Social Determinants of Health and Health Equity in the Treatment and Rehabilitation of Sport-Related Concussion: A Content Analysis of Intervention Research and Call-To-Action.

This review was designed to (i) determine the extent to which the clinical science on sport-related concussion treatment and rehabilitation has considered social determinants of health (SDoH) or health equity and (ii) offer recommendations to enhance the incorporation of SDoH and health equity in concussion treatment research and clinical care. The Concussion in Sport Group consensus statement (2023) was informed by two systematic reviews examining prescribed rest or exercise following concussion and targeted interventions to facilitate concussion recovery. We examined 31 studies, including 2,698 participants, from those two reviews. Race (k=6; 19.4%) and ethnicity (k=4; 12.9%) were usually not reported. Four studies examined ethnicity (i.e., Hispanic), exclusively as a demographic category. Five studies (16.1%) examined race as a demographic category. Three studies (9.7%) examined socioeconomic status (SES; measured as household income) as a demographic category/sample descriptor and one study (3.2%) examined SES in depth, by testing whether the treatment and control groups differed by SES. Five studies examined a SDoH domain in a descriptive manner and four studies in an inferential/intentional manner. No study mentioned SDoH, health equity, or disparities by name. Many studies (61.3%) excluded participants based on demographic, sociocultural, or health factors, primarily due to language proficiency. The new consensus statement includes recommendations for concussion treatment and rehabilitation that rely on an evidence base that has not included SDoH or studies addressing health equity. Researchers are encouraged to design treatment and rehabilitation studies that focus specifically on under-represented groups to determine if they have specific and unique treatment and rehabilitation needs, whether certain practical modifications to treatment protocols might be necessary, and whether completion rates and treatment adherence and response are similar.

Adverse childhood experiences are associated with perceived cognitive difficulties among high school students in the United States.

Objective: Adverse childhood experiences (ACEs) are associated with mental health and cognitive problems, and mental health problems are associated with perceived cognitive difficulties among adolescents. The unique contribution of ACEs to cognitive difficulties after adjusting for poor mental health is not well understood and represents the purpose of this study. Methods: The Adolescent Behaviors and Experiences Survey was conducted in 2021 with high school students in the United States. Cognitive difficulty was assessed with: 'Because of a physical, mental, or emotional problem, do you have serious difficulty concentrating, remembering, or making decisions?' Four ACEs were examined: sexual violence (lifetime and past 12 months), parental emotional abuse, and parental physical abuse. Students were asked about feeling sad or hopeless (past year), considering suicide (past year), and having poor mental health (past month). Binary logistic regressions examined the association between ACEs and cognitive problems, adjusting for mental health. Results: Participants were 6,945 students. Students reporting poor mental health were very likely to endorse difficulty concentrating, remembering, or making decisions (girls = 81% and boys = 67%). Cognitive difficulty was uncommon among students who denied poor mental health (girls = 17% and boys = 12%). For boys [p < 0.001; R2 = 0.22] and girls [p < 0.001; R2 = 0.31], after adjusting for mental health problems, independent predictors of cognitive difficulties included parental verbal abuse and physical abuse. For girls, lifetime forced sexual intercourse and sexual violence during the past year were also independently associated. Conclusion: ACEs are associated with perceived cognitive difficulty in both adolescent girls and boys, even after adjusting for poor mental health.

The prevalence and correlates of scores falling below ImPACT embedded validity indicators among adolescent student athletes.

Objective: Valid performance on preseason baseline neurocognitive testing is essential for accurate comparison between preseason and post-concussion test results. Immediate Post-Concussion and Cognitive Testing (ImPACT) is commonly used to measure baseline neurocognitive function in athletes. We examined the prevalence of invalid performance on ImPACT baseline testing and identified correlates of invalid performance. Method: The sample included 66,998 adolescents (ages 14-18, M = 15.51 years, SD = 1.22) who completed ImPACT baseline tests between 2009 and 2019. Invalid performance was determined by the embedded validity indicators (EVI). Associations between invalid performance, demographic characteristics, and health conditions were assessed using chi-square tests and odds ratios (ORs). Results: Overall, 7.2% of adolescents had baseline tests identified as invalid by one or more of the EVIs. Individual validity indicators classified between 0.5% and 3.7% tests as invalid. Higher frequencies of invalid scores were observed among youth with neurodevelopmental, academic, and medical conditions. Youth who reported having learning disabilities (n = 3126), receiving special education (n = 3563), or problems with attention-deficit/hyperactivity disorder (ADHD; n = 5104) obtained invalid baselines at frequencies of 16.4%, 16.0%, and 11.1%, respectively. Moreover, youth who reported receiving treatment for a substance use disorder (n = 311) or epilepsy (n = 718) obtained invalid baselines at frequencies of 17.0% and 11.1%, respectively. Conclusions: The base rate of invalid performance on ImPACT's EVIs was approximately 7%, consistent with prior research. Adolescents self-reporting neurodevelopmental conditions, academic difficulties, or a history of treatment for medical conditions obtained invalid baseline tests at higher frequencies. More research is needed to better understand invalid scores in youth with pre-existing conditions.

Social Determinants of Health and Perceived Cognitive Difficulties in High School Students in the United States.

OBJECTIVE: The United States Centers for Disease Control and Prevention (CDC) conducted the Adolescent Behavior and Experiences Survey (ABES) to examine disruption and adversity during the COVID-19 pandemic. We examined the association between social determinants of health (SDoH) and cognitive problems attributed to physical or mental health problems among high school students. METHOD: The ABES was an online survey. Perceived cognitive problems were assessed with the question: "Because of a physical, mental, or emotional problem, do you have serious difficulty concentrating, remembering, or making decisions?" A SDoH index was created by summing endorsements to 12 variables. RESULTS: Participants were 6,992 students, age 14-18, with 3,294 boys (47%) and 3,698 girls (53%). Many adolescents reported experiencing cognitive problems (i.e., 45%), with girls (56%) more likely to report cognitive difficulties than boys (33%) [χ2(1) = 392.55, p < 0.001]. Having poor mental health was strongly associated with cognitive problems in both girls [81%, χ2(1, 3680) = 650.20, p < 0.001] and boys [67%, χ2(1, 3267) = 418.69, p < 0.001]. There was a positive, linear association between the number of SDoH experienced and reporting cognitive problems. Binary logistic regressions were used to identify predictors of cognitive difficulty for both boys and girls (e.g., being bullied electronically, experiencing food insecurity during the pandemic, being treated unfairly because of their race or ethnicity, and being in a physical fight). CONCLUSIONS: A strikingly high proportion of adolescents reported experiencing problems with their cognitive functioning. After adjusting for current mental health problems, several SDoH remained associated with adolescents' reported cognitive difficulties, including experiencing racism, bullying, parental job loss, and food insecurity.

Neighborhood Disadvantage and Clinical Outcome Following Concussion in Adolescents.

Whether social determinants of health are associated with clinical outcome following concussion among adolescents is not well established. The present study examined whether neighborhood-level determinants are associated with clinical recovery time following concussion in adolescents. Participants included adolescent student athletes (n = 130; mean age = 16.6, standard deviation = 1.2; 60.8% boys, 39.2% girls) who attended one of nine selected high schools in Maine, USA. The Area of Deprivation Index (ADI), an indicator of neighborhood disadvantage was used to group high schools as either high or low in neighborhood disadvantage. Athletic trainers entered injury and recovery dates into an online surveillance application between September 2014 and January 2020. Chi-squared analyses and Kaplan-Meier survival analyses were used to compare the groups on two clinical outcomes: days to return to school and days to return to sports. Results of chi-squared tests did not reveal between-group differences in return to school at 21 or 28 days. However, groups differed in the percentage of adolescents who had returned to sports by 21 days (greater neighborhood disadvantage, 62.5%, lesser neighborhood disadvantage 82.0%, χ2 = 4.96, p = 0.03, odds ratio [OR] = 2.73, 95% confidence interval [CI], 1.11-6.74) and 28 days (greater neighborhood disadvantage, 78.6%, lesser neighborhood disadvantage 94.0%, χ2 = 5.18, p = 0.02, OR = 4.27, 95% CI, 1.13-16.16) following concussion. A larger proportion of adolescents attending schools located in areas of greater neighborhood disadvantage took more than 21 and 28 days to return to sports. These results indicate an association between a multi-faceted proxy indicator of neighborhood disadvantage and clinical outcome following concussion. Further research is needed to better characterize factors underlying group differences in time to return to sports and the interactions between neighborhood disadvantage and other correlates of clinical recovery following concussion.

Race, ethnicity, and clinical outcome following sport-related concussion: a systematic review.

Introduction: This systematic review examined whether race or ethnicity are associated with clinical outcomes (e.g., time to return to school/sports, symptom duration, vestibular deficits, and neurocognitive functioning) following sport-related concussion among child, adolescent, or college-aged student athletes. Additionally, this review assessed whether the existing literature on this topic incorporated or included broader coverage of social determinants of health. Methods: The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched. Results: A total of 5,118 abstracts were screened and 12 studies met inclusion criteria, including 2,887 youth and young adults. Among the included articles, only 3 studies (25%) examined whether race and ethnicity were associated with outcomes following concussion as a primary objective. None of the studies assessed the association between social determinants of health and outcomes following concussion as a primary objective, although 5 studies (41.7%) addressed a social determinant of health or closely related topic as a secondary objective. Discussion: Overall, the literature to date is extremely limited and insufficient for drawing conclusions about whether race or ethnicity are categorically associated with outcomes from sport-related concussion, or more specifically, whether there are socioeconomic, structural, or cultural differences or disparities that might be associated with clinical outcome. Systematic review registration: identifier: PROSPERO, CRD42016041479, CRD42019128300.

Neurocognitive Test Performance and Concussion-Like Symptom Reporting Among Adolescent Athletes With Self-Reported Autism on Preseason Assessments.

OBJECTIVE: To examine baseline neurocognitive functioning and symptom reporting among adolescents with self-reported autism. METHOD: Participants in this cross-sectional, observational study were 60,751 adolescents who completed preseason testing. There were 425 students (0.7%) who self-reported an autism spectrum disorder (ASD) diagnosis. Cognitive functioning was measured by Immediate Post-Concussion Assessment and Cognitive Testing and symptom ratings were obtained from the Post-Concussion Symptom Scale. RESULTS: Groups differed significantly across all neurocognitive composites (p values <.002); effect size magnitudes for most differences were small, though among boys a noteworthy difference on visual memory and among girls differences on verbal memory and visual motor speed composites were noted. Among boys, the ASD group endorsed 21 of the 22 symptoms at a greater rate. Among girls, the ASD group endorsed 11 of the 22 symptoms at a greater rate. Some examples of symptoms that were endorsed at a higher rate among adolescents with self-reported autism were sensitivity to noise (girls: odds ratio, OR = 4.38; boys: OR = 4.99), numbness or tingling (girls: OR = 3.67; boys: OR = 3.25), difficulty remembering (girls: OR = 2.01; boys: OR = 2.49), difficulty concentrating (girls: OR = 1.82; boys: OR = 2.40), sensitivity to light (girls: OR = 1.82; boys: OR = 1.76), sadness (girls: OR = 1.72; boys: OR = 2.56), nervousness (girls: OR = 1.80; boys: OR = 2.27), and feeling more emotional (girls: OR = 1.79; boys: OR = 2.84). CONCLUSION: Students with self-reported autism participating in organized sports likely experience a low degree of functional impairment, on average. If they sustain a concussion, their clinical management should be more intensive to maximize the likelihood of swift and favorable recovery.

An At-Home, Virtually Administered Graded Exertion Protocol for Use in Concussion Management: Preliminary Evaluation of Safety and Feasibility for Determining Clearance to Return to High-Intensity Exercise in Healthy Youth and Children With Subacute Concussion.

Graded exertion testing (GXT) is an important tool for concussion management, as it is used to personalize post-concussion exercise prescription and return athletes to sport. However, most GXT requires expensive equipment and in-person supervision. Our objective was to assess the safety and feasibility of the Montreal Virtual Exertion (MOVE) protocol, a no-equipment, virtually compatible GXT, in healthy children and children with subacute concussion. The MOVE protocol consists of seven stages of bodyweight and plyometric exercises performed for 60 sec each. Twenty healthy (i.e., non-concussed) children completed the MOVE protocol virtually over Zoom Enterprise. Next, 30 children with subacute concussion (median: 31.5 days post-injury) were randomized to the MOVE protocol or Buffalo Concussion Treadmill Test (BCTT), which increases the incline or speed of the treadmill every minute until maximum exertion. Out of an abundance of caution, all concussed participants completed the MOVE protocol in an in-person clinical space. However, the test evaluator was stationed in a different room within the clinic and administered the MOVE protocol using Zoom Enterprise software to mimic telehealth conditions. Safety and feasibility outcomes were recorded throughout GXT, including heart rate, rate of perceived exertion (RPE), and symptom outcomes. No adverse events were recorded, and all feasibility criteria were successfully met in healthy youth and youth with concussion. Among concussed youth, increases in heart rate (MOVE: 82.4 ± 17.9 bpm, BCTT: 72.1 ± 23.0 bpm; t(28) = 1.36, p = 0.18), RPE (MOVE: 5.87 ± 1.92, BCTT: 5.07 ± 2.34, t(28) = 1.02, p = 0.32), and overall symptom presentation were similar between the MOVE and BCTT protocols. The MOVE protocol is a safe and feasible GXT in healthy youth and youth with subacute concussion. Future studies should assess the fully virtual administration of the MOVE in children with concussion, MOVE protocol tolerability in children with acute concussion, and whether the MOVE protocol can be used to guide individualized exercise prescription.

Social Determinants of Health and Health Equity in the Diagnosis and Management of Pediatric Mild Traumatic Brain Injury: A Content Analysis of Research Underlying Clinical Guidelines.

We conducted a content analysis of the literature underlying the Centers for Disease Control and Prevention (CDC) Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children (i.e., the "Guideline") to determine the extent to which social determinants of health (SDoH) were examined or addressed. The systematic review forming the basis for the Guideline included 37 studies addressing diagnosis, prognosis, and treatment/rehabilitation. We examined those studies to identify SDoH domains derived from the U.S. Department of Health and Human Services' Healthy People 2020 and 2030 websites. No study explicitly mentioned "social determinants of health," by name, and few studies addressed SDoH domains as a primary focus (ranging from 0% to 27% of studies across SDoH domains). The most frequently represented SDoH domains, described in an inferential or a descriptive manner, were Education Access and Quality (29.7% of studies), Social and Community Context (27.0% of studies), and Economic Stability (21.6% of studies). Health Care Access (13.5% of studies) was less well represented and no studies (0%) examined Neighborhood and Built Environment. In terms of the CDC clinical questions, SDoH were only examined as predictors of outcome (prognosis) and no studies examined SDoH in relation to diagnosis or treatment/rehabilitation. The Guideline includes some commentary on health literacy and socioeconomic status. Overall, social determinants of health are largely unrepresented as important or meaningful variables influencing the Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children, or in the studies that informed the Guideline.

Prior Concussion History and Clinical Recovery After Sport-Related Concussion in High School Athletes.

Clinical recovery after sport-related concussion varies as a function of pre-injury and acute factors. Whether, or the extent to which, concussion history is associated with clinical outcome after sport-related concussion is uncertain, because research has produced mixed findings. The present study aimed to assess whether a history of previous concussions was associated with prolonged clinical recovery after a subsequent sport-related concussion. The sample comprised 780 adolescent student athletes (mean age = 16.3, standard deviation = 1.3 years; 56.8% boys, 43.2% girls) whose school participated in the Maine Concussion Management Initiative (MCMI). Survival analyses were used to compare recovery times among adolescents with a history of 0, 1, or ≥2 previous concussions after a subsequent sport-related concussion. The two primary outcomes of interest were the number of days to return to school and sports. There were no statistically significant differences in total time to return to school and sports, or the proportion of adolescents who returned to school and sports at most intervals (e.g., 7, 14, 28 days), between those with 0, 1, or ≥2 previous concussions. A greater proportion of adolescents, however, with a history of ≥2 previous concussions remained out of sports at 28 days compared with those with no previous concussions (23.5% vs. 12.7%; odds ratio [OR] = 2.10, 95% confidence interval [CI] 1.18-3.73). Having sustained prior concussions was not associated with time to return to school after a subsequent sport-related concussion. A greater proportion of adolescents, however, with two or more previous concussions experienced a prolonged return to sports. Further research is warranted to identify risk factors for worse outcomes among the subset of adolescents with a history of multiple previous concussions who experience prolonged recoveries.

Acute effects of concussion among adolescents with attention-deficit/hyperactivity disorder.

Adolescents with ADHD have a greater lifetime history of concussion and experience concussion-like symptoms in the absence of a concussion, complicating concussion assessment and management. It is well established that individuals who experience greater acute symptoms following concussion are at risk for slower recovery and persistent symptoms. We examined whether youth with ADHD experience worse acute effects, within the first 72 h following concussion, compared to youth without ADHD. We hypothesized that youth with ADHD would perform worse on neurocognitive testing and endorse more severe symptoms acutely following injury, but the magnitude of change from pre injury to post injury would be similar for both groups, and thus comparable to baseline group differences. The sample included 852 adolescents with pre-injury and post-injury ImPACT results (within 72 h); we also conducted supplementary case-control analyses on a subset of youth with and without ADHD matched on demographics and pre-injury health history. For both samples, there were significant interaction effects for the Verbal Memory and Visual Motor Speed composites (p < 0.01, η2=.01-.07, small-medium effect), such that youth with ADHD showed a greater magnitude of diminished cognitive functioning from pre-injury to post-injury testing. There were no significant differences in the magnitudes of changes from pre injury to post injury with regard to overall symptom reporting (i.e., total symptom severity scores, total number of symptoms endorsed); however, there were group differences in endorsement rates for several individual symptoms. Further research is needed to determine whether such differential acute effects are associated with recovery time in youth with ADHD.

Greater Acute Concussion Symptoms Are Associated With Longer Recovery Times in Adolescents.

We examined the association between the severity of acute concussion symptoms and time to return to school and to sports in adolescent student athletes. We hypothesized that there would be an association between the severity of acute symptoms experienced in the first 72 hours and functional recovery such that adolescents with the lowest burden of acute symptoms would have the fastest return to school and sports and those with the highest burden of symptoms would have the slowest return to school and sports. This injury surveillance cohort included 375 adolescent student athletes aged 14-19 years who sustained a sport-related concussion between 2014 and 2020. Athletic trainers documented time to return to school and to sports. A greater proportion of adolescents with the highest acute symptoms remained out of school at 3 (odds ratio [OR] = 2.5, 95% confidence interval [CI] 1.5-4.4), 5 (OR = 2.4, 95% CI 1.4-4.0), 7 (OR = 2.6, 95% CI 1.5-4.3), and 10 days (OR = 2.3, 95% CI 1.3-3.9) compared to those with the lowest acute symptoms. Similarly, a greater proportion of athletes with the highest acute symptoms remained out of sports at 7 (OR = 3.5, 95% CI 1.5-8.1), 10 (OR = 3.1, 95% CI 1.8-5.6), 14 (OR = 1.8, 95% CI 1.1-3.0), and 21 days (OR = 1.9, 95% CI 1.0-3.6) compared to those with the lowest acute symptoms. This study underscores the adverse effect of high acute symptom burden following concussion on return to school and to sports among adolescent student athletes. Conversely, student athletes with a low burden of acute symptoms have a faster return to school and to sports.

Clinical Outcome Following Concussion Among College Athletes with a History of Prior Concussion: A Systematic Review.

BACKGROUND: There is long-standing interest in, and concern about, whether collegiate athletes with a history of concussion will experience worse clinical outcomes, or prolonged recovery, should they sustain a subsequent concussion. OBJECTIVES: This systematic review examined the association between prior concussion history and clinical outcomes following a subsequent sport-related concussion among college-age student athletes. STUDY DESIGN: Systematic review. METHODS: We screened 5,118 abstracts and 619 full-text articles that were appraised to determine whether they met inclusion criteria. We utilized a likelihood heuristic to assess the probability of observing a specific number of statistically significant and nonsignificant studies reporting an association between concussion history and clinical outcomes. We conducted a narrative synthesis of the study findings. RESULTS: Sixteen studies met the inclusion criteria. Thirteen studies reported the number of participants with a history of prior concussions (≥ 1), which totaled 1690 of 4573 total participants (on average 37.0% of study participants; median = 46.0%, range 5.6-63.8%). On the Newcastle-Ottawa Quality Assessment Scale, the risk of bias ratings ranged from 3 to 9 (mean = 5.4, SD = 1.4). Across all studies, 43.8% (k = 7/16) reported at least one statistically significant result among primary analyses showing an association between concussion history and worse clinical outcome. A minority of studies reporting on symptom duration (4/13, 30.8%) and time to return to play (2/7, 28.6%) found an association between concussion history and worse outcome. Studies included in the review reported limited information pertaining to the characteristics of prior concussions, such as presence or duration of loss of consciousness or posttraumatic amnesia, age at first lifetime concussion, time since most recent past concussion, or length of recovery from prior concussions. CONCLUSION: The question of whether college athletes with a prior history of concussion have worse clinical outcome from their next sport-related concussion remains unresolved. The published results are mixed and in aggregate show modest evidence for an association. Many studies have small samples, and only three studies were designed specifically to address this research question. Important outcomes, such as time to return to academics, have not been adequately studied. Larger hypothesis-driven studies considering the number of prior concussions (e.g., 3 or more) are needed. TRIAL REGISTRATION: PROSPERO CRD42016041479, CRD42019128300.

Systematic Review of Pre-injury Migraines as a Vulnerability Factor for Worse Outcome Following Sport-Related Concussion.

Background: Individuals with migraine disorders may be affected differently by concussions compared to individuals without migraine disorders. Prior studies on this topic have had mixed results. The purpose of this study was to systematically examine clinical outcomes following a sport-related concussion in athletes who have a pre-injury history of migraines. Methods: All studies published prior to 15 May 2021 that examined pre-injury migraines as a possible predictor of clinical recovery from concussion were included. The search included (i) sport/athlete-related terms, (ii) concussion-related terms, and (iii) diverse predictor/modifier terms. After removing duplicates, 5,118 abstracts were screened, 538 full-text articles were reviewed, and 27 articles were included for narrative synthesis without meta-analysis (n = 25 with unique samples). Risk of bias was assessed using the domain-based Quality In Prognosis Studies (QUIPS) tool. Results: Most studies did not find pre-injury migraines to be associated with concussion outcome, but several of these studies had small or very small sample sizes, as well as other methodological weaknesses. Risk of bias varied greatly across studies. Some of the larger, better-designed studies suggested pre-injury migraines may be a risk factor for worse concussion outcome. Most articles examined pre-injury migraines as an exploratory/secondary predictor of concussion outcome; very few were designed to examine migraine as the primary focus of the study. Migraine history was predominantly based on self-report and studies included minimal information about migraine (e.g., age of onset, frequency/severity, past treatment). Effect sizes were usually not reported or able to be calculated from reported study data. Conclusion: There is some evidence to suggest that pre-injury migraines may be a vulnerability factor for a worse outcome following concussion, with studies having the lowest risk of bias reporting a positive association. Future studies should focus on improving methodological quality when assessing the relationship between pre-injury migraines and concussion outcome and better characterizing pre-injury migraine status. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128292, identifier: PROSPERO 2019 CRD42019128292.

Clinical Outcome following Sport-Related Concussion among Children and Adolescents with a History of Prior Concussion: A Systematic Review.

Authoritative sources advise clinicians and parents that a history of prior concussion confers increased risk for worse outcome from a future concussion. However, the strength of the evidence supporting such pronouncements and thus the extent to which clinicians should incorporate this information into their care and management of pediatric concussion is unclear. This systematic review critically analyzed and synthesized the literature on the association between a history of prior concussion and prognosis/clinical outcome following a subsequent sport-related concussion among children and adolescents. The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched from inception to May 15, 2021. From 5118 total records screened, 51 studies (46 cohort studies and five case-control studies) met inclusion criteria, reporting concussion recovery or outcome for 26,643 youth. A median of 36% had a prior history of concussion. Across all studies and outcomes, the majority (k = 37, 72.5%) did not find a statistically significant association between lifetime history of concussion and outcome from a subsequent concussion. Important methodological limitations in the literature were identified. Available studies do not provide consistent or compelling evidence that children and adolescents with a history of concussion are at increased risk for worse clinical outcome following a subsequent sport-related concussion-although methodological limitations temper the strength of this conclusion. Clinicians are cautioned against routinely treating children and adolescents with one or more prior injuries differently and more conservatively, because doing so, in some cases, might be counterproductive.

Interpreting change on the Child Sport Concussion Assessment Tool 5th Edition.

OBJECTIVES: The purpose of this study was to examine the one-year test-retest reliability of Child Sport Concussion Assessment Tool 5th Edition component scores and provide recommendations for interpreting change on its component tests. DESIGN: A prospective cohort study was conducted across two years via the Advancing Healthcare Initiatives for Underserved Students (ACHIEVES) Project. METHODS: Participants were 219 children (ages 11 to 12, M = 11.7, SD = 0.5; 52.1% girls, 47.9% boys) playing competitive school-sponsored sports in nine middle schools across a large public-school division in Virginia, USA during the 2017-2018 and 2018-2019 academic years. Athletic Trainers administered the baseline Child Sport Concussion Assessment Tool 5th Edition each year. RESULTS: Test-retest reliability estimates for each Child Sport Concussion Assessment Tool 5th Edition component were low to moderate (ICCs=0.40-0.55). A minority of middle school athletes (15-31%) scored within a different normative classification range upon re-assessment. The following test-retest difference scores occurred in 20% or fewer of the sample: +5 total symptoms, +7 symptom severity, -2 in the Standardized Assessment of Concussion - Child Version total score, and +4 total Modified Balance Error Scoring System balance errors. CONCLUSIONS: Child Sport Concussion Assessment Tool 5th Edition component scores had poor to moderate test-retest reliability coefficients over a one-year period, though most children were classified as falling within the same interpretive category upon re-testing based on local norms. We report the raw score changes that were uncommon in our sample of uninjured children to help clinicians identify changes that might be clinically meaningful.

Attention-Deficit/Hyperactivity Disorder and Outcome from Concussion: Examining Duration of Active Rehabilitation and Clinical Recovery.

AIMS: The objective of this study was to compare recovery time and duration of active rehabilitation following concussion between adolescents with and without attention-deficit/hyperactivity disorder (ADHD). METHODS: A retrospective cohort study was conducted among adolescents presenting to a specialty concussion clinic. One-quarter of the eligible episodes of care were selected. The final sample included 540 adolescents (ages 13-17 years, median age 15 years; 49.8% girls), of which 65 (12.0%) had a pre-injury diagnosis of ADHD. Days to recovery and days of active rehabilitation were examined. RESULTS: ADHD was not associated with recovery time (ADHD: median = 49 days, IQR = 25-77; No ADHD: median = 47 days, IQR = 29-85) in univariate (Z = -0.45; p = 0.65) or multivariable analyses (Hazard Ratio: 1.17 (0.85-1.61); χ2(1) = 0.95; p = 0.33). The duration of active rehabilitation services received did not differ between youth with ADHD (median = 38.5 days, IQR = 27.5-54.5) and without ADHD (median = 37.5 days, IQR = 18.5-66) in univariate (Z = -0.19; p = 0.85) or multivariable analyses (Hazard Ratio: 1.04 (0.67-1.63); χ2(1) = 0.03; p = 0.85). CONCLUSIONS: Our findings support accumulating evidence that ADHD, in and of itself, is not a risk factor for longer recovery or worse outcomes following pediatric concussion.

Cognitive and Psychological Outcomes Following Pediatric Cardiac Arrest.

Cardiac arrest is a rare event in children and adolescents. Those who survive may experience a range of outcomes, from good functional recovery to severe and permanent disability. Many children experience long-term cognitive impairment, including deficits in attention, language, memory, and executive functioning. Deficits in adaptive behavior, such as motor functioning, communication, and daily living skills, have also been reported. These children have a wide range of neurological outcomes, with some experiencing specific deficits such as aphasia, apraxia, and sensorimotor deficits. Some children may experience emotional and psychological difficulties, although many do not, and more research is needed in this area. The burden of pediatric cardiac arrest on the child's family and caregivers can be substantial. This narrative review summarizes current research regarding the cognitive and psychological outcomes following pediatric cardiac arrest, identifies areas for future research, and discusses the needs of these children for rehabilitation services and academic accommodations.

Children with ADHD Have a Greater Lifetime History of Concussion: Results from the ABCD Study.

This case-control study using baseline data from the population cohort Adolescent Brain Cognitive Development (ABCD) Study® compared lifetime history of concussion between children with and without attention-deficit/hyperactivity disorder (ADHD). We hypothesized that children with ADHD would have a greater lifetime history of concussion than children without ADHD. Children were recruited from schools across the United States, sampled to provide strong generalizability to the US population. The current sample included 10,585 children (age: mean = 9.9; standard deviation = 0.6; range 9-10 years; 48.9% girls; 64.6% White), including 1085 with ADHD and 9500 without ADHD. The prevalence of prior concussion among children with ADHD was 7.2% (95% CI: 6.6-7.8%) compared with 3.2% (3.1-3.3%) among children without ADHD, meaning current ADHD status was associated with twice the odds of experiencing a prior concussion [χ2 = 44.54; p < 0.001; odds ratio = 2.34 (1.81-3.03)]. No significant differences were observed in proportion of boys and girls with ADHD who had a prior concussion history. The number of current ADHD symptoms were not meaningfully associated with prior concussion history. Lower socioeconomic status was associated with lower rates of reported concussion, but not differentially in association with ADHD. ADHD is associated with twice the lifetime prevalence of prior concussion before age 11 among children from the general U.S. population. Boys and girls with ADHD did not differ in proportions with prior concussion and concussion history was not related to the number of ADHD symptoms reported by parents.

Child Sport Concussion Assessment Tool 5th Edition: Normative Reference Values in Demographically Diverse Youth.

OBJECTIVES: Examine sociodemographic differences (gender, age, and language spoken at home) on baseline Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) scores and establish normative reference data for the Child SCAT5 among middle school student athletes. DESIGN: Cross-sectional study. SETTING: Nine middle schools in Virginia. PARTICIPANTS: A sample of 1355 athletes playing competitive school-sponsored sports (ages 11-13, M = 12.3 ± 0.8; 40.1% girls, 59.9% boys) during the 2017 and 2018 school year. Certified athletic trainers administered the Child SCAT5 within the first 2 weeks of the sport season. INDEPENDENT VARIABLES: Self-reported gender, age, and language spoken at home. MAIN OUTCOME MEASURES: All Child SCAT5 outcome measures. RESULTS: Gender, age, and language spoken at home were associated with Child SCAT5 scores, but the magnitude of differences was generally small. Specifically, girls endorsed more symptoms (girls: M = 8.4 ± 5.7, boys: M = 7.5 ± 5.7; P = 0.003) and greater symptom severity (girls: M = 11.6 ± 9.4, boys: M = 10.4 ± 9.3; P = 0.006) than boys and performed slightly better than boys on cognitive and balance tasks. Older students performed slightly better than younger students on tests of cognition (eg, SAC-C: 11-year-olds: M = 21.3 ± 2.1, 13-year-olds: M = 21.7 ± 2.1; P = 0.02). Total symptoms (P = 0.01), symptom severity (P = 0.01), immediate memory (P < 0.001), delayed recall (P = 0.001), and SAC-C total scores (P = 0.002) differed across language groups. CONCLUSIONS: Gender, age, and language spoken in the home are associated with baseline scores on multiple components of the Child SCAT5 among middle school students, although the magnitudes of observed differences are small. Normative reference values are provided for clinicians when interpreting Child SCAT5 scores.