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Baseline Neurocognitive Testing For Younger Athletes: Extra Vigilance Required

Invalid rates for 10- to 12-year olds tested in large group setting more than 4 times higher than for 13- to 18-year-olds

With increased interest in implementing baseline "preinjury" neurocognitive testing at the pre-high school level and in recreational and club sports have come concerns about their validity. A first-of-its-kind study[1] of baseline testing among younger athletes suggests that such concerns may be justified.

Examining the results of baseline testing for 502 youth athletes aged 10 to 18 years, researchers at the Sports Concussion Center of New Jersey (SCCNJ) found that athletes ages 10 to 12 years of age provided 2 and 1/2 times more invalid baseline scores than athletes aged 13 to 18 years overall, and, when tested in larger groups (10 per room), were more than four times more likely to deliver invalid baseline scores than their adolescent counterparts, regardless of the older athletes' testing environment. 

Computer class

Large group testing problematic 

The higher rates of invalid test results among younger athletes when they were tested in a large group setting (10 per room), said the study's lead author, Rosemarie Scolaro Moser, PhD, a MomsTEAM concussion expert, and SCCNJ's Director, were likely due, not just to distractions and decreased individualized attention inherant in a large group testing environment. but of a combination of other factors, including the fact that younger, pre-high school athletes:

  • Are developmentally less mature and independent than adolescents;
  • May require more attention and supervision when completing tasks;
  • May not intellectually grasp the importance and utility of baseline testing because of their less mature cognitive development; and 
  • Have less advanced reading skills.

By establishing an athlete's baseline or "normal" score on tests of cognitive functions that are often affected by concussion, such as memory, processing speed, reaction time, and attention, and on measures of physical/emotional/cognitive symptoms, re-testing after a suspected concussion can help determine if and when an athlete's brain has recovered. If the youth feels symptom free, and post-concussion testing is the same or better than baseline (pre-concussion) testing, recovery is likely imminent.

In order for baseline tests to be useful for comparison with postinjury performance and in return-to-play decisionmaking, however, the data must reflect a valid assessment of an athlete's "true" baseline ability. Getting a valid baseline, however, can be problematic.

"Unfortunately," writes Moser, administrators of baseline testing programs [even at the high school and college level] are often inadequately trained in neurocognitive testing and may not be cognizant of the factors that may render a test invalid," ranging from fatigue and anxiety, and poor effort and motivation, to environmental factors, such as testing in a large group (which is the norm), confusion about test directions, noises and distractions, mechanical issues with the computer device, or other individual factors.

Proceed with caution

The fact that younger athletes have a higher rate of suspect valid results than adolescent athletes, even when there is a strong attempt to control for external environmental factors, writes Moser, "support the need for standardized, better controlled administration procedures by trained professionals who understand neurocognitive testing," and, "more importantly, the need to design baseline tools that are tailored to younger athletes."

Given increased concussion awareness, litigation, and legislation, Moser predicted that "there will be increased pressure upon academic institutions and youth sports organizations to provide concussion management programs that include baseline neurocognitive testing.

The problem, she says, is that "Elementary schools and recreational leagues will face the same financial challenges as high school, collegiate, and professional programs when it comes to providing management services, but with even fewer economic resources." 

The findings of the study thus "provide a warning to those who may contemplate implementing computerized baseline testing programs for younger athletes [that they] will require even greater vigilance, caution, individualized attention, and resources for administration."

1. Lichtenstein JD, Moser RS, Schatz P. Age and Test Setting Affect the Prevalence of Invalid Baseline Scores on Neurocognitive Tests. Am J Sports Med. 2013;20(10):DOI:10.1177/0363546513509225 (epub November 15, 2013)

Posted December 5, 2013