Detecting cognitive decline in high-functioning older adults: The relationship between subjective cognitive concerns, frequency of high neuropsychological test scores, and the frontoparietal control network.

OBJECTIVE: Neuropsychologists have difficulty detecting cognitive decline in high-functioning older adults because greater neurological change must occur before cognitive performances are low enough to indicate decline or impairment. For high-functioning older adults, early neurological changes may correspond with subjective cognitive concerns and an absence of high scores. This study compared high-functioning older adults with and without subjective cognitive concerns, hypothesizing those with cognitive concerns would have fewer high scores on neuropsychological testing and lower frontoparietal network volume, thickness, and connectivity. METHOD: Participants had high estimated premorbid functioning (e.g., estimated intelligence ≥75th percentile or college-educated) and were divided based on subjective cognitive concerns. Participants with cognitive concerns (n = 35; 74.0 ± 9.6 years old, 62.9% female, 94.3% White) and without cognitive concerns (n = 33; 71.2 ± 7.1 years old, 75.8% female, 100% White) completed a neuropsychological battery of memory and executive function tests and underwent structural and resting-state magnetic resonance imaging, calculating frontoparietal network volume, thickness, and connectivity. RESULTS: Participants with and without cognitive concerns had comparable numbers of low test scores (≤16th percentile), p = .103, d = .40. Participants with cognitive concerns had fewer high scores (≥75th percentile), p = .004, d = .71, and lower mean frontoparietal network volumes (left: p = .004, d = .74; right: p = .011, d = .66) and cortical thickness (left: p = .010, d = .66; right: p = .033, d = .54), but did not differ in network connectivity. CONCLUSIONS: Among high-functioning older adults, subjective cognitive decline may correspond with an absence of high scores on neuropsychological testing and underlying changes in the frontoparietal network that would not be detected by a traditional focus on low cognitive test scores.

Treatment of chronic symptoms following mild traumatic brain injury with transcranial LED: a sham run-in pilot study of photobiomodulation therapy.

PRIMARY OBJECTIVE: We evaluated whether photobiomodulation with red/near infrared light applied transcranially via light emitting diodes (LED) was associated with reduced symptoms and improved cognitive functioning in patients with chronic symptoms following mild traumatic brain injury. RESEARCH DESIGN: Participants (3 men, 6 women; 22-61 years-old) underwent a 6-week intervention involving 18 40-minute transcranial LED treatment sessions. METHODS AND PROCEDURES: Reliable change indices were calculated for 10 neuropsychological test scores and 3 self-report questionnaires of subjective cognition, post-concussion symptoms, and depression at baseline and following treatment. Questionnaires were also administered after 2-week sham and at 1-month and 2-month follow-ups. MAIN OUTCOME AND RESULTS: Only 2 participants improved on neuropsychological testing. On questionnaires, 4 reported improved cognition, 5 reported improved post-concussion symptoms, and 3 reported improved depression. Significant improvement in 2 or more domains was reported by 4 participants and mostly maintained at both follow-ups. CONCLUSIONS: Most participants did not improve on neuropsychological testing. A minority self-reported improvement in symptoms, potentially explained by the intervention, psychiatric medication changes, placebo effects, or other factors. Selecting participants with different clinical characteristics, and dosing and delivery system changes, may produce different results. A study design accounting for placebo effects appears warranted in future trials.

Intraindividual Variability in Attention-Deficit/Hyperactivity Disorder: An Ex-Gaussian Approach.

Higher intraindividual variability (IIV) of response times is consistently noted in children with attention-deficit/hyperactivity disorder (ADHD). The current study investigated whether an ex-Gaussian estimate of IIV in children ages 6-13 years-old could differentiate between children with and without ADHD. Children completed a computerized go/no-go task to estimate trial-by-trial IIV and a continuous performance test (CPT) to estimate inattention and hyperactivity/impulsivity. Parents completed questionnaires assessing inattention and hyperactive/impulsive behaviors. IIV, commission errors, and attention problems as rated by parents were significantly greater in the ADHD group. Groups did not differ on errors of omission, but IIV was predictive of omission errors and parent ratings of inattention and hyperactivity/impulsivity. IIV predicted group membership (ADHD vs Control) whereas errors of omission did not. However, IIV did not improve diagnostic accuracy when parent ratings were used, such that parent ratings were superior at determining diagnosis. Current results support the use of IIV, based on the ex-Gaussian approach, as an objective measure of attention problems over omission errors on sustained attention CPT-type tasks. Additionally, while parent ratings of attention impairment remain the best predictor of ADHD diagnostic status, IIV may be helpful in determining when further assessment is required in the absence of those ratings.

Recent Advances in Neuropsychological Test Interpretation for Clinical Practice.

Much attention in the field of clinical neuropsychology has focused on adapting to the modern healthcare environment by advancing telehealth and promoting technological innovation in assessment. Perhaps as important (but less discussed) are advances in the development and interpretation of normative neuropsychological test data. These techniques can yield improvement in diagnostic decision-making and treatment planning with little additional cost. Brooks and colleagues (Can Psychol 50: 196-209, 2009) eloquently summarized best practices in normative data creation and interpretation, providing a practical overview of norm development, measurement error, the base rates of low scores, and methods for assessing change. Since the publication of this seminal work, there have been several important advances in research on development and interpretation of normative neuropsychological test data, which may be less familiar to the practicing clinician. Specifically, we provide a review of the literature on regression-based normed scores, item response theory, multivariate base rates, summary/factor scores, cognitive intraindividual variability, and measuring change over time. For each topic, we include (1) an overview of the method, (2) a rapid review of the recent literature, (3) a relevant case example, and (4) a discussion of limitations and controversies. Our goal was to provide a primer for use of normative neuropsychological test data in neuropsychological practice.

Group Differences in Postconcussion Cognitive, Physical, Sleep-Arousal, and Affective Symptom Subscales in High School and Collegiate Athletes by Race, Gender, and Competitive Level.

OBJECTIVE: Prior psychometric research has identified symptom subscales for the Post-Concussion Symptom Scale (PCSS) based on confirmatory factor analysis (CFA), including cognitive, physical, sleep-arousal, and affective symptom factors. Study objectives included: (1) replicate the 4-factor PCSS model in a diverse sample of athletes with concussion, (2) test the model for invariance across race, gender, and competitive level, and (3) compare symptom subscale and total symptom scores across concussed groups with established invariance. SETTING: Three regional concussion care centers. PARTICIPANTS: A total of 400 athletes who completed the PCSS within 21 days of concussion (64% boys/men, 35% Black, and 69.5% collegiate athletes). DESIGN: Cross-sectional. MAIN MEASURES: A CFA tested the 4-factor model and measurement invariance testing was performed across racial, competitive level, and gender groups. Symptom subscales and total symptom severity scores were compared based on demographic groupings with established invariance. RESULTS: The 4-factor model fit well and strong invariance was established across all demographic categories, indicating symptom subscales could be meaningfully compared across groups. Black and White athletes differed on total symptoms (U = 15 714.5, P = .021, r = 0.12), sleep-arousal symptoms (U = 15 953.5, P = .026, r = 0.11), and physical symptoms (U = 16 140, P = .051, r = 0.10), with Black athletes reporting slightly more symptoms. Collegiate athletes reported greater total symptom severity (U = 10 748.5, P < .001, r = 0.30), with greater symptom reporting on the cognitive (U = 12 985, P < .001, r = 0.21), sleep-arousal (U = 12 594, P < .001, r = 0.22), physical (U = 10 959, P < .001, r = 0.29), and emotional (U = 14 727.5, P = .005, r = 0.14) symptom subscales. There were no significant differences by gender in the total symptom score or subscale scores. After controlling for time since injury, no racial differences persisted, but a significant difference by competitive level in physical symptom reporting (F = 7.39, P = .00, η2 = 0.02) and total symptom reporting (F = 9.16, P = .003, η2 = 0.02) remained. CONCLUSION: These results provide external validation for the PCSS 4-factor model and demonstrate that symptom subscale measurements are comparable across race, genders, and competitive levels. These findings support the continued use of the PCSS and 4-factor model for assessing a diverse population of concussed athletes.

A Network Analysis of Executive Functions in Children and Adolescents With and Without Attention-Deficit/Hyperactivity Disorder.

This study applied network analysis to executive function test performances to examine differences in network parameters between demographically matched children and adolescents with and without attention-deficit/hyperactivity disorder (ADHD) (n = 141 per group; M = 12.7 ± 2.9 years-old; 72.3% boys, 66.7% White, 65.2% ≥ 12 years maternal education). All participants completed the NIH Toolbox Cognition Battery, including the Flanker, measuring inhibition, Dimensional Change Card Sort, measuring shifting, and List Sorting test, measuring working memory. Children with and without ADHD had comparable mean test performances (d range: .05-0.11) but presented with differences in network parameters. Among participants with ADHD, shifting was less central, had a weaker relationship with inhibition, and did not mediate the relationship between inhibition and working memory. These network characteristics were consistent with the executive function network structure of younger ages in prior research and may reflect an immature executive function network among children and adolescents with ADHD, aligning with the delayed maturation hypothesis.

Examining associations between intelligence mindset, mental health symptom severity, and academic self-efficacy and performance.

Individuals possess different beliefs regarding the malleability of intelligence, also known as intelligence mindsets. Despite evidence demonstrating a link between a growth mindset of intelligence-the belief that intelligence can develop through effort-and academic achievement, this link has not been closely examined from a mental health perspective. Given the increasing prevalence of mental health conditions, such as anxiety and depression, among undergraduate students, an important question is whether the well-established link between mental health symptom severity and academic outcomes depends on the intelligence mindset beliefs that individuals possess. A growth mindset of intelligence might buffer the negative impact of anxiety and depression on academic outcomes, whereas a fixed mindset-the belief that intelligence cannot be changed-might exacerbate this negative relationship. The present study examined data collected from 660 undergraduate psychology students in the United States to test whether intelligence mindset beliefs moderated the relationship between mental health symptom severity and various indicators of academic outcomes: academic self-efficacy, GPA, and perceived academic standing. Results revealed that intelligence mindset beliefs did not moderate the observed negative association between mental health symptom severity and academic outcomes. Findings indicate that promoting a growth mindset of intelligence might not be a particularly effective strategy for buffering university students from the negative impact of anxiety and depression on academic outcomes. However, this conclusion is limited by the cross-sectional design of the study, and future prospective research is necessary to further clarify the relationship between intelligence mindset, mental health, and academic outcomes.

Cytomegalovirus and Toxoplasma Gondii Serostatus Prospectively Correlated With Problems in Self-Regulation but not Executive Function Among Older Adults.

OBJECTIVE: Cytomegalovirus (CMV) and Toxoplasma gondii are organisms that may infect the brain and have cognitive and behavioral consequences. We hypothesized that these latent infections would be prospectively associated with poorer cognition and more problems in self-regulation among older adults. METHODS: Older adults (n = 138, mean age = 75.5 years, 59% women) had CMV and T. gondii serostatus tested, crystallized intelligence estimated (North American Adult Reading Test), and executive function (EF; e.g., Trail Making Test) and self-regulation (Behavior Regulation Inventory of Executive Function-Adult) assessed in visits occurring every 6 months (mean visits = 16). RESULTS: CMV+ people (79%) had significantly poorer self-regulation versus CMV- people (21%; behavioral regulation: γ = 0.108, 95% confidence interval [CI] = 0.009-0.206; metacognition: γ = 0.117, 95% CI = 0.005-0.229), but not intelligence or EF. T. gondii+ people (24%) were not significantly different from T. gondii- people (76%) on any outcome. However, T. gondii+ men had better self-regulation versus T. gondii- men, and the opposite was true of women (behavioral regulation interaction: γ = 0.267, 95% CI = 0.093-0.441). CONCLUSIONS: CMV latent infection was associated with more problems in self-regulation, and the magnitude of this difference was clinically significant. T. gondii latent infection was associated with more problems, but only for women. Latent infection might associate with self-regulation but not EF because of factors influencing self-regulation but not neuropsychological test performance, such as values and emotion. Efforts to link latent infection with EFs might, in the future, include the application of those functions to self-regulation in daily life.

Pre-Injury headache and post-traumatic headache in patients with mild traumatic brain injury: neuropsychological, psychiatric, and post-concussion symptom outcomes.

PRIMARY OBJECTIVE: Headache, both before and after injury, has been associated with worse outcome following mild traumatic brain injury (MTBI). This study examined whether three MTBI patient groups - no headache (reported no pre-/post-injury headache), pre-injury headache (reported pre-injury headache, nearly all of whom also reported post-injury headache), and post-traumatic headache only (denied pre-injury headache and reported post-injury headache) - differed in acute-to-subacute outcomes. RESEARCH DESIGN: Cross-sectional observational study. METHODS AND PROCEDURES: Patients within 21 days of a MTBI (n = 291) completed neuropsychological tests and questionnaires evaluating depression, anxiety, and post-concussion symptoms. MAIN OUTCOMES AND RESULTS: Neuropsychological test performances did not differ between headache groups. Participants with pre-injury headache and participants with post-traumatic headache only reported greater change in self-reported physical and cognitive symptoms than participants with no headache. Participants with pre-injury headache reported worse post-injury anxiety symptoms than participants with post-traumatic headache only. CONCLUSIONS: The pre-injury headache and post-traumatic headache only groups did not meaningfully differ in outcome within 21 days of MTBI, but they had worse physical and cognitive symptoms than participants with no headache. Future research should assess whether differences in outcome emerge further from injury and whether specific headache subtypes are differentially associated with outcome.

Preexisting conditions in older adults with mild traumatic brain injuries.

OBJECTIVE: This study examined the prevalence of preexisting conditions that could affect premorbid brain health, cognition, and functional independence among older adults with mild traumatic brain injury (MTBI), and the relationship between preexisting conditions, injury characteristics, and emergency department (ED) discharge location (home versus continued care). METHODS: Older adults (N = 1,427; 55-104 years-old; 47.4% men) who underwent head computed tomography (CT) after acute head trauma were recruited from the ED. Researchers documented preexisting medical conditions retrospectively from hospital records. RESULTS: Multiple preexisting conditions increased in frequency with greater age, including circulatory and nervous system diseases and preexisting abnormalities on head CT. Psychiatric and substance use disorders (SUDs) decreased in frequency with greater age. Among participants with uncomplicated MTBI and GCS = 15, preexisting nervous system diseases and preexisting CT abnormalities were associated with higher odds of continued care for all participants, whereas psychiatric disorders and SUDs were only associated with higher odds of continued care among participants <70 years-old. Preexisting circulatory diseases, loss of consciousness, and amnesia were unassociated with discharge location. CONCLUSIONS: Preexisting medical conditions that could affect brain and cognitive health occur commonly among older adults who sustain MTBIs. These conditions can confound research examining post-injury outcomes within this age group.

The Other Side of the Bell Curve: Multivariate Base Rates of High Scores on the Delis-Kaplan Executive Function System.

OBJECTIVE: Previous researchers have examined the frequency at which healthy participants obtain one or more low scores on neuropsychological test batteries, proposing five psychometric principles of multivariate base rates: (a) low scores are common, with their frequency contingent on (b) the low score cutoff used, (c) the number of tests administered/interpreted, and (d) the demographic characteristics and (e) intelligence of participants. The current study explored whether these principles applied to high scores as well, using the Delis-Kaplan Executive Function System (D-KEFS). METHOD: Multivariate base rates of high scores (≥75th, ≥84th, ≥91st, ≥95th, and ≥98th percentiles) were derived for a three-test, four-test, and full D-KEFS battery, using the adult portion of the normative sample (aged 16-89 years; N = 1050) stratified by education and intelligence. The full D-KEFS battery provides 16 total achievement scores (primary indicators of executive function). RESULTS: High scores occurred commonly for all batteries. For the three-test battery, 24.1% and 12.4% had 1 or more scores ≥95th percentile and ≥98th percentile, respectively. High scores occurred more often for longer batteries: 61.6%, 72.9%, and 87.8% obtained 1 or more scores ≥84th percentile for the three-test, four-test, and full batteries, respectively. The frequency of high scores increased with more education and higher intelligence. CONCLUSIONS: The principles of multivariate base rates also applied to high D-KEFS scores: high scores were common and contingent on the cutoff used, number of tests administered/interpreted, and education/intelligence of examinees. Base rates of high scores may help clinicians identify true cognitive strengths and detect cognitive deficits in high functioning people.

Age, symptoms, and functional outcome after mild traumatic brain injury.

OBJECTIVES: Previous older adult studies have examined outcome from moderate-to-severe traumatic brain injury (TBI), but fewer have focused on the effects of milder brain injuries. This study examined age-related differences in symptom reporting and whether symptoms are differentially related to functional outcome based on age. MATERIALS & METHODS: Patients presenting with a head injury at the Tampere University Hospital emergency department (N = 325, aged 18-100) were evaluated at 1 week post injury on the Modified Rankin Scale and Rivermead Post Concussion Symptoms Questionnaire (RPQ). RESULTS: A quarter of participants had missing RPQ data, with missingness associated with greater age and strongly associated with pre-existing functional impairment, dementia, and/or neurological conditions. Among participants with complete data, participants <65 years old endorsed headaches, noise/light sensitivity, irritability, and frustration/impatience at a greater frequency than participants ≥65 years old. However, no differences were found in the number of symptoms endorsed or the total symptom severity score. The correlations between the severity of symptoms and change in function were similar between the two age groups. CONCLUSIONS: Older adults tended to report fewer symptoms, but symptoms had a roughly equivalent relationship with declines in functioning across age groups. A large percentage of older adults in this study had pre-injury dementia or neurological disease that contributed to missing data on the 1-week outcome measures. The results provide insight into the impact of mild spectrum TBI on older adults compared to younger patients.

Complicated mild traumatic brain injury in older adults: Post-concussion symptoms and functional outcome at one week post injury.

Primary Objective: Mild Traumatic Brain Injury (MTBI) is commonly categorized as complicated when injury severity criteria are mild, but an intracranial abnormality is present on acute neuroimaging. The current study examined whether functional outcomes differed at one week post injury among older adult patients based on injury severity and acute computed tomography (CT) findings.Research Design: Participants (≥55 years-old; n = 173) presenting sequentially to the emergency department with a head injury were divided into three groups: complicated MTBI (positive CT; n = 22), uncomplicated MTBI (negative CT; n = 68), and mild head injury (unperformed CT, no documented loss of consciousness or post-traumatic amnesia; n = 83).Methods and Procedures: At one week post injury, the Modified Rankin Scale (i.e., difference score between pre/post-injury ratings; ∆MRS), Glasgow Outcome Scale-Extended (GOS-E), and Rivermead Post-Concussion Symptoms Questionnaire (RPQ) were administered.Main Outcomes and Results: Participants differed on the ∆MRS and GOS-E, but not the RPQ. The complicated MTBI group had worse GOS-E ratings than the uncomplicated MTBI and mild head injury groups and worse ∆MRS than the mild head injury group, but the uncomplicated MTBI and mild head injury groups did not differ on either outcome.Conclusions: Macrostructural abnormality on CT was associated with worse functional outcome at one week post MTBI.

Non-Pharmacologic Interventions for Older Adults with Subjective Cognitive Decline: Systematic Review, Meta-Analysis, and Preliminary Recommendations.

In subjective cognitive decline (SCD), older adults present with concerns about self-perceived cognitive decline but are found to have clinically normal function. However, a significant proportion of those adults are subsequently found to develop mild cognitive impairment, Alzheimer's dementia or other neurocognitive disorder. In other cases, SCD may be associated with mood, personality, and physical health concerns. Regardless of etiology, adults with SCD may benefit from interventions that could enhance current function or slow incipient cognitive decline. The objective of this systematic review and meta-analysis, conducted in accordance with the PRISMA guidelines, is to examine the benefits of non-pharmacologic intervention (NPI) in persons with SCD. Inclusion criteria were studies of adults aged 55 + with SCD defined using published criteria, receiving NPI or any control condition, with cognitive, behavioural, or psychological outcomes in controlled trails. Published empirical studies were obtained through a standardized search of CINAHL Complete, Cochrane Central Register of Controlled Trials, MEDLINE with Full Text, PsycINFO, and PsycARTICLES, supplemented by a manual retrieval of relevant articles. Study quality and bias was determined using PEDro. Nine studies were included in the review and meta-analysis. A wide range of study quality was observed. Overall, a small effect size was found on cognitive outcomes, greater for cognitive versus other intervention types. The available evidence suggests that NPI may benefit current cognitive function in persons with SCD. Recommendations are provided to improve future trials of NPI in SCD.

Blast-related mild traumatic brain injury: a Bayesian random-effects meta-analysis on the cognitive outcomes of concussion among military personnel.

Throughout their careers, many soldiers experience repeated blasts exposures from improvised explosive devices, which often involve head injury. Consequentially, blast-related mild Traumatic Brain Injury (mTBI) has become prevalent in modern conflicts, often occuring co-morbidly with psychiatric illness (e.g., post-traumatic stress disorder [PTSD]). In turn, a growing body of research has begun to explore the cognitive and psychiatric sequelae of blast-related mTBI. The current meta-analysis aimed to evaluate the chronic effects of blast-related mTBI on cognitive performance. A systematic review identified 9 studies reporting 12 samples meeting eligibility criteria. A Bayesian random-effects meta-analysis was conducted with cognitive construct and PTSD symptoms explored as moderators. The overall posterior mean effect size and Highest Density Interval (HDI) came to d = -0.12 [-0.21, -0.04], with executive function (-0.16 [-0.31, 0.00]), verbal delayed memory (-0.19 [-0.44, 0.06]) and processing speed (-0.11 [-0.26, 0.01]) presenting as the most sensitive cognitive domains to blast-related mTBI. When dividing executive function into diverse sub-constructs (i.e., working memory, inhibition, set-shifting), set-shifting presented the largest effect size (-0.33 [-0.55, -0.05]). PTSD symptoms did not predict cognitive effects sizes, ß PTSD = -0.02 [-0.23, 0.20]. The results indicate a subtle, but chronic cognitive impairment following mTBI, especially in set-shifting, a relevant aspect of executive attention. These findings are consistent with past meta-analyses on multiple mTBI and correspond with past neuroimaging research on the cognitive correlates of white matter damage common in mTBI. However, all studies had cross-sectional designs, which resulted in universally low quality ratings and limited the conclusions inferable from this meta-analysis.

The Short Executive Function Scale.

This study involved a psychometric evaluation of the Short Executive Function Scale (SEFS), a new 15-item self-report questionnaire measuring five constructs: Planning, Inhibition, Working Memory, Shifting, and Emotional Control. Participants included 717 U.S. undergraduate students (M = 18.9 years old, SD = 1.9; 78.8% cisgender female, 81.7% White) who completed the SEFS. A subset of 156 participants (M = 18.8 years old, SD = 0.9; 79.5% cisgender female, 83.3% White) completed the SEFS again at 2- to 3-month retest along with the Behavior Rating Inventory of Executive Function-Adult (BRIEF-A) and the Patient Health Questionnaire (PHQ-8). The five-factor model fit well (CFI = 0.941, RMSEA = 0.079) and each scale had acceptable internal consistency (ω range: .68-.81) and test-retest reliability (ICC range: .75-.89). Apart from Shifting, all SEFS scales had significantly larger convergent validity coefficients with their respective BRIEF-A scales (r range: -.25 to -.70) than discriminant validity coefficients with the PHQ-8 (r range: -.06 to -.28). These findings provide preliminary psychometric support for the SEFS.

Post-Concussion Symptoms in Women With Head Injury Due to Intimate Partner Violence.

Limited research has examined the symptom sequelae of head injuries in women survivors of intimate partner violence (IPV), despite this community being at increased risk for neurotrauma due to partner abuse. The current study compared post-concussion symptom severity between women with and without IPV-related head injuries. Women were recruited from court jurisdictions in Kentucky, USA, after receiving a protective order for partner abuse. The sample included 268 women with no prior head injuries (age: M[standard deviation (SD)] = 31.8[9.8], 77.2% White) and 251 women with lifetime IPV-related head injuries (age: M[SD] = 31.8[9.8], 88.0% White). Women with IPV-related head injuries were slightly older (t = 2.46, p = 0.014) with lower education (χ2 = 5.81, p = 0.016), were more frequently unemployed (χ2 = 9.23, p = 0.002), and had a higher likelihood of residing in a rural setting (χ2 = 30.16, p < 0.001). Women with IPV-related head injuries were also more often White (χ2 = 10.47, p = 0.001), but this group difference was almost entirely related to rural versus urban residence. Women with IPV-related head injuries reported a higher severity of lifetime physical IPV (t = 7.27, p < 0.001, d = 0.64, 95% confidence interval [CI]: [.46, .82]) and sexual IPV (t = 4.65, p < 0.001, d = 0.41 [0.24, 0.59]). A three-factor model of post-concussion symptoms, inclusive of cognitive, physical, and emotional symptoms, fit well (χ2 = 368.99, p < 0.0001, comparative fit index [CFI] = 0.974, Tucker-Lewis index [TLI] = 0.968, root mean square error of approximation [RMSEA] = 0.079 [0.071, 0.087]), and showed evidence for strong measurement invariance across women with and without IPV-related head injuries. The subscale and total scores each had acceptable reliability: cognitive (ω = 0.88 [0.86, 0.90]), physical (ω = 0.74 [0.70, 0.77]), and emotional (ω = 0.88 [0.86, 0.89]), and total score (ω = 0.93 [0.92, 0.95]). Women with IPV-related head injuries reported all individual post-concussion symptoms at a significantly higher frequency, with medium group differences in cognitive (t = 7.57, p < 0.001, d = 0.67 [0.50, 0.85]) and physical symptoms (t = 7.73, p < 0.001, d = 0.68 [0.51, 0.86]) and large group differences in emotional (t = 8.51, p < 0.001, d = 0.75 [0.57, 0.93]) and total symptoms (t = 9.07, p < 0.001, d = 0.80 [0.62, 0.98]). All sociodemographic characteristics were independently associated with post-concussion symptoms, as were physical IPV (total score: r = 0.28 [0.19, 0.35], p < 0.001) and sexual IPV severity (total score: r = 0.22 [0.13, 0.30], p < 0.001). In hierarchical regression analyses, controlling for sociodemographic characteristics (i.e., age, race/ethnicity, education, unemployment, and rural/urban residence) and physical and sexual IPV severity, IPV-related head injury was independently significant and accounted for significant additional variance when predicting cognitive (ΔR2 = 0.05, p < 0.001), physical (ΔR2 = 0.03, p < 0.001), emotional (ΔR2 = 0.07, p < 0.001), and total symptoms (ΔR2 = 0.06, p < 0.001). Negative-binomial regression resulted in similar findings. This study demonstrates that multiple sociodemographic and IPV history variables are related to post-concussion symptom severity, but IPV-related head injury was independently associated with greater symptom severity. Women with IPV-related head injuries may be at increased risk for unaddressed health problems spanning cognitive, physical, and emotional domains. Future research is needed to psychometrically evaluate assessment instruments for this population and to assess efficacy of interventions to address their unique health care needs.

Multivariate base rates of potentially problematic scores on the NIH Toolbox Emotion Battery.

OBJECTIVE: To examine the normal frequency of obtaining one or more scores considered potentially problematic based on normative comparisons when completing the NIH Toolbox Emotion Battery (NIHTB-EB). METHOD: Participants (N = 753; ages 18-85, 62.4% women, 66.4% non-Hispanic White) from the NIHTB norming study completed 17 scales of emotional functioning fitting into three subdomains (i.e., Negative Affect, Psychological Well-being, Social Satisfaction). Scores were considered potentially problematic if they were 1 SD above/below the mean, depending on the orientation of the scale, and cutoffs for 1.5 and 2 SD were also included for reference. Multivariate base rates quantified the rate at which participants obtained one or more potentially problematic scale or subdomain scores. RESULTS: The portion of participants obtaining one or more potentially problematic scores on the NIHTB-EB scales and subdomains was 61.2 and 23.2%, respectively. Participants who were younger (i.e., 18-49) or had less education had higher rates of potentially problematic scores within specific subdomains. There were no significant differences by sex or race/ethnicity. CONCLUSIONS: Elevated scores on the NIHTB-EB were common in the normative sample and related to education/age. The multivariate base rates provided indicate obtaining one or more potentially problematic scores on the NIHTB-EB is broadly normal among adults, which may guard against overinterpreting a single score as clinically significant. These base rates should be considered in the context of other assessment findings, such as interviews, medical history or informant reports, to ensure that true emotional problems are not dismissed, and normal variation in emotional functioning is not pathologized.

The Sport Concussion Assessment Tool: A multidimensional symptom model for detecting elevated post-concussion symptoms.

Objective: Investigate whether a four-factor model of post-concussion symptoms (i.e. cognitive, physical, affective, and sleep-arousal) aids in identifying student-athletes with persistent concerns not reflected by a total symptom score. Method: Collegiate student-athletes (N = 32,066) from the Concussion Assessment Research and Education consortium completed the Sport Concussion Assessment Tool, 3rd edition Symptom Evaluation at baseline and two post-injury follow-ups (i.e. beginning RTP and 6-month). Confirmatory factor analysis was used to compare a one- and four-factor model of post-concussion symptoms. Normative reference data were compared across stratifications (e.g. sex, prior concussions, and number of pre-existing conditions) using Mann-Whitney U tests, and elevation rates (i.e. ≥84th percentile) for subscales and the total score were recorded. Results: The four-factor model fit well before and after injury (CFIs > .95). Greater symptom severity on the subscale and total scores was associated with female sex (ps<.001, r range: .07 to .14) and more pre-existing conditions (ps<.001, η2 range: .01 to .04), while having more prior concussions was only related to total symptom scores (ps<.001, η2<.01). After a concussion, a sizeable portion of student-athletes (i.e., RTP = 11.8%; 6-month = 8.3%) had subscale elevations despite no total score elevation. Physical subscale elevations at RTP were the most common (i.e., 11.9%), driven by head and neck pain. Conclusion: After a sport-related concussion, a four-factor symptom model can be used to assess persistent symptoms in collegiate student-athletes. Identifying athletes with domain-specific elevations may help clinicians identify areas for further assessment and, in some cases, personalized rehabilitation plans.

Performance Validity Testing on the NIH Toolbox Cognition Battery: Base Rates of Failed Embedded Validity Indicators in the Adult Normative Sample.

OBJECTIVE: The goal of this study was to determine the base rates of failing proposed embedded validity indicators (EVIs) for the National Institutes of Health Toolbox Cognition Battery (NIHTB-CB) in the normative sample. METHOD: Participants included adults in the NIHTB-CB normative sample with data to calculate age-adjusted standard scores (n = 855; ages: M(SD) = 46.9(17.3), range: 18-85; 65.0% women; education: M(SD) = 14.1(2.5) years) or demographically adjusted T-scores (n = 803; ages: M(SD) = 47.3(17.3), range: 18-85; 65.3% women; education: M(SD) = 14.2(2.5) years) for all tests. The NIHTB-CB includes two tests of crystallized cognition and five tests of fluid cognition. Individual norm-referenced test performances were categorized as falling above or below liberal and conservative cutoffs based on proposed univariate EVIs. The number of univariate EVI failures was summed to compute multivariable EVIs. EVI failure rates above 10% were considered high false-positive rates, indicating specificity < .90. Using chi-square analyses, the frequencies of EVI failures were compared based on gender, race/ethnicity, education, and crystallized composite. RESULTS: The multivariable EVIs had predominantly low false-positive rates in the normative sample. EVI failure rates were most common among participants with low crystallized composites. Using age-adjusted standard scores, EVI failure rates varied by education, race/ethnicity, and estimated premorbid intelligence. These differences were mostly eliminated when using demographically adjusted T-scores. CONCLUSIONS: Multivariable EVIs requiring ≥ 4 failures using liberal cutoffs or ≥ 3 failures using conservative cutoffs had acceptable false-positive rates (i.e., < 10%) using both age-adjusted standard scores and demographically adjusted T-scores. These multivariable EVIs could be applied to large data sets with NIHTB-CB data to screen for potentially invalid test performances.