Prevalence of Invalid Performance on Baseline Testing for Sport-Related Concussion by Age and Validity Indicator

Experiences of Adversity and Validity of Baseline Concussion Testing

CONTEXT

Neurocognitive testing is a critical tool in the management of sport-related concussions. Adversity during childhood and adolescence affects cognitive tasks, behavioral outcomes, and academic performance. Adversity may be important in baseline concussion test validity as well; however, the influence of these experiences is not well understood.

OBJECTIVE

To examine the relationship between individual-level experiences of adversity and baseline test validity of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). We hypothesized that experiences of poverty, maltreatment, or extreme neighborhood deprivation would be associated with lower odds of baseline test validity.

DESIGN

Case-control study.

SETTING

Cuyahoga County, Ohio.

PATIENTS OR OTHER PARTICIPANTS

A total of 6495 student-athletes born from 1995 through 2005 who completed a baseline ImPACT test between 10 and 18 years old and were identified in the Child-Household Integrated Longitudinal Data system, a comprehensive data system with demographic and social service usage outcomes for children in Cuyahoga County, Ohio.

MAIN OUTCOME MEASURE(S)

Baseline concussion test validity was determined using the ImPACT built-in validity measure. Experiences of adversity during the sensitive developmental periods of early childhood and adolescence were key independent variables.

RESULTS

Our findings suggested that social mobility may play an important role in baseline validity. Youth with upward social mobility (ie, poverty or neighborhood deprivation in early childhood only) were not different from youth without such experiences (odds ratio [OR] = 0.91, P = .74). Youth with persistent adversity across childhood or downward social mobility (ie, poverty or high neighborhood deprivation in adolescence only) had 50% to 72% lower odds of achieving a valid baseline test (persistent poverty, OR = 0.59, P = .05; adolescent poverty only, OR = 0.50, P = .004; adolescent neighborhood deprivation only, OR = 0.28, P < .001). Maltreatment had no significant effect on test validity.

CONCLUSIONS

These findings indicated that certain patterns of adversity may predispose youth to invalid baseline testing scores, potentially increasing their risk of inappropriate injury management and poor outcomes.

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.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Psychometric Properties of Computerized Cognitive Tools and Standard Neuropsychological Tests Used to Assess Sport Concussion: A Systematic Review

Athletic programs are more frequently turning to computerized cognitive tools in order to increase efficiencies in concussion assessment. However, assessment using a traditional neuropsychological test battery may provide a more comprehensive and individualized evaluation. Our goal was to inform sport clinicians of the best practices for concussion assessment through a systematic literature review describing the psychometric properties of standard neuropsychological tests and computerized tools. We conducted our search in relevant databases including Ovid Medline, Web of Science, PsycINFO, and Scopus. Journal articles were included if they evaluated psychometric properties (e.g., reliability, sensitivity) of a cognitive assessment within pure athlete samples (up to 30 days post-injury). Searches yielded 4,758 unique results. Ultimately, 103 articles met inclusion criteria, all of which focused on adolescent or young adult participants. Test-retest reliability estimates ranged from .14 to .93 for computerized tools and .02 to .95 for standard neuropsychological tests, with strongest correlations on processing speed tasks for both modalities, although processing speed tasks were most susceptible to practice effects. Reliability was improved with a 2-factor model (processing speed and memory) and by aggregating multiple baseline exams, yet remained below acceptable limits for some studies. Sensitivity to decreased cognitive performance within 72 h of injury ranged from 45%-93% for computerized tools and 18%-80% for standard neuropsychological test batteries. The method for classifying cognitive decline (normative comparison, reliable change indices, regression-based methods) affected sensitivity estimates. Combining computerized tools and standard neuropsychological tests with the strongest psychometric performance provides the greatest value in clinical assessment. To this end, future studies should evaluate the efficacy of hybrid test batteries comprised of top-performing measures from both modalities.

Prevalence of invalid ImPACT baseline test results among high school athletes with invalidity and sandbagging indices

Objective: The comparison of baseline neuropsychological test results with post-concussion neuropsychological test results is a common practice to assess the aftermath of a sport-related concussion. The effectiveness of this approach is compromised when invalid baseline test performances occur. The present study was designed to assess the prevalence of invalid baseline test results of high school athletes, using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Method: A large sample of 8938 high school athletes' baseline test data were examined, including the four ImPACT Composite scores and three sets of embedded invalid indices: five ImPACT Invalidity Indicators, four ImPACT sandbagging red flags, and two ImPACT sandbagging subtest flags. Results: There were 8394 (93.91%) Valid scorers, who failed no Invalidity Indicators; 544 (6.09%) Invalid scorers, who failed at least one Invalidity Indicator, 2718 (30.41%) Red Flag scorers, who had at least one Red Flag score; and 4154 (46.47%) Subtest Flag scorers, who had at least one Subtest Flag score. Of the entire sample, 4485 (54.65%) failed at least one of the invalid indices. Conclusions: As in prior studies of high school athletes, the Invalidity Indicators identified a low portion (6.09%) of the athletes with invalid baseline test results, while other invalidity measures found 30.41% to 46.48% of the athletes producing questionable test results. The high rate of invalid test findings suggested in this research calls for greater efforts to improve the accuracy of baseline test results.

Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review

OBJECTIVES

To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6).

DATA SOURCES

Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation.

ELIGIBILITY CRITERIA

(1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC.

DATA EXTRACTION

Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool.

RESULTS

Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children.

CONCLUSION

Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

The Post-Concussion Symptom Scale: Normative Data for Adolescent Student-Athletes Stratified by Gender and Preexisting Conditions

BACKGROUND

The Post-Concussion Symptom Scale (PCSS) is a self-report questionnaire measuring symptoms that commonly occur after a concussion; however, these symptoms are nonspecific and can be related to co-occurring orthopaedic injuries (eg, cervical strain) or patient characteristics and preexisting conditions, even in the absence of a recent injury. As such, clinicians may have difficulty determining whether symptom elevations are attributable to a recent concussion as opposed to a confounding injury or a preexisting condition, which may be especially difficult when preinjury baseline symptom data are unavailable.

PURPOSE

This study aimed to further validate the 4-factor model of the PCSS (ie, cognitive, sleep-arousal, physical, and affective symptoms) with adolescent student-athletes and provide normative reference data for each factor and the total score, stratified by gender and preexisting health conditions.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Participants were 9358 adolescent student-athletes who completed the PCSS during a preseason baseline evaluation (mean age, 14.9 years; SD, 1.3 years [range, 13-18 years]; 49.3% boys). The 4-factor model of the PCSS was tested for the full sample and separately for boys and girls using confirmatory factor analysis. Symptom severity percentiles were created for the PCSS total score and each factor, stratified by gender and preexisting conditions (ie, attention-deficit/hyperactivity disorder, mental health history, headache/migraine history, learning disability/dyslexia, academic problems, and concussion history).

RESULTS

The 4-factor model of the PCSS replicated in the full sample (comparative fit index [CFI] = 0.959) and in both gender groups (boys: CFI = 0.961; girls: CFI = 0.960). The total PCSS score at the 84th percentile varied by preexisting conditions as follows: healthy participants = 8, attention-deficit/hyperactivity disorder = 18, mental health history = 26, headache/migraine history = 18, learning disability = 19, and academic problems = 17. On all PCSS subscales, participants with a mental health history had the highest scores, and high scores were associated with having >1 preexisting condition. Girls had higher scores than boys for each stratification.

CONCLUSION

The 4-factor model of the PCSS replicates for adolescent student-athletes. Gender, number of preexisting conditions, and mental health history are important factors to account for when interpreting PCSS symptom severity. The normative data provided herein could assist clinicians in determining whether an adolescent student-athlete is presenting with persistent postconcussion symptoms or a typical symptom experience based on their gender and personal health history.

Verbal fluency in Lebanese children: Preliminary normative data, sociodemographic determinants, and patterns of clustering and switching

This study assessed the quantitative and qualitative performance of Lebanese-speaking children on verbal fluency (VF) tasks and investigated the effects of sociodemographic characteristics. This study included 219 Lebanese children aged between 5 and 12 years and 11 months, whose native language is Lebanese-Arabic. Semantic and letter VF tasks were assessed using a range of categories and letters. Switching and clustering strategies were analyzed for 177 Lebanese children. The number of words produced presented a significant increase with age (p < .004) in semantic (SVF), while in letter (LVF), the differences were significant between extreme age groups. Females generated more words in the clothes (p = .003) and household items (p = .002) categories. The total number of switches and clusters showed a significantly increasing pattern with age (p < .05). The number of switches was higher for participants with high maternal (p < .001) and paternal (p < .013) educational levels. Regression analyses showed that the total number of switches and clusters, and the mean cluster size had a significant effect on SVF performance (p < .001). The current study generated preliminary norms for VF tasks for Lebanese-speaking children. The results of the current study have an important contribution to neuropsychology research and clinical practice.

An updated review of the prevalence of invalid performance on the Immediate Post-Concussion and Cognitive Testing (ImPACT)

Objective: Performance validity assessment is an important component of concussion baseline testing and Immediate Post-Concussion and Cognitive Testing (ImPACT) is the most commonly used test in this setting. A review of invalid performance on ImPACT was published in 2017, focusing largely on the default embedded validity indicator (Default EVI) provided within the test. There has since been a proliferation in research evaluating the classification accuracy of the Default EVI against independently developed, alternative ImPACT-based EVIs, necessitating an updated review. The purpose of this study was to provide an up-to-date review of the prevalence of invalid performance on ImPACT and to examine the relative effectiveness of ImPACT-based EVIs. Method: Literature related to the prevalence of invalid performance on ImPACT and the effectiveness of ImPACT-based EVIs, published between January 2000 and May 2020, was critically reviewed. Results: A total of 23 studies reported prevalence of invalid performance at baseline testing using ImPACT. Six percent of baseline assessments were found to be invalid by the ImPACT's Default EVI, and between 22.31% and 34.99% were flagged by alternative EVIs. Six studies assessed the effectiveness of ImPACT-based EVIs, with the Default EVI correctly identifying experimental malingerers only 60% of the time. Alternative ImPACT-based EVIs identified between 73% and 100% of experimental malingerers. Conclusions: The ImPACT's Default EVI is not sufficiently sensitive, and clinicians should consider alternative indicators when assessing invalid performance. Accordingly, the base rate of invalid performance in athletes at baseline testing is likely well above the 6% previously reported.

BNT-15: Revised Performance Validity Cutoffs and Proposed Clinical Classification Ranges

BACKGROUND

Abbreviated neurocognitive tests offer a practical alternative to full-length versions but often lack clear interpretive guidelines, thereby limiting their clinical utility.

OBJECTIVE

To replicate validity cutoffs for the Boston Naming Test-Short Form (BNT-15) and to introduce a clinical classification system for the BNT-15 as a measure of object-naming skills.

METHOD

We collected data from 43 university students and 46 clinical patients. Classification accuracy was computed against psychometrically defined criterion groups. Clinical classification ranges were developed using a z -score transformation.

RESULTS

Previously suggested validity cutoffs (≤11 and ≤12) produced comparable classification accuracy among the university students. However, a more conservative cutoff (≤10) was needed with the clinical patients to contain the false-positive rate (0.20-0.38 sensitivity at 0.92-0.96 specificity). As a measure of cognitive ability, a perfect BNT-15 score suggests above average performance; ≤11 suggests clinically significant deficits. Demographically adjusted prorated BNT-15 T-scores correlated strongly (0.86) with the newly developed z -scores.

CONCLUSION

Given its brevity (<5 minutes), ease of administration and scoring, the BNT-15 can function as a useful and cost-effective screening measure for both object-naming/English proficiency and performance validity. The proposed clinical classification ranges provide useful guidelines for practitioners.

Multivariate Models of Performance Validity: The Erdodi Index Captures the Dual Nature of Non-Credible Responding (Continuous and Categorical)

This study was designed to examine the classification accuracy of the Erdodi Index (EI-5), a novel method for aggregating validity indicators that takes into account both the number and extent of performance validity test (PVT) failures. Archival data were collected from a mixed clinical/forensic sample of 452 adults referred for neuropsychological assessment. The classification accuracy of the EI-5 was evaluated against established free-standing PVTs. The EI-5 achieved a good combination of sensitivity (.65) and specificity (.97), correctly classifying 92% of the sample. Its classification accuracy was comparable with that of another free-standing PVT. An indeterminate range between Pass and Fail emerged as a legitimate third outcome of performance validity assessment, indicating that the underlying construct is an inherently continuous variable. Results support the use of the EI model as a practical and psychometrically sound method of aggregating multiple embedded PVTs into a single-number summary of performance validity. Combining free-standing PVTs with the EI-5 resulted in a better separation between credible and non-credible profiles, demonstrating incremental validity. Findings are consistent with recent endorsements of a three-way outcome for PVTs (Pass, Borderline, and Fail).

The Frequency of Low Scores on ImPACT in Adolescent Student-Athletes: Stratification by Race and Socioeconomic Status Using Multivariate Base Rates

This study examined the associations between the frequency of low scores on the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) by race and socioeconomic status (SES), using the proxy of Title I school status, among adolescent student-athletes and calculated multivariate base rates. There were 753 participants assigned to groups based on race (White: n = 430, 59.8%; Black: n = 289, 40.2%) and SES. Black student-athletes obtained more low neurocognitive test scores, which was associated with lower SES. The current study offers a resource to clinicians involved in concussion management who may wish to consider race and SES when interpreting ImPACT test performances.

Improved post-injury cognitive test results: examining invalid baseline ImPACT testing

OBJECTIVE

Evidence suggests that Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) validity thresholds may not be adequately sensitive to baseline performances that are not representative of an athlete's full, uninjured cognitive abilities. The true prevalence of this occurrence is unknown. This study used improvement on post-injury testing (i.e., better performance after the athlete has been removed from play due to suspected concussion than at baseline) to assess the frequency of unrepresentative baseline ImPACT assessments.

METHOD

Post-injury ImPACT assessments by NCAA athletes with preceding baseline performance that was considered valid using traditional indices were included. Published reliable change indices (RCI) identified acute post-injury composite scores that improved from baseline.

RESULTS

Of 155 post-injury assessments, 68 (43.9%) exhibited reliable improvement from baseline on at least 1 composite score, even after excluding persons with invalid protocols.

CONCLUSIONS

Prevalence of ImPACT unrepresentative baseline ImPACT performances may be higher than previously estimated, and many individuals may not be detected by current validity indices. Further research is needed to refine assessment and promote player safety.

Concussion Baseline Retesting Is Necessary When Initial Scores Are Low

OBJECTIVE

To determine whether (1) initial baseline scores are significantly better for those who have valid (initial valid) versus invalid scores (initial invalid) on their concussion baseline testing, (2) retesting results in significantly improved baseline scores, and (3) there is a significant difference in scores between those who have valid scores on their initial attempt and those who retook baseline tests (retest valid).

DESIGN

Prospective, repeated-measures.

SETTING

Two years of collegiate preparticipation concussion baseline testing.

PARTICIPANTS

Five hundred forty-seven male and female Division I collegiate athletes (19.02 ± 1.31 years, female = 217).

INDEPENDENT VARIABLES

Participants were divided into initial valid and initial invalid. The retest group was further divided into their initial (initial invalid) and final valid attempt (retest valid).

MAIN OUTCOME MEASURES

Data were analyzed to determine the relationship between the 3 groups and overall initial and final scores on 28 individual items: total symptoms score, coordination, near-point convergence, CNS Vital Signs (CNSVS), Senaptec Sensory Station, and Neurocom Sensory Organization Test (SOT).

RESULTS

The initial valid group scored significantly better than the initial invalid group on 8 CNSVS items and 5 Senaptec items (P < 0.002). The retest valid scores were significantly better compared with the initial invalid scores on 17 items (P < 0.002).

CONCLUSIONS

Retesting is recommended for individuals who score below acceptable ranges. This is important because athletes may experience a learning effect and are highly motivated during postinjury testing, so accurate baseline scores are imperative for athlete safety. Completion time for the coordination test may be a more informative option.

Return to Cycling Following Brain Injury: A Proposed Multidisciplinary Approach

Cycling is an important form of exercise, recreation, and transportation. Following traumatic brain injury, the benefits of cycling for health, fitness, and community mobility must be considered alongside potential risk for recurrent injury. In addition to medical concerns and exercise tolerance, key domains include motor function, attention, and visuospatial and executive function, which have previously been explored with regard to driving. Cycling skill is a combination of cognitive and motor function, and can be trained with appropriate education and intervention. We discuss the relationship of brain injury rehabilitation to specific features of cycling, including case studies.

Concussion Characteristics and Early Postinjury Outcomes Between College Students and Intercollegiate Athletes

OBJECTIVE

To describe concussion characteristics among general college students and compare postinjury outcomes to intercollegiate student athletes.

DESIGN

Retrospective cohort.

SETTING

Large university in the Southeast region of the United States.

PARTICIPANTS

A total of 179 (N=179) college students' (female=120; 67.0%; 23.9±3.9 years) and 49 athletes' (female=28, 57.1%;19.3±1.3 years) medical records were examined. Participants self-reported injury mechanism, health history information, and completed clinical assessments acutely (<7 days postinjury).

MAIN OUTCOME MEASURES

Descriptive statistics were calculated for each group. Concussion outcomes between students with and without certain health history diagnoses were assessed using separate t tests. We conducted univariate regression analyses to determine if sex, age, and time from concussion to first clinical assessment were significant predictors of clinical outcomes. Statistically significant variables were included as covariates in a series of 1-way analyses of covariance to identify differences in balance, symptom severity, total symptom presence, and neurocognitive domain performance between students and athletes. Fisher exact tests were used to compare health history information between groups (α<0.05).

RESULTS

Among students, 24% reported sustaining a concussion while participating in recreational sports, and 27% of impacts occurred to the back of the head. Students had higher proportions of headache, migraine, anxiety, and depression (P<.05). Students reported greater total symptom presence (P=.006) and performed worse on the computerized neurocognitive test domain score for complex attention (P=.015) relative to athletes.

CONCLUSIONS

These findings highlight the need for better access to medical care for non- National Collegiate Athletic Association sanctioned athletes because of a large proportion of concussions in the student sample being sustained during sports participation. Identifying common injury mechanisms can provide clinicians with powerful information to improve evaluation and treatment models.

Introducing the ImPACT-5: An Empirically Derived Multivariate Validity Composite

OBJECTIVE

To create novel Immediate Post-Concussion and Cognitive Testing (ImPACT)-based embedded validity indicators (EVIs) and to compare the classification accuracy to 4 existing EVIImPACT.

METHOD

The ImPACT was administered to 82 male varsity football players during preseason baseline cognitive testing. The classification accuracy of existing EVIImPACT was compared with a newly developed index (ImPACT-5A and B). The ImPACT-5A represents the number of cutoffs failed on the 5 ImPACT composite scores at a liberal cutoff (0.85 specificity); ImPACT-5B is the sum of failures on conservative cutoffs (≥0.90 specificity).

RESULTS

ImPACT-5A ≥1 was sensitive (0.81), but not specific (0.49) to invalid performance, consistent with EVIImPACT developed by independent researchers (0.68 sensitivity at 0.73-0.75 specificity). Conversely, ImPACT-5B ≥3 was highly specific (0.98), but insensitive (0.22), similar to Default EVIImPACT (0.04 sensitivity at 1.00 specificity). ImPACT-5A ≥3 or ImPACT-5B ≥2 met forensic standards of specificity (0.91-0.93) at 0.33 to 0.37 sensitivity. Also, the ImPACT-5s had the strongest linear relationship with clinically meaningful levels of invalid performance of existing EVIImPACT.

CONCLUSIONS

The ImPACT-5s were superior to the standard EVIImPACT and comparable to existing aftermarket EVIImPACT, with the flexibility to optimize the detection model for either sensitivity or specificity. The wide range of ImPACT-5 cutoffs allows for a more nuanced clinical interpretation.

Methodological considerations of assessing meaningful/reliable change in computerized neurocognitive testing following sport-related concussion

OBJECTIVE

Traditional reliable change index (RCI) methods may be psychometrically limited due to their inability to account for particularly high or low baseline performance and regression to the mean following serial testing. The current study sought to examine differences between RCI and standardized regression-based (RBz) methods in a cohort of adolescent athletes engaged in sport-related concussion recovery.

METHODS

Consultation records and results of computerized testing data via the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery were retrospectively reviewed among 240 adolescent athletes involved in return-to-play protocols following a sport-related concussion.

RESULTS

High concordance rates were found between RCI and RBz metrics across ImPACT composites, consistent with previous literature. However, especially for those with lower baseline performance, RBz scores tended to suggest cognitive performance not meeting or exceeding baseline scores despite RCI metrics being appropriate across speed-based ImPACT composites. In contrast, results revealed high rates of RCI scores suggesting continued cognitive difficulties despite RBz metrics being within normal limits, especially for adolescents with higher baseline performance.

CONCLUSIONS

Results suggest value in interpreting RBz values in addition to RCI values as these allow for clinical interpretation more sensitive to statistical confounds, including baseline performance and regression to the mean.

Influence of Special Education, ADHD, Autism, and Learning Disorders on ImPACT Validity Scores in High School Athletes

OBJECTIVE

The Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is commonly used to assist with post-concussion return-to-play decisions for athletes. Additional investigation is needed to determine whether embedded indicators used to determine the validity of scores are influenced by the presence of neurodevelopmental disorders (NDs).

METHOD

This study examined standard and novel ImPACT validity indicators in a large sample of high school athletes (n = 33,772) with or without self-reported ND.

RESULTS

Overall, 7.1% of athletes' baselines were judged invalid based on standard ImPACT validity criteria. When analyzed by group (healthy, ND), there were significantly more invalid ImPACT baselines for athletes with an ND diagnosis or special education history (between 9.7% and 54.3% for standard and novel embedded validity criteria) when compared to athletes without NDs. ND history was a significant predictor of invalid baseline performance above and beyond other demographic characteristics (i.e., age, sex, and sport), although it accounted for only a small percentage of variance. Multivariate base rates are presented stratified for age, sex, and ND.

CONCLUSIONS

These data provide evidence of higher than normal rates of invalid baselines in athletes who report ND (based on both the standard and novel embedded validity indicators). Although ND accounted for a small percentage of variance in the prediction of invalid performance, negative consequences (e.g., extended time out of sports) of incorrect decision-making should be considered for those with neurodevelopmental conditions. Also, reasons for the overall increase noted here, such as decreased motivation, "sandbagging", or disability-related cognitive deficit, require additional investigation.

Relationship between Standalone Performance Validity Test Failure and Emotionality among Youth/student Athletes Experiencing Prolonged Recovery following Sports-related Concussion

This study documented the rate of Performance Validity Testing (PVT) failure in 81 youth athletes, aged 10-21 years, experiencing prolonged recovery following sports-related concussion, and the relationship between PVT and emotional symptoms. Neuropsychological assessments were conducted across three test sessions with a stand-alone PVT at each session. Results showed that 48% (39/81) of individuals failed at least one PVT, with an overall PVT failure rate of 26% (64/243). Those failing at least one PVT scored significantly higher on anxiety but not depression or somatization. Results illustrate the importance of including measures of emotional and behavioral functioning in testing following SRC.

Treatment of non-sports related concussion in adolescents following an irritability algorithmic approach: a case series

Background: Concussion management evidence supports the efficacy of gradual active rehabilitation for return to sport in adolescents, however there is paucity of evidence for non-sports-related concussion management.Purpose: The purpose of this case series is to describe the feasibility and practicality of an irritability-based step-by-step model to guide rehabilitation.Case Descriptions: Three adolescent patients diagnosed with concussion during a non-sports related event are described. Each adolescent was classified as high, moderate, or low irritability level based on symptom exacerbation with Vestibular/Ocular-Motor Screening (VOMS), physical exertion based on age-predicted maximum heart rate, and cervicogenic factors. Each Patient's intervention was progressed following the proposed irritability-based algorithm.Outcomes: Patients were assessed using the Brain Injury Functional Status Patient-Reported Outcome Measure, VOMS testing, and a Numeric Pain Rating Scale. Concluding each plan of care, all patients met or exceeded the minimal clinically important difference for age, gender, and risk-adjusted predicted measure on all outcome assessments. All patients returned to school and age-appropriate activities without symptom exacerbation.Conclusion: An irritability-based algorithm model for non-sports-related concussion management may be a practical and feasible treatment approach for adolescents.

Outpatient Management of Sport-Related Concussion, Return to Learn, Return to Play

Outpatient sports-related concussion (SRC) management continues to evolve as evidence emerges supporting a multidisciplinary approach to the clinical assessment of SRC. Early active rehabilitation has replaced strict cognitive and physical rest. With this paradigm shift in management, pragmatic approaches are highly sought by busy clinicians that provide direction to individualized treatment, which can potentially expedite symptom resolution. Treatment strategies that address domain-based symptom constellations continue to be developed by clinician researchers. Although the optimal timing and dose of these domain-specific therapies has yet to be determined, future directions of SRC treatment will answer these and other questions regarding SRC management.

Half of Purposeful Baseline Sandbaggers Undetected by ImPACT's Embedded Invalidity Indicators

OBJECTIVE

The main objectives of this study were to determine how accurately the embedded invalidity indicators (EIIs) identify purposeful underperformers on the baseline Immediate Post-concussion Assessment and Cognitive Test (ImPACT); and to assess the effectiveness of each individual EII.

METHODS

A randomized controlled trial was conducted in which all participants completed a baseline ImPACT assessment. Participants were randomized into a control or purposeful underperformance (sandbagging) group. The primary outcomes measured were the number of participants identified as invalid (via any EII), as well as the ability of each individual EII to detect purposeful sandbagging. Additionally, participants mean raw composite scores and percentiles were evaluated.

RESULTS

Seventy-seven participants completed the study (control n = 37, sandbag n = 40.) None of the participants in the control group, and 50% of the purposeful sandbaggers were identified as invalid via the current EIIs. Of the five EIIs, three were unable to identify more than 15% of purposeful sandbaggers. The best performing EIIs were Word Memory and Three Letters, identifying 40% and 35% of purposeful sandbaggers, respectively. Sixty- five percent of the purposeful sandbaggers had at least one composite score ≤1st percentile. Using a composite score ≤1st percentile as potential marker of invalidity would have accurately identified more purposeful sandbaggers than all existing EIIs combined.

CONCLUSION

Half of purposeful sandbaggers were not identified by ImPACT's current EIIs. Multiple EIIs were only able to identify <15% of purposeful underperformers, suggesting that reevaluation and/or recalibration of EII cutoffs may be appropriate.

Influence of Test Environment, Age, Sex, and Sport on Baseline Computerized Neurocognitive Test Performance

BACKGROUND

Baseline computerized testing is a common component of concussion assessments, and the testing environment has been suggested to influence test performance and validity.

PURPOSE

To compare concussion baseline computerized neurocognitive test performance and validity among adolescent athletes based on testing environment (group, individual), age group (10-12, 13-15, 16-18 years), sex (male, female), and sport type (collision/combat, contact, noncontact).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Through a concussion community outreach program, participants completed baseline computerized neurocognitive testing using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). A total of 2845 athletes aged 10 to 18 years completed the baseline assessment. A total of 2241 (79%) athletes completed baseline testing in a group environment, and 604 (21%) completed testing in an individual environment. A random subsample of 500 athletes from each group was selected for statistical comparison.

RESULTS

No significant differences were supported in baseline computerized neurocognitive test performance between the group and individual administration environments. Test validity was statistically similar across testing environment, age group, and sex. However, patients of older age (16-18 years), female sex, and collision/combat and contact sports performed better on ImPACT. There were differences in total symptom severity scores (t = 2.19, df = 998, P = .03), with participants in the group testing environment reporting lower total symptom severity scores than those in the individual testing environment. The rates of invalid tests were low across all age groups, averaging from 4.0% in the 10- to 12-year age group to 4.8% in the 13- to 15-year age group.

CONCLUSION

The findings indicated that concussion baseline neurocognitive test performance is similar when administered in group and individual testing environments. However, differences based on age group, sex, and sport type should be considered when interpreting baseline computerized neurocognitive test scores. The finding of higher symptom scores in older adolescents in the individual testing environment suggests that they may be less forthcoming about symptoms in a group setting.

Invalid Baseline Testing with ImPACT: Does Sandbagging Occur with High School Athletes?

The aim of this large-scale research was to determine the frequency of valid, invalid, and sandbagging results in ImPACT baseline testing of high school athletes. This retrospective study identified valid, invalid (identified by five embedded Invalidity Indicators), and sandbagging (identified by three "red flags") results in the ImPACT baseline test scores of 6,346 high school athletes. In addition, the ImPACT postconcussion scores of 266 athletes who sustained a concussion during the school year were evaluated to compare the baseline-to-postconcussion changes of valid versus a combined group of invalid and sandbagging scorers. There were 3,299 (51.99%) athletes who had valid baseline scores, 269 (4.24%) had invalid scores, and 3,009 (47.42%) had sandbagging scores. (There were 231 who obtained both invalidity and sandbagging scores.) The overall difference in baseline-to-postconcussion changes between the valid scorers and the combined group of invalid and sandbagging scorers was statistically significant. The high rate of athletes who had invalid and sandbagging scores raised concern that the underperformance of baseline testing occurs more commonly than is probably realized by those who utilize computerized neuropsychological testing with high school athletes. Accordingly, efforts are needed to improve test administration procedures so that maximal attention and effort can be maintained among the test takers. In the meantime, increased caution is called for in employing the baseline-to-postconcussion paradigm when return-to-play decisions are made.

Investigating the psychometric properties of the Suicide Stroop Task

Behavioral measures are increasingly used to assess suicidal thoughts and behaviors. Some measures, such as the Suicide Stroop Task, have yielded mixed findings in the literature. An understudied feature of these behavioral measures has been their psychometric properties, which may affect the probability of detecting significant effects and reproducibility. In the largest investigation of its kind, we tested the internal consistency and concurrent validity of the Suicide Stroop Task in its current form, drawing from seven separate studies (N = 875 participants, 64% female, aged 12 to 81 years). Results indicated that the most common Suicide Stroop scoring approach, interference scores, yielded unacceptably low internal consistency (rs = -.09-.13) and failed to demonstrate concurrent validity. Internal consistency coefficients for mean reaction times (RTs) to each stimulus type ranged from rs = .93-.94. All scoring approaches for suicide-related interference demonstrated poor classification accuracy (AUCs = .52-.56) indicating that scores performed near chance in their ability to classify suicide attempters from nonattempters. In the case of mean RTs, we did not find evidence for concurrent validity despite our excellent reliability findings, highlighting that reliability does not guarantee a measure is clinically useful. These results are discussed in the context of the wider implications for testing and reporting psychometric properties of behavioral measures in mental health research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Rise of the Concussion Clinic for Diagnosis of Pediatric Mild Traumatic Brain Injury

It was not too long ago that being struck violently in the head or "getting your bell rung" was often brushed off as nothing to worry about. These days the pendulum has swung and there is growing appreciation that this mild traumatic brain injury (mTBI), often called concussion, must be taken seriously and is now on the forefront of public health concerns. As a growing body of research continues to expand our understanding of concussion, the paradigm of diagnosis and treatment is transforming rapidly. The recent rise of specialty concussion clinics across the country has grown out of a need for safe, effective, and efficient evaluation of these injuries by healthcare professionals qualified to implement diagnostic and management strategies that align with the latest evidence-based practice guidelines. Due to the complex nature of each injury, a comprehensive multidisciplinary team can provide a valuable individualized approach to concussion care.

Sport concussion and attention deficit hyperactivity disorder in student athletes: A cohort study

Background

Attention deficit hyperactivity disorder (ADHD) is associated with impulsive behavior and inattention, making it a potential risk factor for sport-related concussion (SRC). The objectives of this study were to determine whether ADHD is an antecedent risk factor for SRC and whether ADHD complicates recovery from SRC in youth athletes.

Methods

Student athletes with a history of SRC were evaluated for the presence of ADHD using diagnostic interview and to determine whether ADHD symptoms began before or after SRC. Concussion-specific measures of concussive symptoms and cognitive function were compared in SRC + ADHD and SRC + No ADHD groups to assess SRC recovery between groups.

Results

ADHD was overrepresented in youth with SRC compared with population rates. ADHD was found to be an antecedent risk factor for SRC, with age at ADHD onset earlier than the date of SRC. Student athletes with SRC and ADHD reported more concussive symptoms compared with athletes without ADHD and were more likely to have a history of greater than one concussion.

Conclusions

The results of this study support our hypothesis that ADHD is an antecedent risk factor for SRC and may contribute to a more complicated course of recovery from SRC. Future research should focus on determining whether screening, diagnosis, and treating ADHD in youth athletes may prevent SRC. Providers that care for youth athletes with ADHD should be aware of the vulnerabilities of this population toward SRC and its complications.