1.94) 1.05 (1.76) 
Difficulty remembering — 0.16 (0.69) 0.20 (0.75) 0.18 (0.72) — 1.00 (1.75) 1.43 (1.99) 1.12 (1.88) — 0.84 (1.65) 1.24 (1.89) 1.02 (1.78) 
Blurry vision — 0.08 (0.49) 0.10 (0.50) 0.09 (0.49) — 1.19 (1.84) 1.39 (1.94) 1.28 (1.89) — 1.11 (1.87) 1.29 (1.92) 1.20 (1.89) 
Confused with directions or tasks — — 0.14 (0.67) 0.14 (0.67) — — 0.98 (1.70) 0.98 (1.70) — — 0.84 (1.60) 0.84 (1.60) 
Clumsy — — 0.26 (0.85) 0.26 (0.85) — — 1.14 (1.78) 1.14 (1.78) — — 0.88 (1.64) 0.88 (1.64) 
Answers questions more slowly — — 0.06 (0.38) 0.06 (0.38) — — 1.61 (1.89) 1.61 (1.89) — — 1.55 (1.86) 1.55 (1.86) 
Physical factor 1.11 (2.27) 1.34 (3.17) 1.37 (2.90) 1.30 (2.91) 11.85 (7.89) 14.64 (9.21) 17.43 (10.33) 15.14 (9.63) 10.73 (7.90) 13.30 (9.18) 16.07 (10.35) 13.83 (9.60) 
Fatigue factor  0.31 (1.23) 0.54 (1.57) 0.42 (1.40) — 7.08 (5.28) 7.48 (5.38) 7.27 (5.33) — 6.77 (5.31) 6.94 (5.48) 6.85 (5.39) 
Emotional factor 0.94 (2.20) 0.98 (2.51) 0.99 (2.51) 0.98 (2.45) 5.54 (5.50) 4.87 (5.16) 4.75 (5.39) 4.96 (5.32) 4.59 (5.47) 3.89 (5.06) 3.76 (5.17) 3.98 (5.19) 
Cognitive factor 0.62 (1.64) 0.82 (2.26) 0.85 (2.51) 0.79 (2.25) 5.09 (6.25) 6.11 (6.86) 7.90 (7.61) 6.59 (7.12) 4.47 (6.01) 5.29 (6.61) 7.06 (7.35) 5.79 (6.86) 
Total PCSI score 2.87 (4.95) 3.45 (6.86) 3.75 (7.34) 3.45 (6.73) 30.35 (19.60) 32.70 (20.22) 37.56 (22.49) 34.06 (21.17) 27.47 (19.31) 29.25 (19.60) 33.83 (22.11) 30.62 (20.67) 
“Feels different” summary question — — — — 1.77 (1.32) 1.70 (1.26) 1.83 (1.29) 1.77 (1.28) — — — — 

—, not applicable.

Total and Cluster (Factor) Scores

The ICC for the total PCSI adjusted score was fair (ICC = 0.66). Physical (ICC = 0.71), cognitive (ICC = 0.62), and fatigue (ICC = 0.59) factor scores also had fair agreement, whereas emotional factors revealed poor agreement (ICC = 0.44). Between age groups, the ICC for the total PCSI adjusted score was highest for the 13- to 18-year-olds (ICC = 0.84) and lowest for the 5- to 7-year-olds (ICC = 0.12). For all age groups, the physical factor always generated the greatest agreement.

Individual Item Scores

The lowest agreement among preinjury scores across age groups was found for answers questions more slowly (ICC = 0.25) and the highest agreement was found for headache and sensitivity to light (both ICC = 0.56). Postconcussion score agreement was generally higher. The lowest postconcussion agreement was found for irritable (ICC = 0.42) and the highest for nausea (ICC = 0.70). Between age groups, agreement in preinjury scores, postconcussion scores, and adjusted scores was consistently greatest for the 13- to 18-year-olds and lowest for the 5- to 7-year-olds.

“Feels Different” Summary Score

Overall agreement for this question across age group was poor, with an ICC of 0.39. As per other PCSI items, 13- to 18-year-olds and their parents reported higher agreement (ICC = 0.55) than 8- to 12- or 5- to 7-year-olds, with ICCs of 0.34 and 0.22, respectively. The ICCs for all parent-child agreement outcomes can be found in Table 4.

TABLE 4

Agreement (ICC) Between Parent and Child PCSI Scores

PrescoresPostscoresDifference Between Prescores and Postscores
Age 5–7Age 8–12Age 13–18TotalAge 5–7Age 8–12Age 13–18TotalAge 5–7Age 8–12Age 13–18Total
Headache 0.18 0.50 0.77 0.56 0.46 0.55 0.72 0.58 0.42 0.50 0.71 0.55 
Nausea 0.21 0.33 0.53 0.36 0.63 0.65 0.80 0.70 0.61 0.61 0.78 0.67 
Balance — 0.36 0.51 0.41 — 0.53 0.71 0.61 — 0.51 0.71 0.60 
Dizziness 0.00 0.27 0.50 0.30 0.41 0.57 0.69 0.60 0.39 0.54 0.68 0.58 
Fatigue — 0.29 0.52 0.40 — 0.47 0.69 0.56 — 0.46 0.69 0.55 
Drowsy — 0.23 0.35 0.28 — 0.47 0.63 0.55 — 0.47 0.63 0.54 
Sensitivity to light — 0.46 0.74 0.56 — 0.65 0.81 0.73 — 0.64 0.79 0.72 
Sensitivity to noise — 0.44 0.67 0.51 — 0.60 0.75 0.68 — 0.57 0.75 0.67 
Irritable 0.25 0.24 0.55 0.39 0.21 0.29 0.58 0.42 0.21 0.27 0.54 0.38 
Sad — 0.42 0.56 0.48 — 0.41 0.53 0.46 — 0.37 0.54 0.44 
Nervous — 0.41 0.50 0.45 — 0.36 0.56 0.44 — 0.34 0.56 0.43 
More emotional — — 0.53 0.53 — — 0.62 0.62 — — 0.28 0.28 
Feeling mentally foggy — — 0.41 0.41 — — 0.64 0.64 — — 0.65 0.65 
Difficulty concentrating 0.24 0.43 0.56 0.42 0.20 0.41 0.59 0.46 0.15 0.38 0.60 0.45 
Difficulty remembering — 0.34 0.53 0.42 — 0.52 0.71 0.60 — 0.49 0.71 0.59 
Blurry vision — 0.20 0.49 0.35 — 0.59 0.73 0.65 — 0.59 0.73 0.65 
Confused with directions or tasks — — 0.53 0.53 — — 0.56 0.56 — — 0.54 0.54 
Clumsy — — 0.51 0.51 — — 0.60 0.60 — — 0.58 0.58 
Answers questions more slowly — — 0.25 0.25 — — 0.65 0.65 — — 0.66 0.66 
Physical factor 0.18 0.50 0.70 0.55 0.32 0.66 0.85 0.73 0.33 0.64 0.84 0.71 
Fatigue factor — 0.32 0.51 0.41 — 0.55 0.65 0.60 — 0.54 0.65 0.59 
Emotional factor 0.14 0.43 0.66 0.51 0.06 0.42 0.69 0.45 0.06 0.39 0.70 0.44 
Cognitive factor 0.27 0.43 0.63 0.50 0.09 0.58 0.72 0.63 0.10 0.55 0.73 0.62 
Total PCSI score 0.27 0.52 0.71 0.59 0.10 0.68 0.83 0.66 0.12 0.66 0.84 0.66 
“Feels different” summary question — — — — 0.22 0.34 0.55 0.39 — — — — 
PrescoresPostscoresDifference Between Prescores and Postscores
Age 5–7Age 8–12Age 13–18TotalAge 5–7Age 8–12Age 13–18TotalAge 5–7Age 8–12Age 13–18Total
Headache 0.18 0.50 0.77 0.56 0.46 0.55 0.72 0.58 0.42 0.50 0.71 0.55 
Nausea 0.21 0.33 0.53 0.36 0.63 0.65 0.80 0.70 0.61 0.61 0.78 0.67 
Balance — 0.36 0.51 0.41 — 0.53 0.71 0.61 — 0.51 0.71 0.60 
Dizziness 0.00 0.27 0.50 0.30 0.41 0.57 0.69 0.60 0.39 0.54 0.68 0.58 
Fatigue — 0.29 0.52 0.40 — 0.47 0.69 0.56 — 0.46 0.69 0.55 
Drowsy — 0.23 0.35 0.28 — 0.47 0.63 0.55 — 0.47 0.63 0.54 
Sensitivity to light — 0.46 0.74 0.56 — 0.65 0.81 0.73 — 0.64 0.79 0.72 
Sensitivity to noise — 0.44 0.67 0.51 — 0.60 0.75 0.68 — 0.57 0.75 0.67 
Irritable 0.25 0.24 0.55 0.39 0.21 0.29 0.58 0.42 0.21 0.27 0.54 0.38 
Sad — 0.42 0.56 0.48 — 0.41 0.53 0.46 — 0.37 0.54 0.44 
Nervous — 0.41 0.50 0.45 — 0.36 0.56 0.44 — 0.34 0.56 0.43 
More emotional — — 0.53 0.53 — — 0.62 0.62 — — 0.28 0.28 
Feeling mentally foggy — — 0.41 0.41 — — 0.64 0.64 — — 0.65 0.65 
Difficulty concentrating 0.24 0.43 0.56 0.42 0.20 0.41 0.59 0.46 0.15 0.38 0.60 0.45 
Difficulty remembering — 0.34 0.53 0.42 — 0.52 0.71 0.60 — 0.49 0.71 0.59 
Blurry vision — 0.20 0.49 0.35 — 0.59 0.73 0.65 — 0.59 0.73 0.65 
Confused with directions or tasks — — 0.53 0.53 — — 0.56 0.56 — — 0.54 0.54 
Clumsy — — 0.51 0.51 — — 0.60 0.60 — — 0.58 0.58 
Answers questions more slowly — — 0.25 0.25 — — 0.65 0.65 — — 0.66 0.66 
Physical factor 0.18 0.50 0.70 0.55 0.32 0.66 0.85 0.73 0.33 0.64 0.84 0.71 
Fatigue factor — 0.32 0.51 0.41 — 0.55 0.65 0.60 — 0.54 0.65 0.59 
Emotional factor 0.14 0.43 0.66 0.51 0.06 0.42 0.69 0.45 0.06 0.39 0.70 0.44 
Cognitive factor 0.27 0.43 0.63 0.50 0.09 0.58 0.72 0.63 0.10 0.55 0.73 0.62 
Total PCSI score 0.27 0.52 0.71 0.59 0.10 0.68 0.83 0.66 0.12 0.66 0.84 0.66 
“Feels different” summary question — — — — 0.22 0.34 0.55 0.39 — — — — 

—, not applicable.

The clinical prediction rule, using child-reported PCSI, had similar predictive power to the parent-reported model (child report: area under the curve [AUC] = 0.70 [95% CI: 0.67–0.72]; parent report: AUC = 0.71 [95% CI: 0.68–0.74]), as presented in Fig 1. DeLong’s test for 2 correlated ROC curves yields a nonstatistically significant P value of .23 (D = −1.1977; degree of freedom = 1641.657) when comparing the rule with parent-reported and child-reported PCSI items, demonstrating the similarity between the models. When comparing the child-reported model with physician prediction alone11  (AUC = 0.55; 95% CI: 0.50–0.59), Delong’s test yields a statistically significant difference (P < .001; D = −4.72672; degree of freedom = 11.98.963).

FIGURE 1

ROC curves for the parent (left; AUC: 0.71 [95% CI: 0.68–0.74]) and child (right; AUC: 0.70 [95% CI: 0.67–0.72]) reports. Diagonal segments are produced by ties.

FIGURE 1

ROC curves for the parent (left; AUC: 0.71 [95% CI: 0.68–0.74]) and child (right; AUC: 0.70 [95% CI: 0.67–0.72]) reports. Diagonal segments are produced by ties.

Table 5 presents the odds ratios and 95% CIs for each predictor in the parent- and child-reported PCSI models. Although headache and fatigue were both statistically significant in the model using parent-reported PCSI, they were not statistically significant in the model using child-reported PCSI (P = .08 and P = .30, respectively).

TABLE 5

Predictor Variables of PPCSs at 28 Days in Multivariable Analysis With Estimated and Observed Risk

Predictor VariablesParent Report11  (n = 1604)Child Report (n = 1637)
Odds Ratio (95% CI)POdds Ratio (95% CI)P
Age, y  <.001  <.001 
 5–7 Reference — Reference — 
 8–12 1.54 (1.09–2.19) — 1.49 (1.05–2.12) — 
 13–18 2.31 (1.62–3.32) — 2.07 (1.44–2.97) — 
Sex  <.001  <.001 
 Male Reference — Reference — 
 Female 2.24 (1.78–2.82) — 2.29 (1.83–2.88) — 
Longest symptom duration  .011  .005 
 No previous concussion or symptom duration <1 wk Reference — Reference — 
 Previous concussion with symptom duration ≥1 wk 1.53 (1.10–2.13) — 1.58 (1.15–2.18) — 
Physician-diagnosed personal migraine history  .001  .007 
 No Reference — Reference — 
 Yes 1.73 (1.24–2.43) — 1.58 (1.15–2.18) — 
Answers questions slowly  .008  .001 
 No Reference — Reference — 
 Yes 1.37 (1.08–1.74) — 1.49 (1.19–1.88) — 
Balance Error Scoring System tandem stance, No. errors  .022  .01 
 0–3 Reference — Reference — 
 ≥4 or unable to complete testing 1.31 (1.04–1.66) — 1.34 (1.07–1.69) — 
Headache  .013  .08 
 No Reference — Reference — 
 Yes 1.66 (1.11–2.48) — 1.39 (0.96–2.01) — 
Sensitivity to noise  .002  .003 
 No Reference — Reference — 
 Yes 1.47 (1.15–1.87) — 1.44 (1.14–1.82) — 
Fatigue  <.001  .304 
 No Reference — Reference — 
 Yes 1.84 (1.37–2.46) — 1.15 (0.88–1.52) — 
Predictor VariablesParent Report11  (n = 1604)Child Report (n = 1637)
Odds Ratio (95% CI)POdds Ratio (95% CI)P
Age, y  <.001  <.001 
 5–7 Reference — Reference — 
 8–12 1.54 (1.09–2.19) — 1.49 (1.05–2.12) — 
 13–18 2.31 (1.62–3.32) — 2.07 (1.44–2.97) — 
Sex  <.001  <.001 
 Male Reference — Reference — 
 Female 2.24 (1.78–2.82) — 2.29 (1.83–2.88) — 
Longest symptom duration  .011  .005 
 No previous concussion or symptom duration <1 wk Reference — Reference — 
 Previous concussion with symptom duration ≥1 wk 1.53 (1.10–2.13) — 1.58 (1.15–2.18) — 
Physician-diagnosed personal migraine history  .001  .007 
 No Reference — Reference — 
 Yes 1.73 (1.24–2.43) — 1.58 (1.15–2.18) — 
Answers questions slowly  .008  .001 
 No Reference — Reference — 
 Yes 1.37 (1.08–1.74) — 1.49 (1.19–1.88) — 
Balance Error Scoring System tandem stance, No. errors  .022  .01 
 0–3 Reference — Reference — 
 ≥4 or unable to complete testing 1.31 (1.04–1.66) — 1.34 (1.07–1.69) — 
Headache  .013  .08 
 No Reference — Reference — 
 Yes 1.66 (1.11–2.48) — 1.39 (0.96–2.01) — 
Sensitivity to noise  .002  .003 
 No Reference — Reference — 
 Yes 1.47 (1.15–1.87) — 1.44 (1.14–1.82) — 
Fatigue  <.001  .304 
 No Reference — Reference — 
 Yes 1.84 (1.37–2.46) — 1.15 (0.88–1.52) — 

—, not applicable.

Overall, parent and child agreement on symptom reporting was fair, particularly for total and factor scores. Parent-child agreement was greater (1) when asked about postconcussion symptoms, (2) for physical symptoms, and (3) for older children. Despite some differences in individual items, applying the clinical prediction rule using the child-reported PCSI maintained similar predictive power to the original rule developed with the parent-reported PCSI and had better predictive abilities than physician opinion alone. Overall, the poor agreement for younger children (≤12 years) suggests that it is important for an experienced interviewer to interact with both the parent and child to obtain a complete picture of functioning. Although clinicians could likely rely on parental reporting for physical or cognitive symptoms, emotional impairments may be better ascertained by directly interviewing the child regardless of age.

The overall fair parent-child agreement observed in this study was largely driven by postinjury scores within the physical and cognitive factors. The emotional domain consistently displayed the poorest parent-child agreement, confirming earlier work.15  In both preinjury and postconcussion contexts, physical health typically produces more observable symptoms that can be recognized by the parent than mental or emotional health, which reflect more internal states.21  Children, especially young children, may not recognize or conceptualize subtle symptoms. This contributes to poorer agreement in emotional domains, illustrates the difficulty for children to express more complex concepts, and represents a challenge for parents to observe behaviors that would illustrate impairments in the emotional spheres. Our findings are similar to those reported in studies by researchers investigating quality of life or reporting on the experience of traumatic events, in which agreement is consistently greater for domains that are easily observed.2225 

Younger children show less agreement with their parents than adolescents at both preinjury and postconcussion time points. This could be explained by developmental difficulties in self-appraisal of impairments in younger children. Young children may have difficulty with accurately verbalizing pain intensity and location,26  and this ability is refined throughout childhood and adolescence, especially for more complex concepts. Adolescents also had better parental agreement than younger children for the PCSI “feels different” summary question. The overall fair agreement for this question, as well as better agreement with increasing age, replicate previous findings.27  The interpretation of this question may vary between parent and child, in turn influencing responses. Additional exploration of what both children and parents understand or conceptualize from this question is needed.

Because postconcussion symptoms have an important role in injury prognosis, evaluating parent-child agreement on concussion outcomes, such as persistent symptom risk, is an important addition to the literature. The original 5P rule was developed to help clinicians orient children to appropriate concussion management in the acute period and includes 9 predictor variables, each providing risk points for the presence of PPCSs 28 days after injury.11,14  Of the 9 variables, 3 are derived from the PCSI (headache, sensitivity to noise, and fatigue). Although 2 of the significant symptoms observed on the parent PCSI reports did not reach significance when using the child PCSI reports, the predictive ability of the overall models were not significantly different. Similar to the parent-derived model, the child model also led to better predictive ability that physician opinion in the PED. This may provide reassurance that symptom reports from either the parent or the child in the context of the busy PED would yield similar results when implementing the 5P clinical prediction rule.

In previous studies, authors evaluated parent-child agreement on the PCSI in subacute and chronic settings13,15,16 ; in our study, we are the first to assess agreement at an acute time point (median: 2.8 hours after concussion). Understanding parent-child agreement and establishing PPCS risk by using the clinical prediction rule acutely can help clinicians direct treatment and refer patients to rehabilitation centers as necessary to prevent prolonged recovery. In this study, we enrolled a large, diverse sample of children and youth. Patients were included under a wide age range (5–17 years), under various mechanisms of injury, and with premorbid behavioral, learning, and psychological problems. This heterogeneous sample increases the generalizability of our findings. The PCSI is a concussion symptom checklist with developmentally appropriate versions that have been validated specifically for children and adolescents.

Although the psychometric properties and developmental appropriateness of the PCSI are strengths, the PCSI is limited by the lack of equivalence among the different child versions. All responses on the 5- to 7- and 8- to 12-year-old versions (0–2 scale) were multiplied by 3 to make equivalent ratings (0–6 scale) for all parent and child PCSI assessments. This assumes that a 1-point discrepancy on the 0 to 2 scale is equal to a 3-point discrepancy on a 0 to 6 scale, which may not be an appropriate assumption and may contribute to the lower ICC values observed in the younger age groups. However, we believe that rescaling is a sensible strategy to overcome this inherent limitation of our assessment tool.

Patients and parents completed the PCSI in the same room and were allowed to communicate throughout the assessment, including for clarification if the child did not comprehend a symptom. This may limit the internal validity of findings; however, this improves external validity because these are the standard administration procedures used in clinical settings nationally and internationally. The authors additionally feel that this did not meaningfully inflate agreement metrics because agreement between parents and the youngest children, who would most likely need to communicate with their parent, was the lowest of any age group. The PCSI was specifically designed and validated to have 3 versions, such that the symptom scales are developmentally appropriate for children aged 5 to 18. However, the child’s comprehension of the PCSI was not directly assessed in this study. Because younger children are more likely to have difficulty comprehending the PCSI, this may have contributed to poorer parent-child agreement among the youngest participants and should be evaluated further in future studies. Therefore, although younger children did display poorer agreement with their parents than adolescents, comparing agreement between the age groups (5–7, 8–12, and 13–18 years) should be done cautiously because of the different rating scales and potential issues with comprehension.

Because patients were recruited in the PED, they may have different symptom burdens, PPCS risk, and patient characteristics from individuals who do not report to the PED. However, we observed similar rates of PPCSs as those established in outpatient settings.6,28  No objective biomarkers or gold standard is currently available for concussion or PPCS diagnosis,1  and the risk prediction score generated by the 5P rule may be less precise than those available for other illnesses or diseases. However, the outcome measures we used are validated tools created by using the best evidence currently available. Patients and parents were asked to retrospectively rate the child’s preinjury level of symptoms. This may induce recall bias, but this methodology has been used in the literature11,29  when a baseline assessment of healthy functioning is unavailable.

Self-assessment of postconcussion symptoms is a critical component of acute concussion assessment and monitoring of recovery. In the absence of specific fluid or imaging biomarkers, clinicians rely not only on a thorough neurologic and physical examination but also on patient-reported symptoms to establish a diagnosis and make appropriate management decisions. Although obtaining information from both children and parents is considered best practice, this may not be feasible in busy clinical settings (such as PEDs). Knowing whether informant-related differences exist and, if so, for which symptoms could help clinicians orient their interview more efficiently.

Parent and child agreement on symptom reporting by using the PCSI was generally fair, particularly for total and factor scores. Two symptom items (fatigue and headache) included in the original 5P clinical prediction rule using parent-reported PCSI failed to reach significance when using the child-reported PCSI; however, the child-reported PCSI still had similar predictive power to the original model. Although it remains best practice to obtain both parent and child symptom reports whenever possible, the high level of agreement between parent and child reports and the similar results when implementing the clinical prediction rule can give clinicians confidence that comparable information is gathered when only interviewing the parent or child is possible.

Additional Pediatric Emergency Research Canada concussion team members include Martin H. Osmond, MDCM (Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada); Stephen B. Freedman, MDCM, MSc (Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, Alberta, Canada); Jocelyn Gravel, MD (Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada); Gurinder Sangha, MD (Department of Pediatrics, Children’s Hospital of Western Ontario, Western University, London, Ontario, Canada); Kathy Boutis, MD (Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada); Darcy Beer, MD (Department of Pediatrics, The Children’s Hospital of Winnipeg, Winnipeg, Manitoba, Canada); William Craig, MDCM (Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Alberta, Canada); Emma Burns, MD (Department of Pediatrics, Izaak Walton Killam Health Center, Halifax, Nova Scotia, Canada); and Ken J. Farion, MD (Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada).

Dr Gagnon conceptualized and designed the study, acquired the data, contributed to the analysis and interpretation of data, and drafted a portion of the initial manuscript; Dr Teel was involved in the analysis and interpretation of the data, drafted a portion of the initial manuscript, and revised the manuscript using feedback from other authors; Drs Gioia, Vaughan, and Sady conceptualized and designed the study, interpreted the data, and critically revised the manuscript for important intellectual content; Ms Aglipay and Dr Barrowman were involved in the analysis and interpretation of data and critically revised the manuscript; Dr Zemek acquired study funding, conceptualized and designed the study, acquired the data, contributed to the analysis and interpretation of data, and revised the original draft of the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Deidentified individual participant data can be requested through Ontario Brain Institute Brain-CODE after registering by using the following link: https://www.braincode.ca/user/register.

This trial has been registered at www.clinicaltrials.gov (identifier NCT01873287).

FUNDING: Supported by a Canadian Institutes of Health Research (CIHR) operating grant (MOP 126197), a CIHR–Ontario Neurotrauma Foundation Mild Traumatic Brain Injury team grant (TM1 127047), and a CIHR planning grant (MRP 119829).

     
  • 5P

    Predicting and Preventing Postconcussive Problems in Pediatrics

  •  
  • AUC

    area under the curve

  •  
  • CI

    confidence interval

  •  
  • ICC

    intraclass correlation coefficient

  •  
  • PCSI

    Postconcussion Symptom Inventory

  •  
  • PED

    pediatric emergency department

  •  
  • PPCS

    persistent postconcussion symptom

  •  
  • ROC

    receiver operating characteristic

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Competing Interests

POTENTIAL CONFLICTS OF INTEREST: Drs Gioia, Sady, and Vaughan are authors of, and receive royalties from, the Postconcussion Symptom Inventory 2; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.