Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

Sensitivity and Specificity of the ImPACT Neurocognitive Test in Collegiate Athletes and US Military Service Academy Cadets with ADHD and/or LD: Findings from the NCAA-DoD CARE Consortium

BACKGROUND AND OBJECTIVE

Computer-based neurocognitive tests are widely used in sport-related concussion management, but the performance of these tests is not well understood in the participant population with attention-deficit/hyperactivity disorder (ADHD) and/or learning disorder (LD). This research estimates the sensitivity and specificity performance of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) computer-based neurocognitive test in identifying concussion in this population.

METHODS

Study participants consisted of collegiate university athletes and military service academy cadets from the National Collegiate Athletic Association-Department of Defense CARE Consortium who completed the ImPACT test between 2014 and 2021. Participants who self-identified as belonging to one of the subgroups of interest (ADHD with or without LD [ADHD:LD+/-], LD with or without ADHD [LD:ADHD+/-], ADHD and/or LD [ADHD a/o LD]) and completed a baseline (1874 ADHD:LD+/-, 779 LD:ADHD+/-, 2338 ADHD a/o LD) or 24-48 h post-concussion (175 ADHD:LD+/-, 77 LD:ADHD+/-, 216 ADHD a/o LD) ImPACT assessment were included. Sensitivity and specificity were calculated using a normative data method and three machine learning classification methods: logistic regression, classification and regression tree, and random forest.

RESULTS

Using the four methods, participants with ADHD:LD+/- had sensitivities that ranged from 0.474 to 0.697, and specificities that ranged from 0.538 to 0.686. Participants with LD:ADHD+/- had sensitivities that ranged from 0.455 to 0.688, and specificities that ranged from 0.456 to 0.588. For participants with ADHD a/o LD, sensitivities ranged from 0.542 to 0.755, and specificities ranged from 0.451 to 0.724.

CONCLUSIONS

For all subgroups and analytical methods, the results illustrate sensitivity and specificity values below typically accepted levels indicative of clinical utility. These findings support that using ImPACT alone may be insufficient to inform concussion diagnoses and encourages the use of a multi-dimensional concussion assessment.

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.

Pediatric Sports-Related Concussion: An Approach to Care

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.

Attention-Deficit/Hyperactivity Disorder Status and Sex Moderate Mild Traumatic Brain Injury Symptom Severity in Children and Adolescents: Implications for Clinical Management

OBJECTIVE

To investigate the impact of pediatric mild traumatic brain injury (mTBI), using a broad parent-reported measure, and to determine whether parent-ratings of mTBI symptoms are higher among those with premorbid attention-deficit/hyperactivity disorder (ADHD) and females.

DESIGN

Retrospective case-control.

SETTING

Hospital-based sports medicine clinic.

PARTICIPANTS

The retrospective chart review included 1346 (age: M = 13.11 years, SD = 2.6; 61.7% male) pediatric patients with (n = 209) and without (n = 1137) ADHD.

INDEPENDENT VARIABLES

Group membership (ADHD vs non-ADHD) and sex (male vs female).

MAIN OUTCOME MEASURES

Baseline and current Post-Concussion Symptom Inventory-Parent Report Form (PCSI-P) Physical, Emotional, Cognitive, and Fatigue subscale scores. This study used a retrospective chart review; therefore, the hypotheses reported for the current study were formed after data were collected.

RESULTS

Controlling for patient age and days from mTBI, patients with ADHD had significantly higher retrospective parent-reported pre-mTBI ratings of physical, emotional, and cognitive symptoms (ds = 0.17-0.62) and higher post-mTBI ratings across all 4 symptom domains (ds = 0.18-0.57) than those without ADHD. There was no group × time interaction for any of the PCSI-P subscales. Females overall had higher retrospective parent-reported pre-injury Fatigue and Emotional symptoms (ds = 0.13-0.19) and higher post-mTBI symptoms in all 4 PCSI-P symptom domains (ds = 0.23-0.35), relative to males.

CONCLUSIONS

Attention-deficit/hyperactivity disorder-related postinjury exacerbations in parent-reported symptoms can be explained, in part, by elevated retrospective parent-reported ADHD-related pre-mTBI ratings. These results highlight the importance of assessing a patient's baseline symptoms post-mTBI. These data also indicate that ADHD status and sex should be considered when interpreting mTBI symptom severity during clinical evaluation of concussion.

Post-Concussion Acute Signs and Reliable Cognitive Decline in a Finnish Youth Ice Hockey Sample

OBJECTIVE

In sports concussion research, the importance of an individualized approach incorporating neuropsychological assessment data has been emphasized. This study examined the impact of acute signs of concussion on post-injury cognitive functioning using reliable change methodology in a sample of Finnish, elite-level, youth ice hockey players.

METHODS

From a sample of 1,823 players (all male, 14-20 years old) who completed preseason baseline testing with the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) battery, two subgroups were identified. First, in total, 312 uninjured athletes, who completed baseline testing twice-1 year apart. The scores were contrasted to calculate reliable change indices (RCIs). Second, from a subsample of 570 athletes participating in an intensive follow-up arm of the project, the analysis included 32 concussed athletes. The RCIs were determined for the five ImPACT composite scores and used in identifying athletes with declined performance 3 days post-injury.

RESULTS

Test-retest reliability ranged from .39 to .71. Athletes who had experienced an acute loss of consciousness, amnesia, or postural instability had increased odds for declines in two or more areas assessed by ImPACT (odds ratio = 7.67-8.00, p < .05). In contrast, acute disorientation or vacant look did not lead to cognitive change that met the reliable change threshold.

CONCLUSIONS

The reliability coefficients and RCIs differed from those published earlier emphasizing the importance of national reference values. The presence of acute loss of consciousness, amnesia, or postural instability may indicate a more severe injury and predict the need for more intensive cognitive follow-up.

Preseason Vestibular Ocular Motor Screening in Children and Adolescents

OBJECTIVES

The primary purpose of this study was to examine vestibular/ocular motor screening (VOMS) test performance in a sample of healthy youth ice hockey players. A particular focus was to investigate the potential effects of age and pre-existing health conditions, including concussion history, attention-deficit/hyperactivity disorder (ADHD), learning disability (LD), headaches/migraines, and depression/anxiety on preseason baseline VOMS performance, including the near point of convergence (NPC) distance.

DESIGN

Cross-sectional cohort.

SETTING

Outpatient physiotherapy clinic.

PARTICIPANTS

Three hundred eighty-seven male youth hockey players, with an average age of 11.9 years (SD = 2.2, range = 8-17), completed the VOMS and responded to self- or parent-reported demographic and medical history questionnaires during preseason baseline assessments.

INDEPENDENT VARIABLES ASSESSED

Age, sex, and mental and physical health history including ADHD, headaches, depression, anxiety, migraine, and LD.

OUTCOME MEASURE

Vestibular/ocular motor screening.

RESULTS

The large majority of boys scored within normal limits on the VOMS, ie, they reported no symptom provocation of more than 2 points on any VOMS subset (89%) and had a normal NPC distance, ie, <5 cm (78%). The individual VOMS subtests had low abnormality rates, and demographic and pre-existing health conditions, such as age, headache or migraine history, previous neurodevelopmental conditions, or mental health problems, were not associated with clinically meaningful symptom provocation during the VOMS.

CONCLUSIONS

There was a low rate of abnormal findings for the individual VOMS subtests, with the exception of NPC distance, among male youth hockey players during preseason assessment.

Network Analysis of Sport-Related Concussion Research During the Past Decade (2010-2019)

CONTEXT

Research into sport-related concussion (SRC) has grown substantially over the past decade, yet no authors to date have synthesized developments over this critical time period.

OBJECTIVE

To apply a network-analysis approach in evaluating trends in the SRC literature using a comprehensive search of original, peer-reviewed research articles involving human participants published between January 1, 2010, and December 15, 2019.

DESIGN

Narrative review.

MAIN OUTCOME MEASURE(S)

Bibliometric maps were derived from a comprehensive search of all published, peer-reviewed SRC articles in the Web of Science database. A clustering algorithm was used to evaluate associations among journals, organizations or institutions, authors, and key words. The online search yielded 6130 articles, 528 journals, 7598 authors, 1966 organizations, and 3293 key words.

RESULTS

The analysis supported 5 thematic clusters of journals: (1) biomechanics/sports medicine (n = 15), (2) pediatrics/rehabilitation (n = 15), (3) neurotrauma/neurology/neurosurgery (n = 11), (4) general sports medicine (n = 11), and (5) neuropsychology (n = 7). The analysis identified 4 organizational clusters of hub institutions: (1) University of North Carolina (n = 19), (2) University of Toronto (n = 19), (3) University of Michigan (n = 11), and (4) University of Pittsburgh (n = 10). Network analysis revealed 8 clusters for SRC key words, each with a central topic area: (1) epidemiology (n = 14), (2) rehabilitation (n = 12), (3) biomechanics (n = 11), (4) imaging (n = 10), (5) assessment (n = 9), (6) mental health/chronic traumatic encephalopathy (n = 9), (7) neurocognition (n = 8), and (8) symptoms/impairments (n = 5).

CONCLUSIONS

The findings suggest that during the past decade SRC research has (1) been published primarily in sports medicine, pediatric, and neuro-focused journals, (2) involved a select group of researchers from several key institutions, and (3) concentrated on new topical areas, including treatment or rehabilitation and mental health.

Reliability of Objective Eye-Tracking Measures Among Healthy Adolescent Athletes

OBJECTIVE

To determine the test-retest correlation of an objective eye-tracking device among uninjured youth athletes.

DESIGN

Repeated-measures study.

SETTING

Sports-medicine clinic.

PARTICIPANTS

Healthy youth athletes (mean age = 14.6 ± 2.2 years; 39% women) completed a brief, automated, and objective eye-tracking assessment.

INDEPENDENT VARIABLES

Participants completed the eye-tracking assessment at 2 different testing sessions.

MAIN OUTCOME MEASURES

During the assessment, participants watched a 220-second video clip while it moved around a computer monitor in a clockwise direction as an eye tracker recorded eye movements. We obtained 13 eye movement outcome variables and assessed correlations between the assessments made at the 2 time points using Spearman's Rho (rs).

RESULTS

Thirty-one participants completed the eye-tracking evaluation at 2 time points [median = 7 (interquartile range = 6-9) days between tests]. No significant differences in outcomes were found between the 2 testing times. Several eye movement variables demonstrated moderate to moderately high test-retest reliability. Combined eye conjugacy metric (BOX score, rs = 0.529, P = 0.008), the variance of the ratio for both eye movements in the horizontal (rs = 0.497, P = 0.013) and vertical (rs = 0.446; P = 0.029) movement planes along the top/bottom of the computer screen, and the variance of the left and right eye movement along the bottom segment of the computer screen (rs = 0.565; P = 0.004) each demonstrated moderate between-test correlations.

CONCLUSIONS

Automated and quantitative eye movement and conjugacy metrics provide relatively stable measurements among a group of healthy youth athletes. Thus, their inclusion as a visual tracking metric may be complementary to other visual examination techniques when monitoring concussion recovery across time.

Utility of a novel perceptual-motor control test for identification of sport-related concussion beyond current clinical assessments

Clinically feasible metrics, that can inform the concussion recovery decision making process by evaluating a unique domain beyond current testing domains (e.g., balance, neurocognition, symptoms, vestibular/ocular function) are still in need. The purpose of this study was to compare perceptual-motor control in adolescent athletes ≤21 days of sport-related concussion and healthy controls and evaluate the association of perceptual-motor control to the outcomes of commonly-used sport-related concussion clinical assessments. Athletes (age: 12-18 years) with sport-related concussion (n = 48) and healthy controls (n = 24) completed the Perception-Action Coupling Task (PACT), whose outcomes are mean reaction, movement, initiation, response time, and accuracy. ImPACT outcomes are verbal/visual memory scores, motor processing speed, and reaction time. Vestibular-Ocular Motor Screen (VOMS) outcomes are symptoms from: smooth pursuit, horizontal/vertical saccades, near-point of convergence, horizontal/vestibular ocular-reflex, and visual motion sensitivity. CONCUSSED demonstrated ~5% deficit in overall perceptual-motor accuracy during PACT compared to CONTROLS (p = 0.03). PACT accuracy negatively correlated with smooth pursuits(r = -0.29), and horizontal (r = -0.35)/vertical (r = -0.30) saccades. The C5.0 decision tree determined PACT accuracy was the most relevant predictor of sport-related concussion when no visual motion sensitivity symptoms were reported and Visual Memory was >66. Perceptual-motor control tests may complement current sport-related concussion assessments when neurocognition and vestibular/ocular motor system are not grossly impaired.

Normal variability within a collegiate athlete sample: A rationale for comprehensive baseline testing

OBJECTIVE

Sport-related concussions continue to garner attention as research emerges about the effects of these injuries. Many have advocated for cognitive baselines; however, there is no uniform practice of neuropsychological baseline testing at the collegiate level leading to variance in administration and interpretation. Continuing clarification on best practices is essential for the field, especially considering previous research highlighting normal variability on cognitive tests in other populations, but also the need for separate normative sources for those with attention and learning problems. This study aimed to evaluate the range of normal variability in a diverse sample of collegiate athletes administered a traditional neuropsychological baseline.

METHOD

Neuropsychological baseline measures were collected on 236 Division 1 University student athletes over 4 years. Frequency of scores that fell at 1, 1.5, and 2 or greater standard deviations were reviewed. Student athletes were further evaluated for likelihood of factors which could impact results (i.e. Attention-Deficit/Hyperactivity Disorder [ADHD], Specific Learning Disorder [SLD], and psychiatric distress).

RESULTS

The results demonstrated high rates of variability in most test scores for the collective sample. Student athletes at risk for ADHD, SLD, and/or psychiatric distress appeared to demonstrate a higher degree of variability relative to individuals with minimal risk.

CONCLUSION

Baseline evaluation data revealed the presence of normal variability in a student athlete population. Left unrecognized, this can lead to errors in clinical recommendations given the nature of concussion. Certain individuals have risk factors which may increase the range of variability, and this should be explored further in future research.

Effect of Diagnosed Sleep Disorders on Baseline Concussion Symptom, Cognitive, and Balance Assessments in Collegiate Athletes

BACKGROUND

Symptoms, cognition, balance, and other domains are commonly assessed at baseline testing as part of comprehensive preseason evaluations among collegiate student-athletes. Although approximately 27% of college students have at least 1 sleep disorder, researchers have yet to examine the role of a preexisting sleep disorder on preinjury baseline performance.

PURPOSE

To compare athletes with and without a reported history of diagnosed sleep disorders on commonly used baseline concussion assessments.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 666 National Collegiate Athletic Association student-athletes completed baseline measures including the Balance Error Scoring System (BESS), Brief Symptom Inventory-18 (BSI-18), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Post-Concussion Symptom Scale (PCSS), Sport Concussion Assessment Tool-5th Edition (SCAT5), and Standardized Assessment of Concussion (SAC). There were 333 athletes with a history of diagnosed sleep disorders who were matched on age, sex, sport, and concussion history to 333 athletes with no history of diagnosed sleep disorders. Participants in both groups had a mean age of 19.89 ± 1.36 years and included 182 (54.7%) male athletes, and 126 (37.8%) reported a history of ≥1 concussions.

RESULTS

A series of 1-way analyses of covariance with Bonferroni corrections revealed significant group differences on the BESS (F_1,559 = 8.88; P < .01); BSI-18 somatization (F_1,640 = 18.48; P < .01), depression (F_1,640 = 18.78; P < .01), anxiety (F_1,640 = 19.42; P < .01), and global severity index (F_1,640 = 27.18; P < .01); PCSS (F_1,424 = 29.42; P < .01); SCAT5 symptom number (F_1,634 = 28.79; P < .01) and symptom severity (F_1,634 = 31.74; P < .01); and SAC (F_1,578 = 4.36; P = .037). Specifically, while the sleep disorder group did perform better on the BESS, they also reported higher symptoms on the BSI-18, PCSS, and SCAT5 and performed worse on the SAC. There were no group differences on ImPACT performance.

CONCLUSION

Collegiate student-athletes with diagnosed sleep disorders reported elevated affective and concussion symptoms at baseline that could affect the interpretation of postinjury impairments and symptoms. Based on the small effect sizes of our findings, however, the magnitude of these differences is of questionable clinical significance. Still, clinicians should consider diagnosed sleep disorders as reported during preparticipation sports physical examinations when interpreting baseline and postinjury concussion assessments.

IMPROVEMENT OF REACTION TIME AFTER A WORKPLACE PHYSICAL ACTIVITY INTERVENTION

ABSTRACT Introduction Work activities have been occupying an increasing amount of time in the daily lives of the population, making individuals less physically active. A job market strategy is to invest in physical exercise programs in the actual workplace to improve the physical and cognitive aspects of these employees. Objective To verify the effects of a workplace physical exercise program on the simple and choice reaction times of public university employees. Methods Twenty-six physically inactive male and female subjects with a mean age of 29.62 ± 6.47 years underwent a program consisting of thirty-six sessions with physical exercises in the workplace, held three times a week over twelve weeks. Simple reaction time (SRT) and choice reaction time (CRT) were assessed before and after the intervention, using the Vienna Test System®, and the results were presented in: I) reaction time, II) movement time; and (III) response time. Descriptive and inferential statistical analyses were conducted using the statistical program SPSS® (version 21.0 for Windows), with a significance level of 5%. Results When observing the SRT and CRT variables before and after the experiment, we noticed an improvement in reaction time, movement time and response time in the experimental group but not in the control group. Conclusion The workplace physical exercise program was able to reduce the SRT and CRT of the experimental group. Level of evidence I; randomized clinical trial.

Children with Attention-Deficit/Hyperactivity Disorder Perform Differently on Pediatric Concussion Assessment

OBJECTIVE

To compare Child Sport Concussion Assessment Tool Fifth Edition (Child SCAT5) performance between uninjured children with attention-deficit/hyperactivity disorder (ADHD) and precisely matched controls without ADHD.

STUDY DESIGN

A nested case-control study was conducted within a cohort of middle school athletes (age 11-12 years) who completed preseason testing. Students with ADHD were individually matched to students without ADHD based on age, sex, language spoken at home, number of prior concussions, sport, and school they attended. The final sample included 54 students (27 with ADHD and 27 controls), 38 (70.4%) boys and 16 (29.6%) girls (average age: 11.7 years, SD = 0.5).

RESULTS

Children with ADHD reported more symptoms (M = 13.33, SD = 5.69, P < .001) and greater symptom severity (M = 22.59, SD = 1 1.60, P < .001) compared with controls (total symptoms: M = 6.44, SD = 4.96; symptom severity: M = 8.04, SD = 6.36). Children with ADHD performed similarly to controls on the Child SCAT5 cognitive tests. Children with ADHD committed 3 times as many total balance errors (median = 6) than children without ADHD (median = 2) and committed twice as many errors on single leg stance (ADHD median = 4; No ADHD median = 2) (P values < .001).

CONCLUSIONS

Children with ADHD endorsed more concussion-like symptoms and performed worse on balance testing during preseason Child SCAT5 assessment compared with matched controls without ADHD. These findings highlight the challenges of interpreting Child SCAT5 performance in children with ADHD following a concussion or suspected concussion and illustrate the value of administering the measure to children to document their pre-injury performance.

Effects of attention deficit hyperactivity disorder and learning disability on vestibular and ocular baseline concussion assessment in pediatric athletes

Vestibular and ocular motor assessment has gained popularity as a tool for sport-related concussion among healthcare professionals. With awareness of premorbid risk factors, such as attentional problems, it is imperative to understand their effects at baseline. The purpose of this study was to examine the effects of attention deficit/hyperactivity disorder (ADHD) and diagnosed learning disability (LD) on vestibular and oculomotor baseline concussion assessment in pediatrics. Pediatric athletes between the ages of 8 and 14 years with ADHD/LD (n = 30) and match controls without ADHD/LD (n = 30) completed baseline concussion testing, consisting of symptom provocation on the Vestibular/Ocular Motor Screening (VOMS) and oculomotor performance on near point of convergence (NPC) and King-Devick (K-D) tools. Those diagnosed with ADHD/LD performed worse on baseline saccades (p range = .02-.10), convergence (p = .04), vestibular ocular reflex (VOR) (p = .03) and visual motion sensitivity (VMS) (p = .04) of the VOMS. Base rate analyses revealed that 26% of athletes in the ADHD/LD group had ≥1 and 13.3% had ≥2 VOMS domains over clinical cutoff levels, compared to 3.3% (≥1 domain) and 0 (≥2 domains) of controls. Individuals with ADHD/LD also performed worse on K-D assessment (p = .005). However, no differences were reported on NPC distance (p = .19). These findings suggest worse baseline concussion assessment scores on vestibular/ocular motor assessment domains in pediatric athletes diagnosed with ADHD/LD. Additional research is needed on assessment outcomes to determine if special consideration to those diagnosed with ADHD/LD is warranted.

Attention Deficit Hyperactivity Disorder in Athletes

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in difficulties with sustaining attention in tasks and/or hyperactivity/impulsivity. Prevalence rates vary and difficulties in objectively diagnosing ADHD may lead to overdiagnosis or underdiagnosis. Assessment should include a comprehensive evaluation, including history, physical, psychological evaluation, and questionnaires for ADHD. Stimulant medications are effective for treatment, but their use, side effects, and potential for misuse and abuse are a concern, particularly in athletes. Athletes and physicians also need to be aware of the governing body's drug policy for the sport.

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

Using concurrent gait and cognitive assessments to identify impairments after concussion: a narrative review

Understanding how a concussion affects an individual is oftentimes difficult for clinicians due to the varying symptom profiles reported by the patient and the multifaceted and heterogeneous nature of the injury. Accordingly, the interpretation of postconcussion performance can be challenging, because many different testing paradigms have been reported as potentially useful in the literature. Among the types of tests clinicians use to understand how concussion affects an individual, both gait and neurocognitive evaluations have demonstrated utility. Our purpose is to describe how combined gait and cognitive (i.e., dual task), as well as single-task gait and computerized neurocognitive examinations can assist clinical decision-making.

Valid but Invalid: Suboptimal ImPACT Baseline Performance in University Athletes

PURPOSE

This study aimed to investigate the frequency of valid yet suboptimal Immediate Postconcussion Assessment and Cognitive Test (ImPACT) performance in university athletes and to explore the benefit of subsequent ImPACT administrations.

METHODS

This descriptive laboratory study involved baseline administration of ImPACT to 769 university athletes per the institution's concussion management protocol. Testing was proctored in groups of ≤2 participants. Participants who scored below the 16th percentile according to ImPACT normative data were readministered the ImPACT test up to two additional times because these scores were thought to be potentially indicative of suboptimal effort or poor understanding of instructions. Descriptive analyses were used to examine validity indicators and individual Verbal and Visual Memory, Visual Motor Speed, and Reaction Time ImPACT composite scores in initial and subsequent administrations.

RESULTS

On the basis of ImPACT's validity criteria, 1% (9/769) of administrations were invalid and 14.6% (112/769) had one or more composite score of <16th percentile but were considered valid. After one readministration, 71.4% (80/112) achieved scores of ≥16th percentile and an additional 18 of 32 scored ≥16th percentile after a third administration. Verbal Memory was most commonly <16th percentile on the first administration (43%), Verbal Memory and Visual Motor Speed on the second administration (44% each), and Visual Motor Speed alone on the third administration (50%).

CONCLUSIONS

Approximately 16% of ImPACT records were flagged as invalid or had one or more composite scores of <16th percentile, potentially indicative of suboptimal performance. Upon readministration, 88% of those participants scored >16th percentile. Clinicians must be aware of suboptimal ImPACT performance as it limits the clinical utility of the baseline assessment. Further research is needed to address factors leading to "valid" but invalid baseline performance.

Socioeconomic Status and Race Outperform Concussion History and Sport Participation in Predicting Collegiate Athlete Baseline Neurocognitive Scores

OBJECTIVES

The purpose of this study was to assess the contribution of socioeconomic status (SES) and other multivariate predictors to baseline neurocognitive functioning in collegiate athletes.

METHODS

Data were obtained from the Concussion Assessment, Research and Education (CARE) Consortium. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) baseline assessments for 403 University of Florida student-athletes (202 males; age range: 18-23) from the 2014-2015 and 2015-2016 seasons were analyzed. ImPACT composite scores were consolidated into one memory and one speed composite score. Hierarchical linear regressions were used for analyses.

RESULTS

In the overall sample, history of learning disability (β=-0.164; p=.001) and attention deficit-hyperactivity disorder (β=-0.102; p=.038) significantly predicted worse memory and speed performance, respectively. Older age predicted better speed performance (β=.176; p<.001). Black/African American race predicted worse memory (β=-0.113; p=.026) and speed performance (β=-.242; p<.001). In football players, higher maternal SES predicted better memory performance (β=0.308; p=.007); older age predicted better speed performance (β=0.346; p=.001); while Black/African American race predicted worse speed performance (β=-0.397; p<.001).

CONCLUSIONS

Baseline memory and speed scores are significantly influenced by history of neurodevelopmental disorder, age, and race. In football players, specifically, maternal SES independently predicted baseline memory scores, but concussion history and years exposed to sport were not predictive. SES, race, and medical history beyond exposure to brain injury or subclinical brain trauma are important factors when interpreting variability in cognitive scores among collegiate athletes. Additionally, sport-specific differences in the proportional representation of various demographic variables (e.g., SES and race) may also be an important consideration within the broader biopsychosocial attributional model. (JINS, 2018, 24, 1-10).

Attention-deficit/hyperactivity disorder is associated with baseline child sport concussion assessment tool third edition scores in child hockey players

OBJECTIVES

The objectives of this study were to report baseline, preseason data for the Child-SCAT3, stratified by attention deficit hyperactivity disorder (ADHD) status, and examine group differences in Child-SCAT3 performance between children with and without ADHD.

DESIGN

Cross-sectional study.

METHODS

Young male hockey players (n = 304), aged 8-12 years, were administered the Child-SCAT3 during pre-season. Child-SCAT3 measures included a 20-item symptom scale, a Standardised Assessment of Concussion Child Version (SAC-C), a modified Balance Error Scoring System (m-BESS), a tandem gait task, and a coordination test.

RESULTS

Children with ADHD (n = 20) endorsed significantly more symptoms (d = 0.95) and greater symptom severity (d = 1.13) compared to children without ADHD. No statistically significant differences were found between groups on Child-SCAT3 measures of cognitive or physical functioning (e.g. balance and coordination).

CONCLUSIONS

ADHD should be considered when interpreting Child-SCAT3 scores, especially symptom reporting, in the context of concussion assessment. Better understanding of symptom reporting in uninjured child athletes with ADHD can inform the clinical interpretation of symptoms at baseline and following an actual or suspected concussion. Normative data for the Child-SCAT3 that is not stratified by or otherwise accounts for ADHD status should be used with caution when appraising performance of children with ADHD.

Comparison of baseline and post-concussion ImPACT test scores in young athletes with stimulant-treated and untreated ADHD

OBJECTIVES

Baseline and post-concussion neurocognitive testing is useful in managing concussed athletes. Attention deficit hyperactivity disorder (ADHD) and stimulant medications are recognized as potential modifiers of performance on neurocognitive testing by the Concussion in Sport Group. Our goal was to assess whether individuals with ADHD perform differently on post-concussion testing and if this difference is related to the use of stimulants.

METHODS

Retrospective case-control study in which 4373 athletes underwent baseline and post-concussion testing using the ImPACT battery. 277 athletes self-reported a history of ADHD, of which, 206 reported no stimulant treatment and 69 reported stimulant treatment. Each group was matched with participants reporting no history of ADHD or stimulant use on several biopsychosocial characteristics. Non-parametric tests were used to assess ImPACT composite score differences between groups.

RESULTS

Participants with ADHD had worse verbal memory, visual memory, visual motor speed, and reaction time scores than matched controls at baseline and post-concussion, all with p ≤ .001 and |r|≥ 0.100. Athletes without stimulant treatment had lower verbal memory, visual memory, visual motor speed, and reaction time scores than controls at baseline (p ≤ 0.01, |r|≥ 0.100 [except verbal memory, r = -0.088]) and post-concussion (p = 0.000, |r|> 0.100). Athletes with stimulant treatment had lower verbal memory (Baseline: p = 0.047, r = -0.108; Post-concussion: p = 0.023, r = -0.124) and visual memory scores (Baseline: p = 0.013, r = -0.134; Post-concussion: p = 0.003, r = -0.162) but equivalent visual motor speed and reaction time scores versus controls at baseline and post-concussion.

CONCLUSIONS

ADHD-specific baseline and post-concussion neuropsychological profiles, as well as stimulant medication status, may need to be considered when interpreting ImPACT test results. Further investigation into the effects of ADHD and stimulant use on recovery from sport-related concussion (SRC) is warranted.

Concussion Baseline Testing: Preexisting Factors, Symptoms, and Neurocognitive Performance

CONTEXT

Neurocognitive test scores are often considered an important aspect of concussion management. To best use these data, clinicians must understand potential factors that may influence baseline performance on these tests.

OBJECTIVE

To determine preexisting factors that may influence performance on the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT).

DESIGN

Cross-sectional study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 486 National Collegiate Athletic Association Division I collegiate student-athletes.

MAIN OUTCOME MEASURE(S)

To determine neurocognitive functioning and total symptom score at baseline, ImPACT was administered. Outcomes were verbal memory, visual memory, visual motor speed, reaction time, and total symptom score. A self-report demographic section at the beginning of ImPACT was used to gather information concerning previous treatment for headaches, migraines, and psychiatric conditions; diagnosis of attention-deficit/hyperactivity disorder; and exposure to previous strenuous exercise. We conducted multivariate analyses of variance to determine if the ImPACT composite and total symptom scores differed according to preexisting factors (P < .0083).

RESULTS

Sex showed an effect on verbal memory (P = .001), visual motor speed (P < .001), and reaction time (P = .006), with women performing better than men. A previous diagnosis of attention-deficit/hyperactivity disorder affected visual motor speed (P = .008). Previous treatment for headaches (P < .001), migraines (P = .001), a psychiatric condition (P < .001), or a diagnosis of attention-deficit/hyperactivity disorder (P < .001) all showed effects on the total symptom score. Strenuous exercise did not affect neurocogntive performance or total symptom score.

CONCLUSIONS

Based on our findings and the previous literature, we suggest that many preexisting factors influence baseline neurocognitive data. Baseline testing is an important aspect of concussion management. Sports medicine professionals should be cognizant of these factors when developing concussion-management protocols.