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Original Investigation
June 2018

Prevalence of Invalid Performance on Baseline Testing for Sport-Related Concussion by Age and Validity Indicator

Author Affiliations
  • 1Department of Psychology, University of Windsor, Windsor, Ontario, Canada
  • 2Department of Behavioral Health, Henry Ford Health System, Detroit, Michigan
JAMA Neurol. 2018;75(6):697-703. doi:10.1001/jamaneurol.2018.0031
Key Points

Questions  What is the prevalence of invalid neurocognitive performance at baseline in the management of sport-related concussion and does it vary by age and validity indicator?

Findings  In this cross-sectional study of 7897 participants who completed baseline neurocognitive testing for the management of sport-related concussion, 56% failed at least 1 of 4 published validity indicators. Base rates of failure varied considerably across age groups from 84% in those aged 10 years to 29% in those aged 21 years.

Meaning  Base rates of failure were surprisingly high overall, suggesting a need for a critical examination of performance validity assessment practices on baseline testing in concussion management programs.

Abstract

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.

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