Applied Neuropsychology: Child

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Parent Perceptions of Their Adolescent Athlete's Concussion: A Preliminary Retrospective Study Natalie Sandel, Luke C. Henry, Jonathan French & Mark R. Lovell To cite this article: Natalie Sandel, Luke C. Henry, Jonathan French & Mark R. Lovell (2015) Parent Perceptions of Their Adolescent Athlete's Concussion: A Preliminary Retrospective Study, Applied Neuropsychology: Child, 4:3, 211-216, DOI: 10.1080/21622965.2013.850692 To link to this article: http://dx.doi.org/10.1080/21622965.2013.850692

Published online: 25 Sep 2014.

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Date: 05 November 2015, At: 23:19

APPLIED NEUROPSYCHOLOGY: CHILD, 4: 211–216, 2015 Copyright # Taylor & Francis Group, LLC ISSN: 2162-2965 print=2162-2973 online DOI: 10.1080/21622965.2013.850692

Parent Perceptions of Their Adolescent Athlete’s Concussion: A Preliminary Retrospective Study Natalie Sandel

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Institute for Graduate Clinical Psychology, Widener University, Chester, Pennsylvania

Luke C. Henry and Jonathan French Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Mark R. Lovell ImPACT Applications Inc., Pittsburgh, Pennsylvania

Parent reports of their adolescent athletes’ recovery from concussion are often considered by clinicians, but limited research has explored the factors (i.e., athletes’ symptoms and neurocognitive performance) predicting parents’ perceptions of athletes’ recovery and how these factors relate to previous research on athletes’ self-perceptions of recovery. The current study included 67 athletes aged 12 to 18 years old (M ¼ 14.69 years, SD ¼ 1.67) who were evaluated for a sports-related concussion within 6 months postinjury and were accompanied by a parent to their evaluation. Athletes and parents were asked to rate athletes’ percent ‘‘back to normal’’ (i.e., perception of recovery), and athletes completed Immediate Post-Concussion Assessment and Cognitive Testing and symptom reports on the Post-Concussion Symptom Scale. Results of a multiple regression for athletes’ total symptom score and neurocognitive performance (Verbal Memory, Visual Memory, Visuomotor Speed, and Reaction Time) was significant and accounted for 47.9% of the variance in parents’ perceptions of recovery with total symptoms as the only significant predictor. A stepwise regression for symptom clusters (somatic, cognitive, sleep, and neuropsychiatric) demonstrated that somatic complaints were the most predictive of parents’ perceptions. Parents’ and athletes’ perceptions are predicted by athletes’ somatic symptoms, rather than athletes’ performance on objective assessments.

Key words:

athlete, concussion, neurocognitive, parent, symptoms

INTRODUCTION Each year approximately 1.6 million to 3.8 million sports-related concussions occur in the United States, with an increasing prevalence among youth athletes Disclaimer: Natalie Sandel is a consultant to ImPACT Applications Inc.; Mark R. Lovell is founder and chief scientific officer of ImPACT Applications Inc. Address correspondence to Natalie Sandel, Institute for Graduate Clinical Psychology, Widener University, One University Place, Chester, PA 19013. E-mail: [email protected]

(Bakhos, Lockhart, Myers, & Linakis, 2010; Langlois, Rutland-Brown, & Wald, 2006). For every 10,000 high school athletic exposures, 2.5 will result in a concussion, accounting for nearly 9% of all high school athletic injuries (Gessel, Fields, Collins, Dick, & Comstock, 2007; Guerriero, Proctor, Mannix, & Meehan, 2012). Concussion is defined as a ‘‘transitory complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces’’ (McCrory et al., 2009, p. i76). Concussion symptoms can be factored into four main symptom clusters: somatic, cognitive, sleep,

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SANDEL ET AL. TABLE 1 Symptom Clusters on the Post-Concussion Symptom Scale (Lau et al., 2009; Pardini et al., 2004)

Symptom Clusters Somatic Cognitive

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Neuropsychiatric Sleep

Component Symptoms Balance problems, sensitivity to light, sensitivity to noise, headache, dizziness, nausea, vomiting, numbness= tingling, visual problems Difficulty concentrating, difficulty remembering, feeling mentally foggy, feeling mentally slowed down, fatigue, drowsiness Irritability, feeling more emotional, sadness, nervousness Trouble falling asleep, sleeping more than usual, sleeping less than usual

and neuropsychiatric (Lau, Lovell, Collins, & Pardini, 2009; Pardini et al., 2004; see Table 1). Adolescent athletes are a particularly vulnerable population to sports-related concussion (Kontos et al., 2013; Marar, McIlvain, Fields, & Comstock, 2012) as they demonstrate a prolonged recovery period relative to adults (Collins et al., 2002; Lovell et al., 2003; Maugans, Farley, Altaye, Leach, & Cecil, 2012; Pellman, Lovell, Viano, & Casson, 2006). Persistent symptoms put adolescents at risk for additional injury, which can subsequently result in long-term impairments (Eisenberg, Andrea, Meehan, & Mannix, 2013; Moser, Schatz, & Jordan, 2005). Traditional neuroimaging techniques (e.g., computed tomography scan, magnetic resonance imaging) are not sensitive to the effects of concussion and thus cannot offer any objective contribution beyond detecting intracranial pathology. More recently developed experimental neuroimaging techniques demonstrate some promise for detecting concussion; however, the clinical use of these techniques is not yet feasible because of cost and a lack of expertise and availability (Chen et al., 2004; Gardner et al., 2012; Maugans et al., 2012; Shenton et al., 2012). Indeed, prior to the advancement of objective assessments of concussion, sports medicine professionals relied primarily on athletes’ self-report of symptoms when making return-to-play decisions. However, solely relying on athletes’ self-report of symptoms is an unreliable approach to concussion management because of athletes’ tendency to underreport symptoms (Delaney, Lacroix, Leclerc, & Johnston, 2002). Adolescent athletes mainly focus on somatic symptoms (e.g., headaches, nausea) rather than more subtle deficits when judging their recovery from concussion (Sandel, Lovell, Kegel, Collins, & Kontos, 2013). For instance, athletes who report being asymptomatic can still exhibit evidence of concussion on objective neurocognitive tests (Fazio, Lovell, Pardini, & Collins, 2007; Lovell & Solomon, 2013; Schatz & Sandel, 2012; Van Kampen, Lovell, Pardini, Collins, & Fu, 2006). Expert consensus groups advocate for a comprehensive evaluation of concussion that includes multiple sources of data when making return-to-play decisions (McCrory et al., 2013). At the youth level, parent

reports are often considered by clinicians because they offer an additional, unique source of information regarding athletes’ performance in the home and school environments (Ayr, Yeates, Taylor, & Browne, 2009; Gioia, Schneider, Vaughan, & Isquith, 2009; Hajek et al., 2011; Taylor et al., 2010). However, parents may also only consider certain factors when judging their child’s recovery from concussion. Stevens, Penprase, Kepros, & Dunneback (2010) found that approximately 47% of parents, who initially identified their concussed children as asymptomatic, endorsed one or more symptoms when asked about common concussion symptoms individually (e.g., ‘‘Does your child have trouble concentrating?’’). Parents may not have the education or knowledge to identify symptoms and=or may only be considering a small subset of the possible symptoms that follow after concussion. Limited research to date has explored the criteria parents consider when reporting athletes’ recovery. The first goal of the current study was to identify the factors (i.e., symptoms and neurocognitive performance measures) predictive of parents’ perceptions of their adolescent athletes’ recovery from concussion. A secondary goal was to compare these results to a similar study conducted by Sandel et al. (2013) on adolescent athletes’ self-perceptions of their recovery, which generally indicated that athletes primarily consider somatic symptoms when evaluating their return ‘‘back to normal’’ from concussion.

METHODS Participants Participants included two paired samples of adolescent athletes and their parents. A total of 67 adolescent athletes (40 male, 27 female) aged 12 to 18 years old (M ¼ 14.69 years, SD ¼ 1.67) who were evaluated for concussion by neuropsychologists at the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program were included in this study. All athletes had to be accompanied by a parent and had to have sustained a medically diagnosed sports-related

PARENT PERCEPTIONS

concussion within 6 months of the evaluation (median ¼ 29 days, range ¼ 149 days), with approximately 40% of athletes seen at or within 21 days postinjury. Athletes were excluded from the study if they had any of the following: (a) moderate-to-severe traumatic brain injury, (b) substance abuse, (c) psychiatric disorder, or (d) neurological disorder. Concussion history was determined by clinical interview and athletes’ self-reports. Other than their most recently sustained concussion, 76% of athletes had no history of concussion, 15% had one previous concussion, and 9% had two or more previous concussions.

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Measures Athletes were diagnosed with a concussion by a sports medicine professional (e.g., certified athletic trainer, sports medicine physician) and were subsequently referred to the UPMC Sports Medicine Concussion Program for postinjury follow-up in which the concussion diagnosis was confirmed using information gathered from clinical interviews, symptom reports, neurocognitive data, and vestibular-ocular screening results. There are currently no validated measures that assess parents’ perceptions of the extent of athletes’ recovery from concussion. Because the goal of this study was to assess the relationship between parents’ perceptions and athletes’ reported symptoms and neurocognitive performance, measurement of parents’ overall perceptions of athletes’ recovery from concussion for this study was performed using a single-item inventory in which parents rated athletes’ percent ‘‘back to normal’’ at the time of evaluation. Percent ‘‘back to normal’’ (i.e., perceived recovery) from concussion was rated utilizing a Likert scale ranging from 0% (no improvement in recovery since concussion) to 100% (fully recovered since concussion). Neurocognitive testing and symptom report were measured using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) computerized test battery, which yields four composite scores (Verbal Memory, Visual Memory, Visual Motor Speed, and Reaction Time [RT]) derived from six neurocognitive test modules (Word Memory, Design Memory, Xs and Os, Symbol Match, Color Match, Three Letters). The ImPACT test battery also includes the Post-Concussion Symptom Scale (PCSS), a 7-point Likert scale detailing 22 common postconcussive symptoms across four symptom clusters (somatic, cognitive, sleep, and neuropsychiatric) that yields individual and total symptom scores (Lau et al., 2009; Pardini et al., 2004). The ImPACT battery has been demonstrated as a reliable (Elbin, Schatz, & Covassin, 2011; Schatz, 2010; Schatz & Ferris, 2013) and valid (Maerlender et al., 2010, 2013; Schatz, Pardini, Lovell, Collins, & Podell, 2006; Schatz & Sandel, 2013) tool for evaluating concussion.

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Procedures Institutional review board approval was obtained through the participating institutions for an exempt retrospective medical records protocol. Athletes diagnosed with a concussion per sports medicine professionals were referred to the clinic for follow-up and were accompanied by a parent during the time of evaluation. All athletes with a confirmed diagnosis of concussion who met the inclusion and exclusion criteria were included in the study. Gender was not used as a criterion for selecting participants in this study because previous studies have indicated there are no sex differences between adolescent boys’ and girls’ perceptions of recovery, and the small sample size prevented splitting based on gender (Sandel et al., 2013). At the time of evaluation, both athletes and their parents completed the percent ‘‘back to normal’’ rating, and athletes underwent a clinical interview, neurocognitive testing, symptom reporting, and vestibular-ocular screening. Athletes’ symptom scores on the PCSS were clustered and totaled to yield the four main symptom scores (Lau et al., 2009; Pardini et al., 2004). Data Analyses Pearson product–moment correlations were conducted to assess the relationship between parents’ perceptions of athletes’ recovery from concussion and athletes’ performance on the ImPACT composite scores (Verbal Memory, Visual Memory, Visual Motor Speed, RT) and reported symptoms across four main symptom clusters (somatic, cognitive, sleep, and neuropsychiatric) and total symptom score. Multiple regression analyses were conducted to determine which neurocognitive and symptom scores were most predictive of parents’ perceptions of athletes’ recovery. A paired-samples t test was conducted to compare athletes’ perceptions and their corresponding parents’ perceptions of overall recovery from concussion as measured by their respective ratings of percent ‘‘back to normal,’’ with 0% being no recovery and 100% being complete recovery. The significance level for all tests was set at p < .05. All statistical analyses were conducted using the Statistical Package for the Social Sciences Version 20.

RESULTS Parents’ perceived recovery (i.e., percent ‘‘back to normal’’) and athletes’ reported symptoms and neurocognitive performance were all significantly correlated (see Table 2). With regard to athletes’ neurocognitive performance and parents’ perceived recovery, moderate positive correlations were found for Verbal Memory,

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SANDEL ET AL.

TABLE 2 Correlations Between Parents’ Perceived Recovery of Athletes and Neurocognitive and Symptom Scores (N ¼ 67)

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Neurocognitive Composite Scores Verbal Memory Visual Memory Visuomotor Speed Reaction Time Athletes’ Symptom Scores Somatic Cognitive Sleep Neuropsychiatric Total

r

p

.47 .48 .38 .35

.000 .000 .002 .004

.75 .46 .54 .41 .65

.000 .000 .000 .001 .000

Visual Memory, and Visual Motor Speed (r ¼ .38–.48), while a moderate negative correlation (r ¼ .35) was found between RT and perceived recovery (which is to be expected given that a faster, or lower, RT indicates a better performance). In comparison, moderate-tostrong negative correlations were found between symptom cluster and total symptom scores and perceived recovery (r ¼ .41 to .75), which is again to be expected as lower symptom scores equate to greater recovery. The strength of these correlations indicates that symptoms reported by athletes are in general more strongly associated with parents’ perceptions of athletes’ recovery than athletes’ performance on objective neurocognitive testing. Comparison of these results to previous research on athletes’ self-perceptions (see Table 3) indicates that parents’ and athletes’ perceptions demonstrate similar relationships to neurocognitive performance and reported symptoms. To explore the factors that were related to parents’ perceptions of recovery, a multiple regression using the forced-entry method was conducted with perceived recovery as the dependent variable and neurocognitive composite and total symptom scores as the independent

TABLE 3 Correlations Between Athletes’ Self-Perceived Recovery and Neurocognitive and Symptom Scores (Sandel et al., 2013)

Neurocognitive Composite Scores Verbal Memory Visual Memory Visuomotor Speed Reaction Time Athletes’ Symptom Scores Somatic Cognitive Neuropsychiatric Sleep Total

r

p

.30 .44 .37 .43

.003 .000 .000 .000

.74 .63 .47 .49 .72

.000 .000 .000 .000 .000

TABLE 4 Results of the Exploratory Multiple Regression for Parents’ Perceived Recovery (N ¼ 67)

Neurocognitive Verbal Memory1 Visual Memory2 Visuomotor Speed3 Reaction Time4 Total Symptom Score5

B

SE B

b

p

0.403 0.094 0.270 8.639 0.657

0.251 0.225 0.330 21.050 0.143

.193 .057 .102 .048 .525

.113 .678 .416 .683 .000

 Regression Equation: Y ¼ 34.076 þ 0.403x1 þ 0.094x2 þ 0.270x3 þ 8.639x4 þ 0.657x5.

variables. Data were screened for violations of assumptions: No collinearity (tolerance range ¼ .458– .655 and variance inflation factors were

Parent Perceptions of Their Adolescent Athlete's Concussion: A Preliminary Retrospective Study.

Parent reports of their adolescent athletes' recovery from concussion are often considered by clinicians, but limited research has explored the factor...
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