Psychological Constructs From the Fear Avoidance Model and Beyond as Predictors for Persisting Symptoms After Concussion: An Integrative Review.

OBJECTIVES: To identify the range of evidence for relationships between psychological factors using the Fear Avoidance Model (FAM) as a guiding framework and relevant clinical outcomes in adult patients with persisting symptoms after concussion (PSaC), develop a comprehensive understanding of psychological factors that have been identified as predictors of clinical outcomes for PSaC, and contribute to the theoretical framework of the FAM for PSaC. DATA SOURCES: Six databases (CINAHL, Embase, PsycINFO, PubMed, SportDiscus, and Web of Science) were searched by a librarian for empirical and theoretical publications and experimental and quasi-experimental study designs. The literature search was not limited by publication date restrictions. Gray literature, with the exception of doctoral dissertations, was excluded. STUDY SELECTION: We included studies in the English language consisting of human participants aged ≥18 years. Articles must have included both outcomes pertaining to PSaC (≥3mo after injury) and psychological constructs. DATA EXTRACTION: One reviewer extracted data from the resulting studies using a standardized data extraction form designed for this review. Two reviewers independently assessed risk of bias using the Quality in Prognosis Studies tool. DATA SYNTHESIS: This review found numerous psychological constructs, some directly linked to the FAM, that have potential prognostic relationships with PSaC. However, research remains limited and some psychological factors central to FAM were only identified in a small number of studies (catastrophizing, cogniphobia, and avoidance), whereas other psychological factors were studied more extensively (anxiety and depression). CONCLUSIONS: There is the need for additional evidence, and this integrative review provides an adaptation of the FAM for PSaC to be used as a guiding preliminary framework for future research. Future research should aim to include psychological factors proposed in this modified FAM to fully understand PSaC.

Computerized adaptive test strategies for the matrix reasoning subtest of the Wechsler Adult Intelligence Scale, 4th Edition (WAIS-IV).

OBJECTIVE: Most neuropsychological tests were developed without the benefit of modern psychometric theory. We used item response theory (IRT) methods to determine whether a widely used test - the 26-item Matrix Reasoning subtest of the WAIS-IV - might be used more efficiently if it were administered using computerized adaptive testing (CAT). METHOD: Data on the Matrix Reasoning subtest from 2197 participants enrolled in the National Neuropsychology Network (NNN) were analyzed using a two-parameter logistic (2PL) IRT model. Simulated CAT results were generated to examine optimal short forms using fixed-length CATs of 3, 6, and 12 items and scores were compared to the original full subtest score. CAT models further explored how many items were needed to achieve a selected precision of measurement (standard error ≤ .40). RESULTS: The fixed-length CATs of 3, 6, and 12 items correlated well with full-length test results (with r = .90, .97 and .99, respectively). To achieve a standard error of .40 (approximate reliability = .84) only 3-7 items had to be administered for a large percentage of individuals. CONCLUSIONS: This proof-of-concept investigation suggests that the widely used Matrix Reasoning subtest of the WAIS-IV might be shortened by more than 70% in most examinees while maintaining acceptable measurement precision. If similar savings could be realized in other tests, the accessibility of neuropsychological assessment might be markedly enhanced, and more efficient time use could lead to broader subdomain assessment.

The Future of Cognitive Screening in Neurodegenerative Diseases.

Cognitive screening instruments (CSI) have variable sensitivity and specificity to the cognitive changes associated with dementia syndromes, and the most recent systematic review found insufficient evidence to support the benefit of cognitive screening tools in older adults residing within the community. Consequently, there is a critical need to improve CSI methods, which have not yet incorporated advances in psychometrics, neuroscience, and technology. The primary goal of this article is to provide a framework for transitioning from legacy CSIs to advanced dementia screening measurement. In line with ongoing efforts in neuropsychology and the call for next-generation digital assessment for early detection of AD, we propose a psychometrically advanced (including application of item response theory methods), automated selective assessment model that provides a framework to help propel an assessment revolution. Further, we present a three-phase model for modernizing CSIs and discuss critical diversity and inclusion issues, current challenges in differentiating normal from pathological aging, and ethical considerations.

Construct identification in the neuropsychological battery: What are we measuring?

OBJECTIVE: Major obstacles to data harmonization in neuropsychology include lack of consensus about what constructs and tests are most important and invariant across healthy and clinical populations. This study addressed these challenges using data from the National Neuropsychology Network (NNN). METHOD: Data were obtained from 5,000 NNN participants and Pearson standardization samples. Analyses included variables from four instruments: Wechsler Adult Intelligence Scale, 4th Edition (WAIS-IV); Wechsler Memory Scale, 4th Edition (WMS-IV); California Verbal Learning Test, 3rd Edition (CVLT3); and Delis-Kaplan Executive Function System (D-KEFS). We used confirmatory factor analysis to evaluate models suggested by prior work and examined fit statistics and measurement invariance across samples. We examined relations of factor scores to demographic and clinical characteristics. RESULTS: For each instrument, we identified four first-order and one second-order factor. Optimal models in patients generally paralleled the best-fitting models in the standardization samples, including task-specific factors. Analysis of the NNN data prompted specification of a Recognition-Familiarity factor on the WMS-IV and an Inhibition-Switching factor on the D-KEFS. Analyses showed strong to strict factorial invariance across samples with expected differences in factor means and variances. The Recognition-Familiarity factor correlated with age more strongly in NNN than in the standardization sample. CONCLUSIONS: Factor models derived from healthy groups generally fit well in patients. NNN data helped identify novel Recognition-Familiarity and Inhibition-Switching factors that were also invariant across samples and may be clinically useful. The findings support efforts to identify evidence-based and optimally efficient measurements of neuropsychological constructs that are valid across groups. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Predicting Clinical Outcomes 7-10 Years after Severe Traumatic Brain Injury: Exploring the Prognostic Utility of the IMPACT Lab Model and Cerebrospinal Fluid UCH-L1 and MAP-2.

BACKGROUND: Severe traumatic brain injury (TBI) is a major contributor to disability and mortality in the industrialized world. Outcomes of severe TBI are profoundly heterogeneous, complicating outcome prognostication. Several prognostic models have been validated for acute prediction of 6-month global outcomes following TBI (e.g., morbidity/mortality). In this preliminary observational prognostic study, we assess the utility of the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) Lab model in predicting longer term global and cognitive outcomes (7-10 years post injury) and the extent to which cerebrospinal fluid (CSF) biomarkers enhance outcome prediction. METHODS: Very long-term global outcome was assessed in a total of 59 participants (41 of whom did not survive their injuries) using the Glasgow Outcome Scale-Extended and Disability Rating Scale. More detailed outcome information regarding cognitive functioning in daily life was collected from 18 participants surviving to 7-10 years post injury using the Cognitive Subscale of the Functional Independence Measure. A subset (n = 10) of these participants also completed performance-based cognitive testing (Digit Span Test) by telephone. The IMPACT lab model was applied to determine its prognostic value in relation to very long-term outcomes as well as the additive effects of acute CSF ubiquitin C-terminal hydrolase-L1 (UCH-L1) and microtubule associated protein 2 (MAP-2) concentrations. RESULTS: The IMPACT lab model discriminated favorable versus unfavorable 7- to 10-year outcome with an area under the receiver operating characteristic curve of 0.80. Higher IMPACT lab model risk scores predicted greater extent of very long-term morbidity (ß = 0.488 p = 0.000) as well as reduced cognitive independence (ß = - 0.515, p = 0.034). Acute elevations in UCH-L1 levels were also predictive of lesser independence in cognitive activities in daily life at very long-term follow-up (ß = 0.286, p = 0.048). Addition of two CSF biomarkers significantly improved prediction of very long-term neuropsychological performance among survivors, with the overall model (including IMPACT lab score, UCH-L1, and MAP-2) explaining 89.6% of variance in cognitive performance 7-10 years post injury (p = 0.008). Higher acute UCH-L1 concentrations were predictive of poorer cognitive performance (ß = - 0.496, p = 0.029), whereas higher acute MAP-2 concentrations demonstrated a strong cognitive protective effect (ß = 0.679, p = 0.010). CONCLUSIONS: Although preliminary, results suggest that existing prognostic models, including models with incorporation of CSF markers, may be applied to predict outcome of severe TBI years after injury. Continued research is needed examining early predictors of longer-term outcomes following TBI to identify potential targets for clinical trials that could impact long-ranging functional and cognitive outcomes.

Estimated Duration of Continued Sport Participation Following Concussions and Its Association with Recovery Outcomes in Collegiate Athletes: Findings from the NCAA/DoD CARE Consortium.

BACKGROUND: Continued participation after sport-related concussion (SRC) worsens outcomes, but it is unknown if duration of continued participation after SRC impacts recovery outcomes, and which athletes who continue to participate are at greatest risk for poor SRC outcomes. The purpose of this National Collegiate Athletic Association/Department of Defense (NCAA/DoD) Concussion Assessment, Research, and Education (CARE) Consortium study was to evaluate the association of estimated duration of continued participation after SRC with symptom severity and recovery time in collegiate athletes. METHODS: Clinicians estimated if/how long athletes continued participation after SRC. Collegiate athletes who continued participation after suspected SRC (n = 195/373, 52.3%) completed the Graded Symptom Checklist to evaluate the severity of total symptoms and migraine/fatigue, cognitive/ocular, and affective symptom clusters. Linear regression analyzed the associations between estimated duration of continued participation, symptom severity, and recovery time. Binary logistic regression examined the association of estimated duration of continued participation with the odds of recovery ≥ 14 and ≥ 21 days. Statistical significance was p < 0.05. RESULTS: Athletes who continued to participate did so for 27.9 ± 25.3 min (mean ± standard deviation; range 1-90 min). Longer estimated continued participation (1-90 min) was associated with greater symptom severity (ß = 0.122, p = 0.02), affective (ß = 0.171, p = 0.001) and migraine/fatigue symptoms (ß = 0.104, p = 0.049), longer symptom duration (ß = 0.193, p < 0.001), and longer time missed (ß = 0.156, p = 0.003). Longer estimated continued participation positively interacted with female sex (cognitive/ocular: female R2 = 0.03, male R2 = 0.01, p = 0.02; affective: female R2 = 0.06, male R2 = 0.02, p = 0.006), migraine history (affective symptoms: no migraine R2 = 0.02; migraine R2 = 0.18; p = 0.04), and concussion history (affective: 2 + prior concussions [R2 = 0.14] compared with those with 1 [R2 = 0.07] or 0 [R2 < 0.01] prior concussions [p = 0.003]). CONCLUSIONS: Longer estimated duration of continued participation after SRC was associated with higher symptom severity, particularly affective and migraine/fatigue; longer symptom duration; and more time missed from sport. SRC outcomes in those who continue to play may be especially severe for female athletes, athletes with migraine history, and athletes with prior concussion(s). The findings can help clinicians and administrators to educate athletes on the importance of immediate removal following a suspected SRC.

Rationale and Design of the National Neuropsychology Network.

OBJECTIVE: The National Neuropsychology Network (NNN) is a multicenter clinical research initiative funded by the National Institute of Mental Health (NIMH; R01 MH118514) to facilitate neuropsychology's transition to contemporary psychometric assessment methods with resultant improvement in test validation and assessment efficiency. METHOD: The NNN includes four clinical research sites (Emory University; Medical College of Wisconsin; University of California, Los Angeles (UCLA); University of Florida) and Pearson Clinical Assessment. Pearson Q-interactive (Q-i) is used for data capture for Pearson published tests; web-based data capture tools programmed by UCLA, which serves as the Coordinating Center, are employed for remaining measures. RESULTS: NNN is acquiring item-level data from 500-10,000 patients across 47 widely used Neuropsychology (NP) tests and sharing these data via the NIMH Data Archive. Modern psychometric methods (e.g., item response theory) will specify the constructs measured by different tests and determine their positive/negative predictive power regarding diagnostic outcomes and relationships to other clinical, historical, and demographic factors. The Structured History Protocol for NP (SHiP-NP) helps standardize acquisition of relevant history and self-report data. CONCLUSIONS: NNN is a proof-of-principle collaboration: by addressing logistical challenges, NNN aims to engage other clinics to create a national and ultimately an international network. The mature NNN will provide mechanisms for data aggregation enabling shared analysis and collaborative research. NNN promises ultimately to enable robust diagnostic inferences about neuropsychological test patterns and to promote the validation of novel adaptive assessment strategies that will be more efficient, more precise, and more sensitive to clinical contexts and individual/cultural differences.

Behavioral and Cognitive Aspects of Concussion.

PURPOSE OF REVIEW: This review provides the reader with an overview of concussion and mild traumatic brain injury (TBI). Key aspects of the pathophysiology, signs, and symptoms, treatment and rehabilitation, and recovery from concussion/mild TBI are reviewed with an emphasis on the variety of factors that may contribute to cognitive concerns following injury. RECENT FINDINGS: Concussion remains a clinical diagnosis based on symptoms that occur in the immediate aftermath of an applied force and in the hours, days, and weeks thereafter. Although advances have been made in advanced diagnostics, including neuroimaging and fluid biomarkers in hopes of developing objective indicators of injury, such markers currently lack sufficient specificity to be used in clinical diagnostics. The symptoms of concussion are heterogeneous and may be seen to form subtypes, each of which suggests a targeted rehabilitation by the interdisciplinary team. Although the majority of patients with concussion recover within the first 30 to 90 days after injury, some have persistent disabling symptoms. The concept of postconcussion syndrome, implying a chronic syndrome of injury-specific symptoms, is replaced by a broader concept of persistent symptoms after concussion. This concept emphasizes the fact that most persistent symptoms have their basis in complex somatic, cognitive, psychiatric, and psychosocial factors related to risk and resilience. This framework leads to the important conclusion that concussion is a treatable injury from which nearly all patients can be expected to recover. SUMMARY: Concussion/mild TBI is a significant public health problem in civilian, military, and organized athletic settings. Recent advances have led to a better understanding of underlying pathophysiology and symptom presentation and efficacious treatment and rehabilitation of the resulting symptoms. An interdisciplinary team is well-positioned to provide problem-oriented, integrated care to facilitate recovery and to advance the evidence base supporting effective practice in diagnosis, treatment, and prevention.

The Effect of Aerobic Exercise on Concussion Recovery: A Pilot Clinical Trial.

OBJECTIVE: The purpose of this study was to pilot safety and tolerability of a 1-week aerobic exercise program during the post-acute phase of concussion (14-25 days post-injury) by examining adherence, symptom response, and key functional outcomes (e.g., cognition, mood, sleep, postural stability, and neurocognitive performance) in young adults. METHOD: A randomized, non-blinded pilot clinical trial was performed to compare the effects of aerobic versus non-aerobic exercise (placebo) in concussion patients. The study enrolled three groups: 1) patients with concussion/mild traumatic brain injury (mTBI) randomized to an aerobic exercise intervention performed daily for 1-week, 2) patients with concussion/mTBI randomized to a non-aerobic (stretching and calisthenics) exercise program performed daily for 1-week, and 3) non-injured, no intervention reference group. RESULTS: Mixed-model analysis of variance results indicated a significant decrease in symptom severity scores from pre- to post-intervention (mean difference = -7.44, 95% CI [-12.37, -2.20]) for both concussion groups. However, the pre- to post-change was not different between groups. Secondary outcomes all showed improvements by post-intervention, but no differences in trajectory between the groups. By three months post-injury, all outcomes in the concussion groups were within ranges of the non-injured reference group. CONCLUSIONS: Results from this study indicate that the feasibility and tolerability of administering aerobic exercise via stationary cycling in the post-acute time frame following post-concussion (14-25 days) period are tentatively favorable. Aerobic exercise does not appear to negatively impact recovery trajectories of neurobehavioral outcomes; however, tolerability may be poorer for patients with high symptom burden.

Double blind randomized controlled trial of deep brain stimulation for obsessive-compulsive disorder: Clinical trial design.

Obsessive-compulsive disorder (OCD), a leading cause of disability, affects ~1-2% of the population, and can be distressing and disabling. About 1/3 of individuals demonstrate poor responsiveness to conventional treatments. A small proportion of these individuals may be deep brain stimulation (DBS) candidates. Candidacy is assessed through a multidisciplinary process including assessment of illness severity, chronicity, and functional impact. Optimization failure, despite multiple treatments, is critical during screening. Few patients nationwide are eligible for OCD DBS and thus a multi-center approach was necessary to obtain adequate sample size. The study was conducted over a six-year period and was a NIH-funded, eight-center sham-controlled trial of DBS targeting the ventral capsule/ventral striatum (VC/VS) region. There were 269 individuals who initially contacted the sites, in order to achieve 27 participants enrolled. Study enrollment required extensive review for eligibility, which was overseen by an independent advisory board. Disabling OCD had to be persistent for ≥5 years despite exhaustive medication and behavioral treatment. The final cohort was derived from a detailed consent process that included consent monitoring. Mean illness duration was 27.2 years. OCD symptom subtypes and psychiatric comorbidities varied, but all had severe disability with impaired quality of life and functioning. Participants were randomized to receive sham or active DBS for three months. Following this period, all participants received active DBS. Treatment assignment was masked to participants and raters and assessments were blinded. The final sample was consistent in demographic characteristics and clinical features when compared to other contemporary published prospective studies of OCD DBS. We report the clinical trial design, methods, and general demographics of this OCD DBS sample.

Making a Difference: Affective Distress Explains Discrepancy Between Objective and Subjective Cognitive Functioning After Mild Traumatic Brain Injury.

OBJECTIVE: To assess the relationship between subjective cognitive symptoms and objective cognitive test scores in patients after concussion. We additionally examined factors associated with subjective and objective cognitive dysfunction, as well as their discrepancy. PARTICIPANTS: Eighty-six individuals (65.1% female; 74.4% adult) from an interdisciplinary concussion clinic. METHODS: Subjective and objective cognitive functioning was measured via the SCAT-Symptom Evaluation and the CNS Vital Signs Neurocognition Index (NCI), respectively. Cognitive discrepancy scores were derived by calculating standardized residuals (via linear regression) using subjective symptoms as the outcome and NCI score as the predictor. Hierarchical regression assessed predictors (age, education, time postinjury, attention-deficit/hyperactivity disorder, affective distress, and sleep disturbance) of cognitive discrepancy scores. Nonparametric analyses evaluated relationships between predictor variables, subjective symptoms, and NCI. RESULTS: More severe affective and sleep symptoms (large and medium effects), less time postinjury (small effect), and older age (small effect) were associated with higher subjective cognitive symptoms. Higher levels of affective distress and less time since injury were associated with higher cognitive discrepancy scores (ß = .723, P < .001; ß = -.204, P < .05, respectively). CONCLUSION: Clinical interpretation of subjective cognitive dysfunction should consider these additional variables. Evaluation of affective distress is warranted in the context of higher subjective cognitive complaints than objective test performance.

Impact of a Sleep Enhancement Protocol on Nighttime Room Entries in an Inpatient Rehabilitation Facility.

PURPOSE: This study examined whether a sleep enhancement protocol (SEP) could reduce nighttime room entries (NREs) for patients with orthopedic injury (OI) or acquired brain injury (ABI) in an inpatient rehabilitation facility. DESIGN: A two-wave prospective study assessing standard of care (SOC) versus SEP. METHODS: Sixty-five participants completed baseline and follow-up questionnaires and wore an actigraph for approximately 7 days. In the SEP, nighttime care was "bundled." FINDINGS: In SOC, NREs were associated with less efficient sleep and greater daytime fatigue. Nighttime room entries were approximately 50% lower in the SEP than SOC. Participants in the OI SOC had more room entries than any other group. There were no significant changes in room entries in the ABI SEP group. CONCLUSIONS: There was a relationship between NREs and sleep. The SEP was effective at reducing NREs for patients with OI, but not ABI. CLINICAL RELEVANCE: Sleep enhancement protocols in inpatient rehabilitation facilities may be effective at improving sleep. Future research may focus on developing individualized protocols to improve sleep across patients with a variety of presenting diagnoses.

Impaired motor control after sport-related concussion could increase risk for musculoskeletal injury: Implications for clinical management and rehabilitation.

This review presents a conceptual framework and supporting evidence that links impaired motor control after sport-related concussion (SRC) to increased risk for musculoskeletal injury. Multiple studies have found that athletes who are post-SRC have higher risk for musculoskeletal injury compared to their counterparts. A small body of research suggests that impairments in motor control are associated with musculoskeletal injury risk. Motor control involves the perception and processing of sensory information and subsequent coordination of motor output within the central nervous system to perform a motor task. Motor control is inclusive of motor planning and motor learning. If sensory information is not accurately perceived or there is interference with sensory information processing and cognition, motor function will be altered, and an athlete may become vulnerable to injury during sport participation. Athletes with SRC show neuroanatomic and neurophysiological changes relevant to motor control even after meeting return to sport criteria, including a normal neurological examination, resolution of symptoms, and return to baseline function on traditional concussion testing. In conjunction, altered motor function is demonstrated after SRC in muscle activation and force production, movement patterns, balance/postural stability, and motor task performance, especially performance of a motor task paired with a cognitive task (i.e., dual-task condition). The clinical implications of this conceptual framework include a need to intentionally address motor control impairments after SRC to mitigate musculoskeletal injury risk and to monitor motor control as the athlete progresses through the return to sport continuum.

Validity of teleneuropsychology for older adults in response to COVID-19: A systematic and critical review.

Objective: Due to the recent COVID-19 pandemic, the field of neuropsychology must rapidly evolve to incorporate assessments delivered via telehealth, or teleneuropsychology (TNP). Given the increasing demand to deliver services electronically due to public health concerns, it is important to review available TNP validity studies. This systematic review builds upon the work of Brearly and colleagues' (2017) meta-analysis and provides an updated review of the literature, with special emphasis on test-level validity data.Method: Using similar methodology as Brearly and colleagues (2017) three internet databases (PubMed, EBSCOhost, PsycINFO) were searched for relevant articles published since 2016. Studies with older adults (aged 65+) who underwent face-to-face and TNP assessments in a counterbalanced cross-over design were included. After review, 10 articles were retained. Combined with nine articles from Brearly's analysis, a total of 19 studies were included in the systematic review.Results: Retained studies included samples from 5 different countries, various ethnic/cultural backgrounds, and diverse diagnostic populations. Test-level analysis suggests there are cognitive screeners (MMSE, MoCA), language tests (BNT, Letter Fluency), attention/working memory tasks (Digit Span Total), and memory tests (HVLT-R) with strong support for TNP validity. Other measures are promising but lack sufficient support at this time. Few TNP studies have done in-home assessments and most studies rely on a PC or laptop.Conclusions: Overall, there appears to be good support for TNP assessments in older adults. Challenges to TNP in the current climate are discussed. Finally, a provisional outline of viable TNP procedures used in our clinic is provided.

Correction to: A Normative Reference vs. Baseline Testing Compromise for ImPACT: The CARE Consortium Multiple Variable Prediction (CARE-MVP) Norms.

Unfortunately, in the published article the symbol "% ile" has incorrectly been published as "‰". We have now corrected this in all the occurrences.

A Normative Reference vs. Baseline Testing Compromise for ImPACT: The CARE Consortium Multiple Variable Prediction (CARE-MVP) Norms.

BACKGROUND: Sports medicine clinicians routinely use computerized neurocognitive testing in sport-related concussion management programs. Debates continue regarding the appropriateness of normative reference comparisons versus obtaining individual baseline assessments, particularly for populations with greater likelihood of having below- or above-average cognitive abilities. Improving normative reference methods could offer alternatives to perceived logistical and financial burdens imposed by universal baseline testing. OBJECTIVES: To develop and validate the Concussion Assessment, Research, and Education (CARE) Consortium Multiple Variable Prediction (MVP) norms for the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT). METHODS: We developed the CARE-MVP norms for ImPACT composite scores using regression-based equations. Predictor variables included sex, race (white/Caucasian, black/African American, Asian, or Multiple Races), medical history [attention-deficit/hyperactivity disorder (ADHD), learning disorder (LD), prior concussion(s), prior psychiatric diagnosis], and an estimate of premorbid intellect (Wechsler Test of Adult Reading). CARE-MVP norms were first validated in an independent sample of healthy collegiate athletes by comparing predicted and actual baseline test scores using independent-samples t-tests and Cohen's d effect sizes. We then evaluated base rates of low scores in athletes self-reporting ADHD/LD (vs. non-ADHD/LD) and black/African American race (vs. white/Caucasian) across multiple normative reference methods (Chi square, Cramer's V effect size). Lastly, we validated the CARE-MVP norms in a concussed sample (dependent samples t test, Cohen's d effect size). RESULTS: A total of 5233 collegiate athletes (18.8 ± 1.2 years, 70.5% white/Caucasian, 39.1% female) contributed to the CARE-MVP norms (development N = 2616; internal validation N = 2617). Race and WTAR score were the strongest and most consistent ImPACT score predictors. There were negligible mean differences between observed and predicted (CARE-MVP) baseline scores (Cohen's d < 0.1) for all ImPACT composite scores except Reaction Time (predicted ~ 20 ms faster than observed, d = - 0.28). Low score base rates were similar for athletes across subpopulations when using CARE-MVP norms (ADHD/LD, V = 0.017-0.028; black/African American, V = 0.043-0.053); while, other normative reference methods resulted in disproportionately higher rates of low scores (ADHD/LD, V = 0.062-0.101; black/African American race, V = 0.163-0.221). Acute (24-48 h) postconcussion ImPACT scores were significantly worse than CARE-MVP norms but notably varied as a function of concussion symptom severity. CONCLUSIONS: Results support CARE-MVP norm use in populations typically underrepresented or not adjusted for in traditional normative reference samples, such as those self-reporting ADHD/LD or black/African American race. CARE-MVP norms improve upon prior normative methods and may offer a practical, simple alternative for collegiate institutions concerned about logistical and financial burden associated with baseline testing. An automated scoring program is provided.

Acute Effects of Sport-Related Concussion on Serum Glial Fibrillary Acidic Protein, Ubiquitin C-Terminal Hydrolase L1, Total Tau, and Neurofilament Light Measured by a Multiplex Assay.

We prospectively evaluated serum concentrations of glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase L1 (UCH-L1), total tau (T-Tau), and neurofilament light (NF-L) from collegiate athletes at baseline and acutely after sport-related concussion (SRC) using the Quanterix Neurology 4Plex "B" (N4PB) multiplex assay. Uninjured controls were matched on age, sex, race, sport, and concussion history. Clinical outcomes included acute symptom severity, balance, rapid automated naming, computerized cognitive testing, and recovery duration. Baseline (n = 110; median [interquartile range] age = 19 [18-20] years, 54% male, 61% white/Caucasian) and post-SRC (n = 36; median [interquartile range] age = 19 [18-20] years, 50% male, 61% white/Caucasian) blood samples were analyzed. We observed post-SRC elevations from baseline for GFAP (p = 0.001, d = 1.7), T-Tau (p = 0.004, d = 1.3), and NF-L (p = 0.010, d = 1.1). GFAP (area under the curve [AUC] = 0.958, 95% confidence interval [CI] 0.927-0.989, p < 0.001) and NF-L (AUC = 0.904, 95% CI 0.851-0.957, p < 0.001) accurately discriminated SRC from control cases. There were no associations between biomarker concentrations and clinical measurements post-SRC or recovery duration. These findings suggest that, using the multiplex assay, GFAP, T-Tau, and NF-L elevate from baseline acutely after SRC, and both GFAP and NF-L excellently distinguished concussed from control cases. Serum biomarker changes do not necessarily correspond with clinical measurements or recovery duration.

The other face of illness-deception: Diagnostic criteria for factitious disorder with proposed standards for clinical practice and research.

Objective: This paper aims to develop diagnostic criteria for factitious disorder (FD) and a heuristic for research by creating standards for delineating criterion groups.Method: Both FD and malingering are conceptualized within a rubric of illness-deception. The history of FD research was compared to the research history on malingering. Differences in the measurement of these constructs were described. The potential utility of performance validity tests (PVTs) and symptom validity tests (SVTs) in FD is discussed in light of successful applications in malingering. Methods for obtaining evidence for FD are delineated in a table of diagnostic criteria.Results: The comparison of FD and malingering research shows that the scientific measurement of malingering evolved rapidly with the introduction of forced-choice validity testing and cogent guidelines for the formation of criterion groups. Likewise, PVTs and SVTs hold promise as methods of measuring deceptive behavior in FD. The most salient differences between FD and malingering are understood to be matter of context/setting: malingering occurs in an external incentive context, while FD occurs in a medical/psychological context. Guidelines to assess FD are developed to fill the need for known-groups research.Conclusions: Evidence for FD, a form of illness-deception, can be obtained by using validity testing, which, together with careful clinical observation, allows for the development of probabilistic diagnostic criteria. Similar to the other form of illness-deception - malingering - these criteria can be used to form known groups for research.

SCAT5 vs. SCAT3 Symptom Reporting Differences and Convergent Validity in Collegiate Athletes.

OBJECTIVE: The Sport Concussion Assessment Tool (SCAT), fifth Edition, Symptom Evaluation (S5SE) differs from previous versions by having examinees report trait (i.e. "typical" feelings) as opposed to state (i.e., "how you feel right now") concussion-like symptoms at baseline. This study assessed differences among, and convergent validity of, scores on the S5SE, SCAT3 Symptom Evaluation (S3SE), and the Brief Symptom Inventory (BSI-18). METHODS: A total of 113 University of Florida varsity athletes completed symptom questionnaires on the same day in a counterbalanced administration. The final sample consisted of 94 participants (mean age ± SD = 18.4 ± 0.8 years, 57% male, 65% white) from 17 sports. We assessed convergent validity using Spearman rank-order correlations. Within-participant differences were analyzed with Wilcoxon Signed-Rank tests. We qualitatively described free-response answers to the S5SE question that asks, "if not feeling 100%, why?". RESULTS: S5SE total severity score demonstrated adequate convergent validity with both the S3SE (rho = .407, p < .001) and BSI-18 (rho = .432, p < .001). Domain-specific analyses indicated variable convergent validity (rho < 0.4 to rho > 0.6). Severity scores did not differ between the S3SE and S5SE (p = .500), but 24.5% of participants reported S3SE > S5SE and 34.0% S5SE > S3SE. Three themes emerged from qualitative examination of reasons for "not feeling 100%": (1) tiredness/sleep, (2) adjustment difficulties, and (3) academic/athletic stress. CONCLUSIONS: Adequate convergent validity exists between SCAT5 and SCAT3 symptom severity in collegiate athletes. However, most examinees report different baseline symptom severity when asked to describe their trait (S5SE) versus state symptoms (S3SE). Clinicians should consider using the new SCAT5 Symptom Evaluation as a screening tool for identifying otherwise healthy or "undiagnosed" individuals who would benefit from targeted interventions.