Development of Psychiatric Disorders after Mild Head Trauma according to Birth History

Ki Taek Oh; Byung Ho Cha

doi:10.26815/acn.2025.00843

Ann Child Neurol > Volume 33(3); 2025 > Article

Oh and Cha: Development of Psychiatric Disorders after Mild Head Trauma according to Birth History

Original article

Annals of Child Neurology 2025;33(3):85-92.

Published online: June 25, 2025

DOI: https://doi.org/10.26815/acn.2025.00843

Development of Psychiatric Disorders after Mild Head Trauma according to Birth History

Ki Taek Oh, BS

, Byung Ho Cha, MD

Department of Pediatrics, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea

Corresponding author: Ki Taek Oh, MD Department of Pediatrics, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea
Tel: +82-33-741-0114, Fax: +82-33-741-0421 E-mail: ohgt90@naver.com

Received March 5, 2025 Revised April 25, 2025 Accepted April 28, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Mild head trauma in children has been associated with an increased risk of psychiatric disorders; however, the role of perinatal factors such as birth weight remains unclear. Children born large for gestational age (LGA) may have a higher risk for psychiatric disorders due to altered brain development. This study examined the relationship between birth weight and psychiatric outcomes following mild head trauma.

Methods

We retrospectively reviewed pediatric patients (<18 years) who experienced mild head trauma (Glasgow Coma Scale scores 13-15) between January 1, 2013, and December 31, 2013. Psychiatric diagnoses were established by child psychiatrists according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Birth weight categories—small for gestational age, appropriate for gestational age, and LGA—were assessed for their impact on psychiatric outcomes using logistic regression analysis. Additionally, correlation analyses examined the relationship between birth weight and body weight at the time of trauma.

Results

Among 178 patients, 18 (10.6%) developed psychiatric disorders, including posttraumatic stress disorder, attention-deficit/hyperactivity disorder, and adjustment disorder. Higher birth weight and LGA status were significantly associated with an increased risk of psychiatric disorders (birth weight: odds ratio [OR], 10.080; LGA: OR, 11.662; P<0.05). No significant correlation was identified between birth weight and body weight at the time of trauma (Pearson’s r=-0.091, P=0.206; Spearman’s rho=0.005, P=0.948).

Conclusion

LGA status and higher birth weight may increase vulnerability to psychiatric disorders following mild head trauma. Further research incorporating genetic and neuroimaging factors is needed to enhance risk assessment and facilitate early intervention.

Keywords: Brain injuries, traumatic; Birth weight; Infant, large for gestational age; Mental disorders; Pediatrics

Introduction

Mild head trauma has been associated with an increased likelihood of psychiatric conditions such as depression, mania, attention-deficit/hyperactivity disorder (ADHD), posttraumatic stress disorder (PTSD), schizophrenia, and anxiety disorders among children and adolescents [1]. However, existing research predominantly addresses moderate to severe traumatic brain injury (TBI) in adults, while studies specifically examining mild head trauma in pediatric populations are limited [2-5]. A systematic review on pediatric head injuries further emphasizes the scarcity of research exploring psychiatric outcomes following mild head trauma [6].

Perinatal factors, including birth weight (BWT), intrauterine period (IUP), and BWT relative to gestational age—classified as appropriate for gestational age (AGA) or large for gestational age (LGA)—are recognized as influential determinants of long-term neurodevelopmental and psychiatric outcomes in children [7,8]. Early identification of these factors can enable prompt interventions [9].

Children classified as LGA typically have higher BWTs, a condition often linked with maternal gestational diabetes and excessive prenatal nutrition [10,11]. Prior research suggests that LGA status may predispose children to neurodevelopmental and psychiatric disorders later in life [12,13]. This increased vulnerability may result from disruptions in brain development, hormonal regulation, and neuroplasticity during early development, potentially leading to conditions such as ADHD, anxiety disorders, and mood disorders.

Previous studies have also indicated that children born LGA may exhibit atypical neurodevelopmental trajectories, potentially elevating their susceptibility to psychiatric disorders over time [12,14].

The current study aimed to investigate the relationship between BWT—including BWT relative to gestational age—and the development of psychiatric disorders following mild head trauma. Perinatal complications such as perinatal asphyxia, preterm birth, and severe neonatal illnesses have been previously associated with an elevated risk of neurodevelopmental and psychiatric disorders [15-17]. Including individuals who experienced these complications could confound the assessment of the specific impact of mild head trauma. Thus, the present study specifically evaluated the influence of BWT and gestational age-related BWT on the likelihood of psychiatric disorders in children who sustained mild head trauma but did not experience significant perinatal complications.

Materials and Methods

1. Study design and population

This retrospective cohort study reviewed medical records of pediatric patients under 18 years of age who presented with head trauma at Wonju Severance Christian Hospital from January 1 through December 31, 2013. The study was approved by the Institutional Review Board of Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine (IRB No. CR324125). Written informed consent by the patients was waived due to a retrospective nature of our study.

The year 2013 was selected for the chart review as it marked the implementation of electronic medical records at the institution. This approach permitted a full 10-year follow-up period extending to 2023, ensuring consistent and high-quality data. Including records from prior years could have compromised data reliability due to the absence of standardized electronic records. Psychiatric diagnoses were tracked for 10 years following head trauma using data obtained from electronic medical records.

2. Definitions and inclusion criteria

Mild head trauma was defined as a blunt head injury (e.g., due to a fall or collision) accompanied by a Glasgow Coma Scale (GCS) score between 13 and 15 at presentation, without evidence of skull fracture or intracranial hemorrhage on imaging, and without loss of consciousness exceeding 30 minutes [18].

Since the medical records lacked information on body weight percentiles at the time of trauma, correlation analysis between BWT and body weight percentile was not conducted.

A psychiatric disorder was defined as any diagnosis made by the Department of Psychiatry at Wonju Severance Christian Hospital within 10 years after the head trauma. All psychiatric diagnoses were established by board-certified child and adolescent psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Diagnoses were determined through clinical interviews conducted during outpatient follow-up visits, incorporating reports from both the child and their caregivers. For ADHD, evaluations focused on symptoms of inattention and/or hyperactivity-impulsivity observed over a 6-month period in multiple settings. PTSD was diagnosed based on the presence of intrusive trauma-related symptoms, avoidance behaviors, and negative alterations in mood or cognition. Adjustment disorder was identified when emotional or behavioral symptoms emerged within 3 months following a stressor and caused significant distress or functional impairment.

The inclusion criteria consisted of patients younger than 18 years with mild head trauma (GCS score of 13-15) and available 10-year follow-up data. Patients with a previous psychiatric diagnosis or major perinatal complications, such as perinatal asphyxia, severe congenital anomalies, or neurological conditions, were excluded.

3. Data collection and variables

1) Demographic and clinical characteristics

Information on age, sex, and birth history—including BWT, IUP, and classification as small for gestational age (SGA), AGA, and LGA—was obtained from medical records. The IUP was defined as the gestational age at birth, recorded in completed weeks of gestation. However, specific details regarding intrauterine complications such as gestational diabetes, pregnancy-induced hypertension, or maternal tobacco or alcohol use were not available in the medical records and were therefore excluded from the analysis.

2) Psychiatric outcomes

Patients were diagnosed with psychiatric disorders including ADHD, PTSD, depression, impulse control disorder, adjustment disorder, and Tourette syndrome.

3) Follow-up period

Psychiatric diagnoses were monitored for up to 10 years after head trauma.

4) Statistical analysis

Baseline characteristics were compared between patients with and without psychiatric disorders using the chi-square tests for categorical variables and the independent t-test for continuous variables. Logistic regression analysis was conducted to evaluate associations between BWT, gestational age-related BWT categories (SGA, AGA, and LGA), age, and sex with the occurrence of psychiatric disorders following mild head trauma. Additionally, Pearson and Spearman correlation analyses were performed to investigate relationships between BWT and body weight at the time of trauma. The analysis was adjusted for potential confounding variables, including age and sex. A P value of less than 0.05 was considered statistically significant. All statistical analyses were performed using SPSS version 28 (IBM Corp., Armonk, NY, USA).

Results

1. Patient characteristics

A total of 426 children were identified, and GCS scores were available for 305 of these patients. Among them, 178 children completed a 10-year follow-up, and 18 children (10.6%) received psychiatric diagnoses. Psychiatric disorders included ADHD (three cases), adjustment disorder (three cases), depression (one case), impulse control disorder (one case), PTSD (nine cases), and Tourette syndrome (one case). Demographic characteristics of the patients are presented in Table 1.

2. Statistical analysis findings

Higher BWT was associated with an increased risk of developing psychiatric disorders. Differences in demographic and birth-related characteristics, including BWT distribution, between patients with and without psychiatric disorders, are summarized in Table 2 and illustrated in Fig. 1. A significant association between higher BWT and psychiatric disorders was identified (odds ratio [OR], 10.08; P=0.017).

Both BWT and LGA status demonstrated significant associations with psychiatric disorders (BWT: OR, 10.080; LGA: OR, 11.662). The results of logistic regression analyses, including ORs and confidence intervals for BWT, LGA status, age, sex, and IUP, are provided in Table 3 and graphically shown in Fig. 2. LGA status was independently associated with psychiatric disorders (OR=11.662, P=0.043). In contrast, IUP, age, and sex did not show significant associations with psychiatric outcomes. Additionally, no significant correlation was found between BWT and body weight at the time of trauma (Pearson’s r=−0.091, P=0.206; Spearman’s rho=0.005, P=0.948).

Discussion

1. Key findings

The results indicate a possible association between BWT, specifically LGA status, and psychiatric outcomes following mild head trauma. However, further studies are necessary to clarify the nature of this relationship. Given the limitations inherent in retrospective studies, prospective research should explore this association in more detail, considering additional confounding factors. Specifically, the role of perinatal factors in increasing vulnerability to psychiatric disorders following mild head trauma warrants further investigation. It is also critical to determine whether LGA status alone might contribute to psychiatric vulnerability independent of trauma.

This study specifically targeted children who had mild head trauma to evaluate whether birth-related factors, such as LGA, influence the risk of psychiatric disorders after neurological stress. This method allows examination of potential interactions between perinatal factors and environmental triggers, interactions that may not be evident when each factor is studied independently. By focusing on mild head trauma, we aimed to assess whether birth characteristics like LGA serve as vulnerability factors under conditions of stress rather than as independent risk factors. Although both BWT and body weight percentile at the time of trauma are important indicators, the relationship between these two measures was not explored here and should be addressed in future studies. Additionally, the absence of a significant association between IUP and psychiatric disorders might result from the exclusion of very preterm infants (<29 weeks) and unmeasured environmental factors, such as parental mental health and genetic predisposition.

2. Potential mechanisms

Several biological mechanisms have been proposed to explain the potential link between BWT, LGA status, and psychiatric outcomes following mild head trauma. These include hormonal imbalances, neurodevelopmental changes, neuroinflammation, white matter vulnerability, and gene-environment interactions.

1) Hormonal and stress response dysregulation

Infants born LGA often exhibit elevated levels of growth-related hormones, such as insulin-like growth factor 1, which influence brain development and stress regulation. Dysregulation of the hypothalamic-pituitary-adrenal axis might increase sensitivity to psychological stress, potentially contributing to psychiatric disorders [19-21].

2) Altered brain development and connectivity

Infants with LGA may experience atypical or accelerated brain growth, leading to imbalances in neuroplasticity and emotional regulation. Such neurodevelopmental changes could elevate the risk for disorders like ADHD or mood disorders [22,23].

3) Immune-related brain changes

LGA status has been associated with variations in early immune function and inflammatory processes, including altered microglial activity crucial to brain maturation. These immune-related differences could affect the brain’s response to injury or stress [24,25].

4) White matter vulnerability

LGA infants are susceptible to perinatal alterations in white matter structure that can affect cognitive and emotional regulation. Such vulnerability might increase susceptibility to psychiatric disorders following head trauma [26,27].

5) Gene-environment interactions

Genetic predispositions influencing brain development may interact with birth characteristics, such as LGA status. These interactions could alter neural responses to stress or injury, influencing long-term psychiatric outcomes [28,29].

In summary, these biological mechanisms may collectively contribute to the heightened risk of psychiatric disorders observed among children with certain birth characteristics, especially under neurological stress such as mild head trauma.

3. Comparison with the existing literature

Previous research has predominantly addressed moderate to severe TBIs in adult populations [30,31]. Most studies have focused on more severe forms of TBI, whereas this investigation specifically examined the association between birth history (BWT, LGA status) and psychiatric outcomes following mild head trauma. Although perinatal factors are recognized to impact neurodevelopmental outcomes, their influence on psychiatric disorders after mild head trauma remains understudied. Consequently, further research in this area is essential.

4. Limitations

This study has several limitations. First, the sample size of the LGA group was relatively small, restricting statistical power and the generalizability of the results. The wide confidence intervals in the logistic regression analysis highlight the necessity for validation in larger and more representative cohorts.

Additionally, the current study did not consider the specific mechanisms of injury, such as trauma type, emotional impact, or the context surrounding the trauma event. Since most psychiatric outcomes involved PTSD, which can be strongly influenced by trauma specifics, the observed association between BWT and psychiatric disorders should be interpreted with caution.

Second, due to the retrospective nature of the study, the reliance on medical records might have led to the underreporting or misclassification of psychiatric disorders. The absence of baseline psychiatric assessments limited the ability to ascertain if certain psychiatric conditions existed before the trauma occurred.

Third, key confounding factors, such as maternal psychiatric history, socioeconomic status, and prenatal environmental exposures, were not accounted for in the analysis. These factors could significantly influence psychiatric outcomes, complicating efforts to isolate an independent relationship between BWT and psychiatric disorders following trauma. Although sensitivity analyses were not possible due to data limitations, future studies should incorporate these variables using stratification or matching techniques.

The wide confidence intervals indicate instability in estimates, suggesting potential overestimation or diminished reliability of the findings. Given the observational study design, further research is needed to clarify these relationships.

Finally, mild head trauma was defined exclusively by GCS scores without consideration of injury mechanisms, loss of consciousness duration, or detailed neuroimaging results—factors that could have affected outcome assessments.

BWT percentile at the time of trauma was unavailable due to the study’s retrospective design. Future studies should include this variable to evaluate its potential role as a mediating factor.

The absence of a significant correlation between BWT and body weight at the time of trauma suggests that BWT might independently impact long-term neuropsychiatric outcomes, irrespective of weight at the time of trauma.

5. Future directions

To address limitations related to causal inference inherent in observational studies, future research should employ prospective cohort or randomized controlled designs to validate these associations.

To improve the reliability of the findings, future research should utilize larger, multicenter prospective cohort studies, thus improving statistical power and the generalizability of findings. Expanding sample sizes, particularly for LGA and SGA groups, will yield more precise risk estimates and reduce variability.

Future studies should also incorporate robust confounding adjustment methods—such as propensity score matching, stratified analyses, and multivariable regression models—to account for essential covariates including parental psychiatric history, socioeconomic status, and delivery methods. To improve diagnostic accuracy and capture subthreshold psychiatric symptoms potentially overlooked in retrospective studies, standardized psychiatric assessments should be employed, and comprehensive long-term follow-up data collected.

To improve risk stratification, future research should incorporate neuroimaging data and trauma-related variables, including injury mechanisms, duration of loss of consciousness, and advanced neuroimaging modalities (e.g., magnetic resonance imaging, diffusion tensor imaging). Longitudinal neuroimaging studies could provide valuable insights into structural and functional changes following mild head trauma, facilitating improved early identification and intervention strategies.

Future investigations into biological mechanisms should include biomarker analyses (e.g., inflammatory markers, stress hormones, neurotrophic factors) and genetic studies. Understanding biological responses to mild head trauma may provide insights into how BWT and neurodevelopment interact, thus enhancing comprehension of long-term psychiatric vulnerability.

Finally, future research should aim to develop predictive models for psychiatric risk stratification, incorporating BWT, gestational age-related growth parameters, neuroimaging results, and other early-life factors. Such predictive models could enable early identification of high-risk children, guiding targeted intervention strategies.

6. Conclusion

This study identified an association between BWT—particularly LGA status—and psychiatric outcomes following mild head trauma. However, the observational design and small sample size of the LGA group require cautious interpretation of results. Wide confidence intervals emphasize the necessity for larger, prospective studies to confirm these findings.

The observed associations may be influenced by unmeasured confounding factors such as maternal psychiatric history and socioeconomic conditions. Therefore, future prospective research should validate these preliminary findings. Incorporating neuroimaging, biomarker analyses, and genetic studies will be essential for clarifying the biological mechanisms underpinning these associations.

Clinically, these findings suggest that perinatal factors, particularly BWT and gestational age, may significantly influence psychiatric risk assessments following mild head trauma. If confirmed in prospective studies, integrating perinatal data into posttraumatic mental health evaluations could improve early detection and intervention strategies.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Author contribution

Conceptualization: BHC. Data curation: KTO. Formal analysis: KTO. Methodology: BHC. Project administration: KTO. Visualization: KTO. Writing - original draft: KTO. Writing - review & editing: BHC.

Acknowledgments

We sincerely thank the institution for providing the data used in this study. This study did not receive any financial, material, or institutional support.

Fig. 1.

Birth weight of children with and without psychiatric disorders.

Fig. 2.

Impact of birth weight, gestational age (GA), age, and sex on the development of psychiatric disorders. BWT, birth weight; LGA, large for gestational age; AGA, appropriate for gestational age.

Table 1.

Demographic characteristics of the patients

Characteristic	Value
GCS
14	1 (0.60)
15	177 (99.40)
Sex
Female	59 (33.10)
Male	119 (66.90)
Age (yr-old)	7.85±5.409 (0-17)
Birth weight (kg)	3.14±0.53
GA (day)	270.01±15.204
SGA/AGA/LGA
SGA	38
AGA	112
LGA	28
Presence of a psychiatric diagnosis
Yes	18 (10.10)
No	160 (89.90)
Type of psychiatric diagnosis
ADHD	3
Adjustment disorder	3
Depression	1
Impulse control disorder	1
PTSD	9
Tourette syndrome	1

Values are presented as number (%) or mean±standard deviation (range).

GCS, Glasgow Coma Scale; GA, gestational age; SGA, small for gestational age; AGA, appropriate for gestational age; LGA, large for gestational age; ADHD, attention-deficit/hyperactivity diagnosis; PTSD, posttraumatic stress disorder.

Table 2.

Differences between patients with psychiatric disorders and those without after mild head trauma

Variable	Presence of a psychiatric diagnosis	Absence of a psychiatric diagnosis	P value
Age	9.67±4.71	7.65±5.46	0.067
Sex
Female	6	53	0.986
Male	12	107	0.986
GA	270.00±9.79	270.01±15.66	0.998
BWT	3.48±0.44	3.11±0.53	0.046

Values are presented as mean±standard deviation or number. Comparison of perinatal factors between children with psychiatric disorders and those without after mild head trauma. A higher BWT was significantly associated with psychiatric disorders (P=0.046). Meanwhile, there were no statistically significant differences in terms of gestational age, sex, and age between children with psychiatric disorders and those without.

GA, gestational age; BWT, birth weight.

Table 3.

Impact of birth weight, GA, age, and sex on the development of psychiatric disorders based on logistic regression analysis

Variable	OR	Lower limit of the confidence interval	Upper limit of the confidence interval	P value
BWT	10.080	1.504	67.543	0.017
LGA (vs. AGA)	11.662	1.087	125.157	0.043
Age	1.094	0.948	1.263	0.218
Sex	0.962	0.212	4.363	0.960
GA	0.997	0.952	1.043	0.889

Logistic regression analysis showing the impact of BWT, LGA, age, sex, and GA on the risk of psychiatric disorder after mild head trauma. BWT and LGA were significantly associated with psychiatric outcomes (BWT: OR, 10.080; LGA: OR, 11.662). However, the wide confidence interval indicated potential estimation uncertainty, thereby suggesting the need for cautious interpretation and further validation in a larger cohort.

GA, gestational age; OR, odds ratio; BWT, birth weight; LGA, large for gestational age; AGA, appropriate for gestational age.

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