Pre-Season Concussion Baseline Testing and Students with Learning Disabilities or ADHD

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November 1, 2017

By Jeremy D. Howard, MS, LAT, ATC

The National Athletic Trainers’ Association (NATA), published a position statement on concussions in 2014, a document that assists in guiding the practice of ATs caring for concussed athletes. In the position statement, the NATA recommends participants of collision or contact sports should have completed a baseline neurocognitive test prior to the competitive season and that for adolescent athletes this baseline should be re-established annually due to their developing brains.1 This baseline could then be used by the sport team’s AT to establish when the athlete’s brain has healed enough from the concussion to initiate the graduated Return-to-Play (RTP) protocol.

While there are many neurocognitive tests on the market today (Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®), Automated Neuropsychological Assessment Metrics (ANAM), or Headminder Concussion Resolution Index (CRI) for example), there is no ‘Gold Standard’ neurocognitive test to date. Having said that, the ImPACT® test was the first computerized neurocognitive test to receive FDA Approval2 and is currently the most widely used and valid neurocognitive test. During the ImPACT® test, the athlete takes the test before participation in sports. If they sustain a concussion or mild traumatic brain injury, then this test can be used to establish when the brain is ready for RTP. But wait; unfortunately, it‘s not that easy.

Neurocognitive tests, such as ImPACT®, are not as valid or specific for those with learning disabilities and attention deficit-spectrum disorders.3,4 Of the 6 composite scores of the ImPACT® test, those with learning disabilities and/or attention deficit-spectrum disorders typically show deficits in verbal memory, visual memory and visual motor processing speed3,4 and present with an invalid data set on their composite scores 10.5 percent of the time.5

In the United States, as many as 16 percent of children and adolescents aged 3-17 have been diagnosed with either an attention deficit-spectrum disorder or a learning disability.3 Taking those findings into account and combining that information with a 1.6-3.8 million range of concussions associated to sports annually2,5 that suggests that approximately 102,4004 of the concussed athletes have a learning disability or attention deficit-spectrum disorder, that could skew their results on baseline or serial neurocognitive testing. That could result in either potentially returning an athlete too early and risking further brain damage, or holding an athlete out longer due to an inability to return to baseline.

In addition, there is also the fiscal aspect of cost per neurocognitive test being administered. That’s a bunch of big words and numbers that can be blinding, but what does it all mean for the parents, the athletes and ATs? The answer is that ATs need to ensure they have a thorough medical history gathered on each of their patients with regard to any pertinent data around the patient’s history for learning disabilities or attention deficit-spectrum disorders.

Due to the frequency of invalid baselines in this population and decreased composite scores, multiple researchers have called for expanding the research to establish normative data on the ImPACT® test and ImPACT® Pediatric test in this population.4-6 While there is currently no perfect neurocognitive test for concussions either written or computer-based, the researchers are working on it!


1. Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., and Valovich McLeod, T.C. (2014). National athletic trainers’ association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265.

2. Moran, M. (2016). FDA-approved devices assess cognition after possible brain injury in youth. Clinical Research News. Accessed from

3. Zuckerman, .L., Lee, Y.M., Odom, M.J., Solomon, G.S., and Sills, A.K. (2013). Baseline neurocognitive scores in athletes with attention deficit-spectrum disorders and/or learning disability clinical article. Journal of Neurosurgery: Pediatrics, 12(2), 103-109.

4. Elbin, R.J., Kontos, A.P., Kegel, N., Johnson, E., Burkhart, S., and Schatz, P. (2013). Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: Evidence for separate norms. Archives of Clinical Neuropsychology, 28(5), 476-484.

5. Manderino, L. and Gunstad, J. (2017). Collegiate student athletes with history of ADHD or academic difficulties are more likely to produce an invalid protocol on baseline ImPACT testing. Clinical Journal of Sport Medicine. doi: 10.1097/JSM.0000000000000433.


About the Author

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Jeremy Howard is the State Health Promotion Officer for Florida Army National Guard under the Resilience, Risk Reduction, and Suicide Prevention Program. Howard graduated with a Bachelor of Science in Athletic Training from Florida Gulf Coast University (#DunkCity) and from the University of Saint Augustine for Health Sciences’ Master of Health Science in Athletic Training programs. He is currently pursuing an Educational Doctorate in Health Sciences at the same institution. In 2002, Howard enlisted in the Florida Army National Guard and is still currently serving; he is also a veteran of Operation Enduring Freedom-Afghanistan. His professional interests include Concussion/TBI, Injury Prevention Programs and Manual Therapy.

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