Nathan E. Cook

Concussion-Like Symptom Reporting in High School Student Athletes with ADHD.

Disclosures: Nathan Cook: I Have No Relevant Financial Relationships To Disclose Objective: Symptom reporting in student athletes with attentiondeficit hyperactivity disorder (ADHD) who are slow-to-recover from a sport-related concussion can be difficult to interpret; it can be challenging to differentiate pre-existing symptoms from concussionrelated symptoms. This study documents preseason symptom reporting in athletes with and without ADHD. Design: Cross-sectional, case-control, cohort survey study. Setting: High schools from the state of Maine, USA. Participants: Participants were 37,510 high school athletes who completed a baseline preseason health survey and symptom questionnaire between 2009 and 2014. None reported suffering a concussion within the past 6 months. A total of 2,409 (6.4%) self-reported having ADHD, and 786 (32.6%) reported taking medication to treat ADHD. Three groups included: (1) controls, (2) ADHD with medication use (Medication), and (3) ADHD but no medication use (No Medication). Interventions: None. Main Outcome Measures: The Post-Concussion Scale includes 22 symptoms such as headache, dizziness, concentration problems, and forgetfulness. Students rate the severity of each symptom from 0 to 6. Results: Groups differed significantly on the Post-Concussion Scale [girls: X(2)1⁄422.6.29, P <.001; boys: X(2)1⁄4267.15, P <.001]. Pairwise comparisons revealed similar results for both sexes; namely, the Medication group (boys: Md1⁄44; girls: Md1⁄49) and No Medication group (boys: Md1⁄43.5; girls: Md1⁄47) did not differ from one another. Both the No Medication group (girls: Mann-Whitney U1⁄42,881,457, P <.001; boys: U1⁄48,170,938, P <.001) and the Medication group differed significantly from Controls (girls: Md1⁄42; U1⁄41,187,040.5, P <.001; boys: Md1⁄41; U1⁄43,836,183.5, P <.001). Girls with ADHD, regardless of medication status, had greater total symptom scores compared to boys with ADHD. Frequencies of endorsing specific symptoms (ie, item score > 1), stratified by group and gender, are presented. Conclusions: Better understanding of symptom reporting in uninjured student athletes with ADHD can facilitate the clinical interpretation of symptoms in those who are slow to recover following a concussion. Level of Evidence: Level III

Baseline cognitive test performance and concussion-like symptoms among adolescent athletes with ADHD: examining differences based on medication use

Abstract Objective: Youth with attention deficit hyperactivity disorder (ADHD) perform more poorly on preseason cognitive testing and report more baseline concussion-like symptoms but prior studies have not examined the influence of medication use on test performance or symptom reporting. This study investigated whether medication use is relevant when interpreting baseline ImPACT® results from student athletes with ADHD. Method: Participants were 39,247 adolescent athletes, ages 13–18 (mean age = 15.5 years, SD = 1.3), who completed baseline cognitive testing with ImPACT®. The sample included slightly more boys (54.4%) than girls. Differences in ImPACT® composite scores and concussion-like symptom reporting (between ADHD/No medication, ADHD/Medication, No ADHD/Medication, and Control groups) were examined with ANOVAs, conducted separately by gender. Results: In this large, state-wide data-set, youth with ADHD had greater rates of invalid ImPACT results compared to control subjects (ADHD/No Medication: girls = 10.9%, boys = 10%; ADHD/Medication: girls = 8.1%, boys = 9.1%; Controls: girls = 5.2%, boys = 6.7%). Groups differed across all ImPACT® composites (invalid profiles were removed), in the following order (from worse to better performance): ADHD/No Medication, ADHD/Medication, and Control participants. Pairwise effect sizes indicated that the largest differences were on the Visual Motor Speed composite, with the ADHD/No medication group performing worse than the ADHD/Medication group and the Controls. The ADHD/Medication group did not differ meaningfully from Controls on any composite, for either sex (d = 0 to .19). The ADHD groups did not differ on total symptom scores but both ADHD groups endorsed significantly more symptoms compared to Controls. Conclusions: Contrary to our hypothesis, we found medication use had only a subtle effect on cognitive performance and no significant effect on concussion-like symptom reporting. Student athletes reporting medication use for ADHD performed comparably to student athletes with no ADHD on baseline testing.

Pre-injury migraine history as a risk factor for prolonged return to school and sports following concussion

Having a preexisting migraine disorder might be a risk factor for a prolonged recovery following a sport-related concussion. We examined whether having a migraine history was associated with a prolonged return to academics and athletics following a concussion. High school and collegiate athletes (n = 1265; 42% female) who sustained a sport-related concussion were monitored by athletic trainers using a web-based surveillance system that collects information about concussion recovery. Nonparametric Kolmogorov-Smirnov tests (KS) were used to compare days to return to academics/athletics across groups due to non-normally distributed outcome variables and unequal distributions of scores between groups. Chi-squared tests were used to examine the proportion of players who had not returned to academics/athletics at 7, 14, and 21 days post-injury stratified by self-reported migraine history. There were 117 athletes (9.2%) who reported a preinjury migraine history. Athletes with a history of migraine took a median of 6 days to return to academics (mean [M] = 10.6, standard deviation [SD] = 14.2) and 15.5 days to return to athletics (M = 23.8, SD = 30.8), while those with no migraine history took a median of 5 days to return to academics (M = 7.5, SD = 10.9) and 14 days to return to athletics (M = 19.4, SD = 19.4). There were no statistically significant differences in days to return to school or athletics between the groups (KS p > 0.05). However, a lower percentage of athletes with a history of migraine had returned to school after 7 days (57% vs. 68%, χ2 = 5.53, p = 0.02), 14 days (75% vs. 88%, χ2 = 14.21, p < 0.001), and 21 days post-injury (89% vs. 94%, χ2 = 4.90, p = 0.03). Stratifying the analyses by sex showed that this effect was significant in girls and women with preexisting migraines, but not boys and men with preexisting migraines. There were no group differences in recovery rates when examining return to athletics. Athletes with a preinjury migraine history may be at an elevated risk for a protracted return to school after concussion, especially girls and women.

Clinical and functional correlates of processing speed in pediatric Attention-Deficit/Hyperactivity Disorder: a systematic review and meta-analysis

ABSTRACT It is well established that processing speed is negatively impacted in children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD). Unfortunately, exactly how processing speed vulnerabilities manifest in daily functioning has not been well established. To support clinical care of youth with ADHD, it is important to better understand the functional consequences and relevant outcomes associated with processing speed deficits. This systematic review and meta-analysis sought to identify the association between processing speed and clinical or functional correlates among children or adolescents diagnosed with ADHD. A total of 409 abstracts were screened, of which, 60 full-text articles were identified as potentially relevant, and 8 of these studies met inclusion criteria. Domains evaluated across these studies included reading skills, mathematics skills, written expression, anxiety, self-appraisals of competence, and adaptive functioning. Six studies reported an association between processing speed and reading skills, allowing for meta-analysis. Processing speed difficulties among youth with ADHD appear strongly associated with several clinical and functional correlates including weaker academic skills, poorer adaptive skills, increased self-reported anxiety, and overestimates of social competence. Meta-analytic results for studies reporting the association between processing speed and reading skills indicate a medium overall weighted mean effect size (r = 0.33, 95% CI = 0.28 –0.39) with minimal heterogeneity (I2 = 0.17). Clinical implications of these findings, limitations in the current knowledge base, and suggestions for future research are discussed.

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

ABSTRACT 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.