No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Student athlete concussions and postconcussion syndrome: ADHD as a risk factor
... 12 Nuwer et al. explain that "Concussion symptoms can be difficult to separate from ADHD baseline symptoms… Many postconcussion symptoms present as a clinical picture similar to ADHD itself." 13 The Institute of Medicine and National Research Council of the National Academies ("IOM-NRC") report titled Sports-Related Concussion in Youth: Improving the Science, Changing the Culture, identifies ADHD and learning disabilities as co-morbid conditions in neuropsychological testing and recommends collection of such data in concussion evaluation, noting that the presence of these factors may affect test outcomes. 14 The NCAA recognizes LD/ADHD as co-morbidities that may accompany concussions and ADHD as a modifier that may prolong recovery from brain injury. ...
... The Iaccarino et al. study also found that 50% (11/22) SRC patients aged <17 years had full ADHD. Using the Taiwan Health Insurance Research Database to analyze children (ages 3-11), adolescents (ages [12][13][14][15][16][17], and young adults (ages [18][19][20][21][22][23][24][25][26][27][28][29] between 2001 and 2009 and following up in 2011, Liou et al. 115 also found that patients with ADHD had an increased risk of suffering a traumatic brain injury compared to controls. ...
Concussion research in the United States commonly relies on collegiate athletes as study subjects. Such research recognizes
learning disabilities and attention deficit disorders (LD/ADHD) as co-morbidities that should be addressed in concussion research and management. This study had three objectives: 1) to investigate the prevalence of such diagnoses and examine neuropsychological test results among incoming college football players at a major US university; 2) to examinehow LD/ADHD diagnoses were addressed in concussion research that included such athletes; and 3) to address the implication of these results for ongoing concussion research using college athletes, including the NCAA-DoD CARE Consortium. Authors
observed LD/ADHD rates among football athletes exceeding 50% in multiple cohort-years, a degree of magnitude greater
than the rate among general college student populations. Neuropsychological testing revealed scores among some
incoming freshman college football players consistent with those of severe traumatic brain injury (TBI) patients. Evidence of cognitive impairment among incoming college football players raises concern over the potential effects of cumulative exposure to head trauma and the increased risk associated with continued participation in collision sports. The prevalence of prescriptions for stimulant medication among this population limits its ability to serve as a proxy for other populations, including the military, to which results from college athlete samples may be extrapolated in error.
... In that study, collegiate athletes with ADHD were not more likely than controls to report a suspected yet nondisclosed concussion. However, the fact that the athletes with ADHD were given any degree of nondisclosure is concerning as delayed identification of SRC is related to poorer outcomes (Asken et al., 2016;Asken et al., 2018;Patricios et al., 2023), and youth with ADHD display more symptoms of concussion (Iaccarino et al., 2018;Nuwer et al., 2018). Other reasons to be troubled by SRC nondisclosure of ADHD athletes are that symptoms of ADHD can be more difficult to treat postconcussion (White et al., 2014), and those with ADHD who acquire an SRC may endure a prolonged recovery period as compared to those without ADHD (Didehbani et al., 2024;Martin et al., 2022;Pujalte et al., 2023). ...
Objective
Within a sample of young athletes with attention-deficit/hyperactivity disorder (ADHD), to explore the frequency of disclosed and nondisclosed concussions, identify reasons the youth did not report a suspected concussion, and learn the frequency that the youth still practiced or played in a game after a suspected concussion.
Method
Cross-sectional surveys were completed by 448 youth athletes (ages 8–14 years) and a corresponding parent (or caregiver). As part of larger respective surveys, questions regarding ADHD status and concussion history were asked of the youth and parents. Data regarding 40 youth with ADHD were available for analyses. Due to the low frequency of concussive injuries within the total sample, descriptive statistics and qualitative techniques were used to contextualize the data.
Results
The youth with ADHD were not more likely to experience at least one diagnosed concussion or nondisclosed concussion as compared to non-ADHD controls. Three of 40 youth athletes with ADHD (8%) had been diagnosed with a concussion, whereas 5 (13%) self-reported a nondisclosed concussion. Not wanting to lose playing time and not wanting to miss a game were the two most endorsed reasons for concussion nondisclosure.
Conclusions
More research is needed to understand the present results considering other research that puts similarly aged athletes with ADHD at greater risk for concussion. Education for youth with ADHD might help reduce the number of nondisclosed concussions that have a more complex recovery trajectory in this population.
Importance
Estimated base rates of invalid performance on baseline testing (base rates of failure) for the management of sport-related concussion range from 6.1% to 40.0%, depending on the validity indicator used. The instability of this key measure represents a challenge in the clinical interpretation of test results that could undermine the utility of baseline testing.
Objectives
To determine the prevalence of invalid performance on baseline testing and to assess whether the prevalence varies as a function of age and validity indicator.
Design, Setting, and Participants
This retrospective, cross-sectional study included data collected between January 1, 2012, and December 31, 2016, from a clinical referral center in the Midwestern United States. Participants included 7897 consecutively tested, equivalently proportioned male and female athletes aged 10 to 21 years, who completed baseline neurocognitive testing for the purpose of concussion management.
Interventions
Baseline assessment was conducted with the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT), a computerized neurocognitive test designed for assessment of concussion.
Main Outcomes and Measures
Base rates of failure on published ImPACT validity indicators were compared within and across age groups. Hypotheses were developed after data collection but prior to analyses.
Results
Of the 7897 study participants, 4086 (51.7%) were male, mean (SD) age was 14.71 (1.78) years, 7820 (99.0%) were primarily English speaking, and the mean (SD) educational level was 8.79 (1.68) years. The base rate of failure ranged from 6.4% to 47.6% across individual indicators. Most of the sample (55.7%) failed at least 1 of 4 validity indicators. The base rate of failure varied considerably across age groups (117 of 140 [83.6%] for those aged 10 years to 14 of 48 [29.2%] for those aged 21 years), representing a risk ratio of 2.86 (95% CI, 2.60-3.16; P < .001).
Conclusions and Relevance
The results for base rate of failure were surprisingly high overall and varied widely depending on the specific validity indicator and the age of the examinee. The strong age association, with 3 of 4 participants aged 10 to 12 years failing validity indicators, suggests that the clinical interpretation and utility of baseline testing in this age group is questionable. These findings underscore the need for close scrutiny of performance validity indicators on baseline testing across age groups.
Objective:
Attention deficit hyperactivity disorder (ADHD) and other academically-relevant diagnoses have been suggested as modifiers of neurocognitive testing in sport-related concussion, such as Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). These preexisting conditions may suppress ImPACT scores to the extent that they are indistinguishable from low scores because of poor effort. The present study hypothesized that student athletes with history of ADHD or academic difficulties produce lower ImPACT composite scores and are more likely to produce invalid protocols than those without such conditions.
Design:
Cross-sectional study.
Setting:
Midsized public university.
Participants:
Nine hundred forty-nine National College Athletic Association athletes (average age = 19.2 years; 6.8% ADHD, 5.6% Academic Difficulties, 2.0% comorbid ADHD/Academic Difficulties).
Independent variables:
Three seasons of baseline ImPACT protocols were analyzed. Student athletes were grouped using self-reported histories of ADHD or academic difficulties taken from ImPACT demographic questions.
Dependent variables:
ImPACT composite scores and protocol validity.
Results:
Student athletes in the academic difficulties and comorbid groups performed worse on ImPACT composite scores (Pillai's Trace = 0.05), though this pattern did not emerge for those with ADHD. Student athletes with comorbid history were more likely to produce an invalid baseline (10.5% invalid) (χ (2) = 11.08, P = 0.004). Those with ADHD were also more likely to produce an invalid protocol (7.7% invalid, compared with 2.6% in student athletes with no history) (χ (2) = 10.70, P = 0.005).
Conclusions:
These findings suggest that student athletes reporting comorbid histories or histories of academic difficulties alone produce lower ImPACT composite scores, and that those with comorbid histories or histories of ADHD alone produce invalid protocol warnings more frequently than student athletes without such histories. Future studies should further examine invalid score thresholds on the ImPACT, especially in student athletes with conditions that may influence test performance.
Clinical relevance:
Student athletes with history of ADHD or academic difficulties may more frequently fall below validity score thresholds, suggesting caution in interpreting test performance.
The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements1–4 and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement.
This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps.
A series of specific clinical questions were developed as part of the consensus process for the Berlin 2016 meeting. Each consensus question was the subject of a specific formal systematic review, which is published concurrently with this summary statement. Readers are directed to these background papers in conjunction with this summary statement as they provide the context for the issues and include the scope of published research, search strategy and citations reviewed for each question. This 2017 consensus statement also summarises each topic and recommendations in the context of all five CISG meetings (that is, 2001, 2004, 2008, 2012 as well as 2016). Approximately 60 000 published articles were screened by the expert panels for the Berlin …
Objective: Previous research has found ADHD symptoms to be common in the general population but has not compared endorsement of symptoms between ADHD and non-ADHD groups. This study examines self-reported ADHD symptoms and academic complaints in college students. Method: Students without (n = 496) and with ADHD (n = 38) completed a questionnaire covering the 18 ADHD symptoms in the Diagnostic and Statistical Manual of Mental Disorders and academic and test-taking concerns. Results and Conclusion: Students with ADHD diagnoses reported significantly more ADHD symptoms and academic concerns, but none of the 18 symptoms or 6 concerns proved to be both sensitive and specific to ADHD. Poor specificity of symptoms and academic complaints casts doubt on the utility of this self-reported information in diagnosis, particularly if used alone and without regard to severity or extent of impairment. (J. of Att. Dis. 2008; 12(2) 156-161)
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.
Purpose:
Previous studies suggested that patients with attention-deficit hyperactivity disorder (ADHD) were prone to health-risk behaviors and accidents. However, the relationship of ADHD with the risk of traumatic brain injury (TBI) remained uncertain.
Methods:
Using the Taiwan National Health Insurance Research Database, 72,181 children (aged 3-11 years), adolescents (12-17 years), and young adults (18-29 years) with ADHD and 72,181 age-/sex-matched controls were enrolled between 2001 and 2009, and followed up to the end of 2011 in our study. Those who developed any TBI during the follow-up period were identified.
Results:
Children, adolescents, and young adults with ADHD had a higher incidence of developing any TBI (9.8% vs. 2.2%, p < .001), such as skull fracture (.2% vs. .1%, p < .001) and concussion (4.3% vs. 1.0%, p < .001), than the controls did. Cox regression analysis with the adjustment of demographic data, psychiatric comorbidities, and ADHD medications showed that ADHD was related to an increased risk of subsequent TBI (hazard ratio: 4.57, 95% confidence interval: 4.31-4.85), and indicated that long-term use of ADHD medication was associated with a reduced likelihood of subsequent TBI (hazard ratio: .93, 95% confidence interval: .87-.99).
Conclusions:
Patients with ADHD had an increased risk of developing any TBI compared with the controls. Long-term use of ADHD medications would reduce this risk. Our findings suggested that the public health government and clinicians should pay more attention to the TBI risk among patients with ADHD, and further indicated the importance of the optimal treatment for ADHD.
Acknowledgments The authors,thank Richard Sattin for his insightful comments,and Mario Schootman,for preparing,a preliminary version of the report. The authors also offer sincere thanks to Patricia Holmgreen, Dionne White, Lee Annest, and other members of the Office of Statistics and Programming, National Center for Injury Prevention and Control, for their statistical assistance; and Margy Warner, Lois Fingerhut, and other staff of the National Center for Health Statistics for their guidance and consultation.
The 1991 National Health Interview Survey was analysed to describe the incidence of mild and moderate brain injury in the United States. Data were collected from 46 761 households and weighted to reflect all non-institutionalized civilians. The report of one or more occurrences of head injury resulting in loss of consciousness in the previous 12 months was the main outcome measure. Each year an estimated 1.5 million non-institutionalized US civilians sustain a non-fatal brain injury that does not result in institutionalization, a rate of 618 per 100,000 person-years. Motor vehicles were involved in 28% of the brain injuries, sports and physical activity were responsible for 20%, and assaults were responsible for 9%. Medical care was sought by 75% of those with brain injury; 14% were treated in clinics or offices, 35% were treated in emergency departments, and 25% were hospitalized. The risk of medically attended brain injury was highest among three subgroups: teens and young adults, males, and persons with low income who lived alone. The incidence of mild and moderate brain injury in the United States is substantial. The National Health Interview Survey is an important national source of current outpatient brain-injury data.
This article reviews the pathophysiology of mild traumatic brain injury, and the findings from EEG and quantitative EEG (QEEG) testing after such an injury. Research on the clinical presentation and pathophysiology of mild traumatic brain injury is reviewed with an emphasis on details that may pertain to EEG or QEEG and their interpretation. Research reports on EEG and QEEG in mild traumatic brain injury are reviewed in this setting, and conclusions are drawn about general diagnostic results that can be determined using these tests. QEEG strengths and weaknesses are reviewed in the context of factors used to determine the clinical usefulness of proposed diagnostic tests. Clinical signs, symptoms, and the pathophysiologic axonal injury and cytotoxicity tend to clear over weeks or months after a mild head injury. Loss of consciousness might be similar to a non-convulsive seizure and accompanied subsequently by postictal-like symptoms. EEG shows slowing of the posterior dominant rhythm and increased diffuse theta slowing, which may revert to normal within hours or may clear more slowly over many weeks. There are no clear EEG or QEEG features unique to mild traumatic brain injury. Late after head injury, the correspondence is poor between electrophysiologic findings and clinical symptoms. Complicating factors are reviewed for the proposed commercial uses of QEEG as a diagnostic test for brain injury after concussion or mild traumatic brain injury. The pathophysiology, clinical symptoms and electrophysiological features tend to clear over time after mild traumatic brain injury. There are no proven pathognomonic signatures useful for identifying head injury as the cause of signs and symptoms, especially late after the injury.
Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths
- J A Langlois
- W Rutland-Brown
- K E Thomas
- Langlois JA