Symptoms are the Most Effective Child SCAT5 Component for Recognizing Concussion on the Day of Injury

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Kelshaw, Samantha L. Hacherl, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-957510/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Aug, 2022 Read the published version in Sports Medicine-Open → Version 1 posted 9 You are reading this latest preprint version Abstract Background : The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) was developed to evaluate children between 5-12 years of age for a suspected concussion. However, limited empirical evidence exists demonstrating the value of the Child SCAT5 for acute concussion assessment. Therefore, the purpose of our study was to examine differences and assess the diagnostic properties of Child SCAT5 scores among concussed and non-concussed middle school children on the same day as a suspected concussion. Methods : Our participants included 34 concussed (21 boys, 13 girls; age=12.8±0.86 years) and 44 non-concussed (31 boys, 13 girls; age=12.4±0.76 years) middle school children who were administered the Child SCAT5 upon suspicion of a concussion. Child SCAT5 scores were calculated from the symptom evaluation (total symptoms, total severity), child version of the Standardized Assessment of Concussion (SAC-C), and modified Balance Error Scoring System (mBESS). The Child SCAT5 scores were compared between the concussed and non-concussed groups. Non-parametric effect sizes (r=z/√n) were calculated to assess the magnitude of difference for each comparison. The diagnostic properties (sensitivity, specificity, diagnostic accuracy, predictive values, likelihood ratios, and diagnostic odds ratio) of each Child SCAT5 score were also calculated. Results : Concussed children endorsed more symptoms ( p <0.001, r=0.45), higher symptom severity ( p <0.001, r=0.44), and had higher double leg ( p =0.046, r=0.23), single leg ( p =0.035, r=0.24), and total scores ( p =0.022, r=0.26) for the mBESS than non-concussed children. No significant differences were observed for the SAC-C scores ( p’s ≥0.542). The quantity and severity of endorsed symptoms had the best diagnostic accuracy (AUC=0.76–0.77), negative predictive values (NPV=0.84–0.88), and negative likelihood ratios (-LR=0.22–0.31) of the Child SCAT5 scores. Conclusions : The symptom evaluation was the most effective component of the Child SCAT5 for differentiating between concussed and non-concussed middle school children on the same day as a suspected concussion. Sports Medicine and Kinesiology Neurocognitive balance symptomology children diagnostic accuracy Figures Figure 1 Figure 2 Figure 3 Key Points Concussed middle school athletes endorsed more symptoms, reported greater symptom severity, and had worse balance performance as compared to middle school athletes who were not diagnosed with a concussion on the same day as the suspected injury. The number and severity of self-endorsed symptoms were effective at recognizing concussed middle school athletes on the same day as their suspected injury. Highly variable diagnostic properties were observed for the individual assessment of symptoms, neurocognition, and balance when administered to middle school athletes on the same day as a suspected concussion. Background There are approximately 12.3 million middle school (grade level 6-8) age children in the United States and an estimated 36% (≈4.4 million) will participate in organized intramural or interscholastic sport annually.[ 1 , 2 ] Participation in organized sport for children under 14 years of age is the leading cause of concussion (43%)[ 3 ] and has been associated with a six times greater risk of concussion as compared to other leisure physical activities.[ 4 ] Limited on-site medical coverage of school-sanctioned sports[ 5 ] contributes to a majority (86%) of children seeking medical care from healthcare professionals in direct access settings (e.g., emergency department, outpatient clinics)[ 6 , 7 ] where follow up visits are uncommon (1-3%).[ 8 – 10 ] Several governing bodies[ 11 – 14 ] recommend the implementation of a multimodal assessment for the evaluation of children following a suspected concussion. The Sport Concussion Assessment Tool 5th edition (SCAT5)[ 15 ] and the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5)[ 16 ] are two of the most commonly used multimodal assessments.[ 17 – 20 ] The Child SCAT5 is a modified version of the SCAT5 which was developed for administration to children between 5-12 years of age.[ 15 ] Previous literature has demonstrated poor psychometric (e.g., test-retest reliability) and diagnostic properties (e.g., sensitivity, specificity, predictive value, likelihood ratios) for the individual components of prior iterations of the SCAT[ 16 , 21 – 40 ] and the Child SCAT 3rd Edition (Child SCAT3)[ 41 – 44 ]. Despite consensus recommendation and wide adoption, scant evidence exists regarding the psychometric and diagnostic properties of the Child SCAT5.[ 45 ] The lack of empirical evidence regarding the Child SCAT5 necessitates that healthcare professionals rely upon their subjective interpretation of Child SCAT5 scores to inform acute clinical management. An approach which may contribute to misdiagnosis and inconsistent treatment for those children acutely evaluated for concussion using the Child SCAT5.[ 46 ] Therefore, the purpose of our study was to evaluate for differences and assess the diagnostic properties of Child-SCAT5 scores on the same day as a suspected concussion among middle school children who were (“concussed”) or were not (“non-concussed”) subsequently diagnosed with a concussion. We hypothesized that (i) the concussed children would endorse significantly more symptoms and report a significantly higher symptom severity as compared to the non-concussed children; (ii) the concussed children would score lower on the SAC-C and commit significantly more errors on the mBESS as compared to the non-concussed children; and (iii) the symptom evaluation (total symptoms endorsed, symptom severity) would demonstrate better diagnostic properties than the SAC-C or mBESS on the same day as the suspected concussion. Methods Design and Settings The Advancing Healthcare Initiatives for Underserved Students (ACHIEVES) Project provided on-site medical care to sixteen middle schools within a large socio-demographically diverse school district in Virginia, USA.[ 47 ] The George Mason University Institutional Review Board approved the construction of the deidentified database for research purposes as part of the ACHIEVES Project and waived assent and consent. All participants in our study competed in school-sanctioned sports between the 2017-2018 and 2019-2020 academic years. Participants Our sample originally consisted of 186 (103 concussed, 83 non-concussed) middle school children that were evaluated for a suspected concussion (Figure 1 ). Exclusion criteria were set to ensure that injury and assessment data was available from the concussion assessment that was administered at the time of the suspected concussion. Participants were excluded if their suspected concussion occurred outside of sport, the initial assessment was not completed on the same day as the suspected concussion, or there were any missing data elements from the Child SCAT5 (Figure 1 ). After applying all of our exclusion criteria, our final sample consisted of 78 (34 concussed, 44 non-concussed) middle school children that were evaluated for a suspected concussion while participating in school-sanctioned sports. Testing Procedures Consistent with the school system’s concussion management protocol, the Child SCAT5 was administered to middle school children after removing them from participation in school-sanctioned sports due to the suspicion of a concussion. The children in our study were allocated into groups dependent on whether they were (“concussed”) or were not (“non-concussed”) subsequently diagnosed with a concussion. The definition of a concussion was consistent with the most recent international consensus statement on concussion in sport.[ 11 ] Regardless of their Child SCAT5 scores, the children were not permitted to return to sport participation on the same day as the suspected concussion which is in alignment with international consensus statements, several governing bodies, and the state law of Virginia.[ 11 – 14 , 48 , 49 ] Outcomes The administration and scoring of each component of the Child SCAT5 (symptom evaluation, child version of the Standardized Assessment of Concussion [SAC-C], modified version of the balance error scoring system [mBESS]) are described in detail elsewhere.[ 16 ] For the symptom evaluation, the total number of symptoms endorsed (range=0–21) and the total symptom severity (range=0–63) endorsed by the children were calculated. For the SAC-C, points earned for the immediate memory (range=0–15 points), concentration (range=0–6 points), and delayed recall (range=0–5 points) domains were recorded and summed to calculate a composite score (range=0–26 points). For the mBESS, errors committed (range=0–10) during each stance (double leg, single leg, tandem) were recorded and summed to calculate the total score (range=0–30). Lower scores on the SAC-C and higher scores on the mBESS were indicative of worse performance on the respective components of the Child SCAT5. Statistical Analyses Nonparametric analyses were performed due to the non-normal distribution (Shapiro-Wilk=0.78-0.94, p ’s<0.05) of the Child SCAT5 scores. Mann-Whitney U-tests were used to assess for differences between the concussed and non-concussed children for each Child SCAT5 score. Nonparametric effect sizes[ 50 ] ( \(r=\frac{Z}{\sqrt{N}}\) ) were calculated and interpreted as small ( r= 0.10–0.30), moderate ( r= 0.30–0.50), or large ( r≥ 0.50).[ 51 ] Receiver operator curve analyses were performed to calculate the diagnostic accuracy (area under the curve [AUC]) of each Child SCAT5 score.[ 21 , 24 , 25 , 52 – 55 ] Youden’s Index ( J )[ 56 ] was calculated to determine the cutoff score that optimized the combination of sensitivity (Sn) and specificity (Sp) for each Child SCAT5 score.[ 57 – 60 ] Values closer to 1.0 for the Youden Index are indicative of a greater combination of sensitivity and specificity.[ 56 ] The sensitivity and specificity values of each Child SCAT5 score was used to calculate their positive (PPV) and negative (NPV) predictive values, positive (+LR) and negative (-LR) likelihood ratios, and diagnostic odds ratios (DOR). Positive and negative predictive values that are closer to 1.0 are indicative of a more valid test result.[ 61 ] Higher positive likelihood ratios indicate a greater likelihood that the patient has the test condition (e.g., concussed) while lower negative likelihood ratios indicate a greater likelihood that the patient does not have the test condition (e.g., not concussed).[ 62 ] Higher diagnostic odds ratios indicate that the test result has a greater ability to differentiate between patients with (e.g., concussed) and without (e.g., non-concussed) the test condition. All analyses were performed using SPSS (Version 27, IBM Corp., NY, USA). Alpha was set a priori at p <0.05. Results Our sample consisted of 34 concussed (21 male [62%], age=12.8±0.86 years) and 44 non-concussed (31 male [70%], age=12.4±0.76 years) middle school children who participated in a variety of school-sanctioned sports including football, wrestling, baseball, softball, volleyball, cheerleading, basketball, soccer, and track (Figure 1 ). The concussed children endorsed significantly more symptoms (median=6.0 [range=1-20] vs. median=2.0 [range=0-19], p <0.001, r =0.45) and reported greater symptom severity (median=7.5 [range=1-47] vs. median=3.0 [range=0-31], p <0.001, r =0.44) than the non-concussed group (Table 1 , Figure 2 ). The total number and severity of endorsed symptoms resulted in the highest diagnostic accuracy (AUC=0.76-0.77) and negative predictive values (NPV=0.84-0.88) and the lowest negative likelihood ratios (-LR=0.22-0.31) of the Child SCAT5 scores (Table 2 , Figure 3 A). Table 1 Descriptive statistics for the Child Sport Concussion Assessment Tool – 5 th Edition (Child SCAT5) scores. Concussed Non-Concussed Group Comparisons Child SCAT5 Component Range M SD Md IQR Range M SD Md IQR p r Symptoms Total Number 1-20 8.0 5.50 6.0 4-12 0-19 3.72 3.97 2.0 1-5 <.001 0.45 Total Severity 1-47 12.1 10.5 7.5 5-17 0-31 5.0 6.01 3.0 1-9 <.001 0.44 SAC-C Immediate Memory 6-15 13.6 1.46 14.0 13-15 9-15 13.7 1.47 14.0 13-15 .582 0.06 Concentration 2-6 3.9 0.65 4.0 4-4 2-6 4.0 1.02 4.0 3-5 .896 0.01 Delayed Recall 2-5 3.5 1.38 4.0 3-5 1-5 3.7 1.06 4.0 3-5 .684 0.05 Composite Score 13-24 21.0 2.61 21.5 20-23 16-26 21.5 2.48 22.0 19-23 .542 0.07 mBESS Double Leg 0-2 0.2 0.50 0.0 0-0 0-0 0.0 0.00 0.0 0-0 .046 0.23 Single Leg 1-10 5.5 3.12 5.5 3-8 0-10 4.0 2.85 3.0 2-6 .035 0.24 Tandem Leg 0-10 2.2 2.36 1.5 1-3 0-10 1.6 1.83 1.0 0-2 .398 0.10 Total Score 1-20 7.8 4.53 7.5 4-11 1-20 5.6 4.17 5.0 2-7 .022 0.26 Note. SAC-C = Standardized Assessment of Concussion - Child Version, mBESS = Modified Balance Error Scoring System, M = mean, SD = standard deviation, Md = median, IQR = interquartile range (25 th to 75 th percentile), r = Pearson correlation coefficient. None of the SAC-C scores were not significantly different between the concussed and non-concussed children ( p’s ≥.542) and had the lowest diagnostic accuracy values (AUC=0.51–0.54) of the Child SCAT5 scores (Table 2 , Figure 3 B). Table 2 Diagnostic properties for the Child Sport Concussion Assessment Tool 5 th Edition (Child SCAT5) scores. Outcome Measure Cutoff Score Sn Sp J AUC PPV NPV +LR -LR DOR Symptoms Total Endorsed Total Severity ≥ 3 symptoms ≥ 5 points 0.88 0.79 0.54 0.67 0.47 0.42 0.77 0.76 0.54 0.60 0.88 0.84 1.90 2.44 0.22 0.31 8.60 7.97 SAC-C Immediate Memory Concentration Delayed Recall Composite ≤ 12 points ≤ 4 points ≤ 1 point ≤ 18 points 0.24 0.85 0.15 0.88 0.86 0.30 0.98 0.23 0.10 0.15 0.12 0.11 0.54 0.51 0.53 0.54 0.51 0.43 0.80 0.41 0.65 0.77 0.65 0.76 1.73 1.21 6.39 1.14 0.89 0.50 0.87 0.52 1.95 2.43 7.32 2.19 mBESS Double Leg Single Leg Tandem Total ≥ 1 error ≥ 7 errors ≥ 2 errors ≥ 9 errors 0.09 0.44 0.50 0.47 1.00 0.81 0.61 0.86 0.09 0.11 0.26 0.33 0.54 0.55 0.63 0.64 0.98 0.59 0.44 0.67 0.64 0.70 0.66 0.73 88.00 2.37 1.27 3.36 0.91 0.69 0.83 0.62 96.39 3.45 1.53 5.47 SAC-C = child version of the Standardized Assessment of Concussion, mBESS = modified version of the balance error scoring system, Sn = sensitivity, Sp = specificity, J = Youden Index, AUC = area under the curve, PPV/NPV = positive and negative predictive values, +LR/-LR = positive and negative likelihood ratios, DOR = diagnostic odds ratios. The concussed children committed significantly more errors in the double leg (median=0.0 [range=0-2] vs median=0.0 [range=0-0], p =0.046, \(r\) =0.23) and single leg (median=5.5 [range=1-10] vs median=3.0 [range=0-10], p =0.035, \(r\) =0.24) stances of the mBESS as compared to the non-concussed children (Table 1 ). Significantly higher total scores on the mBESS (median=7.5 [range=1-20] vs median=5.0 [range=1-20], p =0.022, \(r\) =0.26) were observed for the concussed children as compared to the non-concussed children (Table 1 ). Committing at least one error in the double leg stance resulted in the highest specificity (Sp=1.00) but the lowest sensitivity (Sn=0.09; Table 2 ) values. A total mBESS score of at least nine errors had higher diagnostic accuracy (AUC=0.64) than interpretation of the individual stances (AUC=0.54–0.63; Table 2 , Figure 3 C). Discussion Our study evaluated for differences in Child SCAT5 scores, and their subsequent diagnostic properties, among concussed and non-concussed middle school children on the day that they were evaluated for a suspected concussion. Our findings demonstrate that concussed children endorse a greater number and severity of symptoms and suggest that the symptom evaluation is the most effective component of the Child SCAT5 for differentiating between concussed and non-concussed children on the same day as a suspected concussion. The concussed children also committed significantly more errors on the mBESS than the non-concussed children, however, the magnitude of these differences were relatively small as supported by the effect sizes. Our data suggests that the SAC-C is the least meaningful component of the Child SCAT5 as no significant differences were observed between the concussed and non-concussed children which resulted in poor diagnostic accuracy values. Overall, our study reinforces the importance of the symptom evaluation as an integral part of the clinical assessment of children on the same day as a suspected concussion. Self-reported symptomology has been a cornerstone of concussion evaluation and remains the key component for informing clinical judgement.[ 11 ] Our data demonstrates that concussed middle school children endorse a significantly greater number and severity of symptoms than children who are not diagnosed with a concussion. Specifically, the concussed children in our sample endorsed nearly double the number of symptoms (8.0±5.50 vs. 3.7±3.97) and symptom severity (12.1±10.5 vs. 12.1±10.9) as compared to the non-concussed children. Previous literature has demonstrated that concussed children evaluated in the emergency department using the Child SCAT3 endorsed significantly more symptoms and greater severity than non-concussed children, which is alignment with our results.[ 44 ] Our findings also align well with previous literature that have reported elevated endorsement and severity of symptoms in older athletic populations (e.g., high school, collegiate) following a diagnosed concussion as compared to preinjury (baseline) data or matched comparisons.[ 23 , 63 , 64 ] We did not incorporate baseline assessments or matched comparisons, thus, we encourage future research to investigate these differences in symptom reporting of middle school children following a suspected concussion. Our study also observed that concussed children committed significantly more errors in two stances (double leg, single leg) of the mBESS and had significantly higher mBESS total scores as compared to the non-concussed children. Furthermore, our mBESS total scores for the concussed children (7.8±4.53 errors) were slightly elevated compared to normative reference values for this population (5.0±3.7 errors).[ 65 ] However, the small effect sizes ( r =0.23–0.26) calculated for the concussed versus non-concussed comparisons suggest that the differences may not be clinically meaningful. Findings from our sample of middle school children align well with extensive literature that have reported that concussed high school and collegiate athletes perform worse on the BESS than non-concussed athletes.[ 22 , 23 , 63 , 64 , 66 , 67 ] Collectively, our findings and those of previous literature that assessed older athletic populations suggest that balance assessment following a suspected concussion may elicit subtle deficits to inform clinical diagnosis and management. The concussed children in our study did not perform significantly different on any component of the SAC-C as compared to the non-concussed children on the same day as the suspected concussion. The SAC-C composite scores were also not significantly different between the concussed and non-concussed groups in our sample and the values for each group align within the “broadly normal” interpretation of normative reference values for this population.[ 65 ] The lack of significant findings between the concussed and non-concussed groups is different than previous literature that evaluated older athletic populations.[ 22 , 23 , 63 , 64 , 66 , 67 ] Possible rationales for the lack of significant differences in SAC-C scores include discrepancies in the age of the participants in our study (middle school children) as compared to those of previous literature study populations (high school or collegiate athletes) and different ranges of composite scores for the SAC (range=0-25) and SAC-C (range=0-26).[ 15 ] To our knowledge, our study is the first to provide evidence of the diagnostic properties of the Child SCAT5 in the population for which it was designed. The total number and severity of endorsed symptoms were found to have the highest levels of diagnostic accuracy (AUC=0.76–0.77) and sensitivity (Sn=0.79–0.88) of the Child SCAT5 scores. Based on the calculated cutoff scores, children who endorse less than four symptoms or report a severity less than six points on the same day as the suspected concussion were less likely (-LR=0.22–0.31) to be diagnosed with a concussion. As mentioned previously, it is important to note that none of the children assessed for a suspected concussion were permitted to return to sport participation on the same day as the assessment regardless of their Child SCAT5 scores. This is in alignment with the recommendations from the leading international consensus group on concussion in sport,[ 11 ] position statements from several governing bodies,[ 12 – 14 ] and the legal requirements of state laws[ 49 ]. The highest positive predictive values and likelihood ratios were observed for interpretation of the double leg stance of the mBESS followed by the delayed recall domain of the SAC-C. However, inordinately low thresholds for a positive test result (e.g., diagnosed concussion) for the double leg stance of the mBESS (≤1 error) and the delayed recall domain of the SAC-C (≤1 point) yielded high specificity values (Sp=0.98–1.00) which artificially elevated the calculated positive predictive values and likelihood ratios. Therefore, we caution healthcare professionals from independent interpretation of the double leg stance of the mBESS or the delayed recall domain of the SAC-C in their clinical decision-making at this time. Future research is warranted to validate our findings related to the diagnostic properties of the individual components (symptom evaluation, SAC-C, mBESS) of the Child SCAT5 in an independent sample of children on the same day as a suspected concussion. The calculated diagnostic properties of the Child SCAT5 scores in our study align with those reported for previous iterations of the SCAT and the Child SCAT3.[ 23 , 44 , 63 , 67 ] More specifically, the values of sensitivity, specificity, and diagnostic accuracy observed in our study are similar to those calculated for the individual components of the SCAT for the assessment of older athletes.[ 23 , 63 , 67 ] A similar methodology as our study has been implemented to evaluate for differences and assess the diagnostic properties of Child SCAT3 scores among children who were evaluated for a suspected concussion in the emergency department.[ 44 ] The authors of this prior study reported similar diagnostic accuracy values for Child SCAT3 scores to those observed in our study which utilized the Child SCAT5.[ 44 ] Overall, our findings support those of previous literature[ 23 , 44 , 63 , 67 ] which suggest that the symptom evaluation has the best combination of diagnostic properties and is the most effective component of the Child SCAT for differentiating between concussed and non-concussed children. Healthcare professionals in direct access settings (e.g., emergency department, outpatient clinics) may be the first to evaluate a child following a suspected concussion[ 6 ] and likely will not have access to preinjury (baseline) scores for comparison. It is vital that healthcare professionals in direct access settings are equipped with age-appropriate assessment tools that can effectively differentiate between those who are and are not concussed in order to appropriately inform patient care. Our findings reinforce the importance of the symptom evaluation of the Child SCAT5 and suggest that healthcare professionals can be confident in the clinical interpretation of acute symptom reporting of children following a suspected concussion. The poorer diagnostic accuracy of the SAC-C and mBESS highlights the inability of these assessments to adequately differentiate between concussed and non-concussed children which limits their clinical utility on the same day as a suspected concussion. Future research should investigate alternative assessment tools (e.g., tandem gait test[ 68 ]) or strategies (e.g., the dual task paradigm[ 69 ]) for the acute evaluation of children following a suspected concussion. Findings from this future research may provide additional objective data to assist in the evaluation of children with a suspected concussion. We recognize that our study is not without limitations. All of the children in our study were participating in school-sanctioned sports at middle schools within a single county in the northern Virginia which limits our generalizability. However, the middle school student population in our study has a unique socio-demographic profile including students of diverse racial backgrounds (e.g., 36.7% Hispanic, 27.8% White/Caucasian, 20.7% Black/African-American) and high academic achievement (e.g., less than a 2% course failure rate overall).[ 47 ] Another limitation is the variability in the time between the removal from sport and the concussion evaluation, however, all participants were evaluated on the same day as the suspected concussive event. Lastly, the diagnosis of a concussion was made by the on-site healthcare professional using their own clinical decision-making which improves the external validity of our study. The healthcare professionals participating in the ACHIVES Project also completed annual training on concussion assessment using the Child SCAT5 and followed an established concussion management protocol which limited variability in their clinical evaluation. Conclusion The concussed middle school children endorsed more symptoms, reported greater symptom severity, and committed more errors during administration of the mBESS on the same day as the suspected concussion than children who were not diagnosed with a concussion. Clinical interpretation of the total quantity and severity of the endorsed symptoms resulted in the greatest combination of diagnostic properties as supported by the best sensitivity, diagnostic accuracy, negative predictive values, and negative likelihood ratios. Our data does not support the clinical interpretation of the SAC-C on the same day as a suspected concussion due to the lack of significant differences observed between the concussed and non-concussed groups and highly variable diagnostic properties. Overall, our findings demonstrate that the symptom evaluation may be the most effective component of the Child SCAT5 for differentiating between concussed and non-concussed middle school children on the day of a suspected concussive event. Declarations Ethics Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Additionally, our study was approved by the George Mason University Institutional Review Board. Consent to Participate: Participants signed informed consent regarding publishing their data. Consent for Publication: Informed consent was obtained from all individual participants included in the study. Availability of Data and Materials: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests: The authors have no competing interests to disclose. Funding: Dr. Shane V. Caswell has received funding from the Virginia Department of Health (Grant #709I832700) and the Centers for Disease Control and Prevention (Grant #NU17CE924832) as well as support from the Prince William County Public Schools. Author’s Contributions: Dr. Nicholas K. Erdman conceptualized the design of the study, carried out the initial analyses, drafted the initial manuscript, and revised the manuscript. Dr. Patricia M. Kelshaw conceptualized the design of the study, designed the data collection instruments, collected data, and critically reviewed the manuscript for important intellectual content. Ms. Samantha Hacherl designed the data collection instruments, collected data, and critically reviewed the manuscript for important intellectual content. Dr. Shane V. Caswell conceptualized the design of the study, designed the data collection instruments, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. References School Enrollment in the United States. October 2018 - Detailed Tables [Internet]. 2019 [cited 2021 Jan 15]. Available from: https://www.census.gov/content/census/en/data/tables/2018/demo/school-enrollment/2018-cps.html . Kanters MA, Bocarro JN, Edwards MB, Casper JM, Floyd MF. School Sport Participation Under Two School Sport Policies: Comparisons by Race/Ethnicity, Gender, and Socioeconomic Status. Ann Behav Med. 2013;45:113–21. Sarmiento K, Daugherty J, DePadilla L, Breiding MJ. 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Available from: http://natajournals.org/doi/10.4085/1062-6050-48.6.09 . Glas AS, Lijmer JG, Prins MH, Bonsel GJ, Bossuyt PMM. The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol [Internet]. 2003 [cited 2020 Apr 4];56:1129–35. Available from: https://linkinghub.elsevier.com/retrieve/pii/S089543560300177X . Biggerstaff BJ. Comparing diagnostic tests: a simple graphic using likelihood ratios. Stat Med. 2000;19:649–63. McGee S. Simplifying likelihood ratios. J Gen Intern Med [Internet]. 2002 [cited 2021 Mar 16];17:647–50. Available from: http://link.springer.com/ 10.1046/j.1525-1497.2002.10750.x . McCrea M, Barr WB, Guskiewicz K, Randolph C, Marshall SW, Cantu R, et al. Standard regression-based methods for measuring recovery after sport-related concussion. J Int Neuropsychol Soc [Internet]. 2005 [cited 2019 May 17];11:58–69. Available from: https://www.cambridge.org/core/product/identifier/S1355617705050083/type/journal_article . Nelson LD, Guskiewicz KM, Barr WB, Hammeke TA, Randolph C, Ahn KW, et al. Age Differences in Recovery After Sport-Related Concussion: A Comparison of High School and Collegiate Athletes. J Athl Train [Internet]. 2016 [cited 2018 Aug 21];51:142–52. Available from: http://natajournals.org/doi/10.4085/1062-6050-51.4.04 . Kelshaw PM, Cook NE, Terry DP, Iverson GL, Caswell SV. Child Sport Concussion Assessment Tool 5th Edition: Normative Reference Values in Demographically Diverse Youth. Clin J Sport Med. 2021;Ahead of Print. McCrea M, Kelly JP, Kluge J, Ackley B, Randolph C. Standardized Assessment of Concussion in football players. Neurology [Internet]. 1997 [cited 2019 Jan 31];48:586–8. Available from: http://www.neurology.org/cgi/doi/ 10.1212/WNL.48.3.586 . Oldham JR, Difabio MS, Kaminski TW, Dewolf RM, Howell DR, Buckley TA. Efficacy of Tandem Gait to Identify Impaired Postural Control after Concussion: Med Sci Sports Exerc [Internet]. 2018 [cited 2018 Aug 21];50:1162–8. 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Cite Share Download PDF Status: Published Journal Publication published 12 Aug, 2022 Read the published version in Sports Medicine-Open → Version 1 posted Editorial decision: Major Revision 15 Mar, 2022 Review # 1 received at journal 21 Oct, 2021 Reviews received at journal 17 Oct, 2021 Reviewer # 1 agreed at journal 16 Oct, 2021 Reviewers invited by journal 13 Oct, 2021 Editor assigned by journal 05 Oct, 2021 Submission checks completed at journal 05 Oct, 2021 Editor invited by journal 05 Oct, 2021 First submitted to journal 04 Oct, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-957510","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Original Research Article","associatedPublications":[],"authors":[{"id":55875195,"identity":"034e5ce5-a317-40ca-aa46-52934979ff14","order_by":0,"name":"Nicholas Kevin Erdman","email":"","orcid":"https://orcid.org/0000-0001-8109-7585","institution":"George Mason University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nicholas","middleName":"Kevin","lastName":"Erdman","suffix":""},{"id":55875196,"identity":"f0c5b20f-6ab9-4271-8a19-21677cc148d1","order_by":1,"name":"Patricia M. Kelshaw","email":"","orcid":"","institution":"University of New Hampshire","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"M.","lastName":"Kelshaw","suffix":""},{"id":55875197,"identity":"418b437d-60ca-41b0-90ee-c26d9dbdb858","order_by":2,"name":"Samantha L. Hacherl","email":"","orcid":"","institution":"George Mason University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Samantha","middleName":"L.","lastName":"Hacherl","suffix":""},{"id":55875198,"identity":"39edb9d3-2501-4871-b415-45ed2365f4ff","order_by":3,"name":"Shane V. Caswell","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYPACCxl+CIOZaC0SPJINJGsxOECsFvn2w48/81RI8BifX50mwVBhndhASIvBmTQzaZ4zEjxmN95uk2A4k06EFgkGM+bcNpCWs9skGNsOE9YiP4P98+fcf0CHzQBp+UeEFoYbPAbSuQ1A7/P3ArU0EKHF4ExOmfSfYxI8Ejd4N1skHEs3Juyw9uObP86osZHj7z+78caHGmtZwg6DA4kEBoYE4pWDAP8B0tSPglEwCkbByAEA9Dw6fFMWNkQAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-8775-2971","institution":"Athletic Training Education Program, Sports Medicine Assessment, Research \u0026 Testing (SMART) Laboratory, George Mason University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Shane","middleName":"V.","lastName":"Caswell","suffix":""}],"badges":[],"createdAt":"2021-10-06 10:22:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-957510/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-957510/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40798-022-00499-8","type":"published","date":"2022-08-13T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":14410298,"identity":"8be4fe84-dea9-4e17-96b3-65e14796d1b6","added_by":"auto","created_at":"2021-10-11 14:41:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42281,"visible":true,"origin":"","legend":"Flow chart for participant evaluation and analyses.","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-957510/v1/606a7aef983f33b09f410d60.png"},{"id":14410300,"identity":"ae53c34a-dfda-47e9-a50d-3a76b06ffc6f","added_by":"auto","created_at":"2021-10-11 14:41:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":29721,"visible":true,"origin":"","legend":"Group comparisons for the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) scores.\n\nNote. Boxes represent the first, second, and third quartile values, error bars represent maximum (third quartile + 1.5*Interquartile Range) and minimum (third quartile – 1.5* Interquartile Range) values, X = group mean, SAC-C = child version of the Standardized Assessment of Concussion, mBESS = modified balance error scoring system. *P\u003c.05\n","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-957510/v1/1c9fbf9c7c737d1ab3290005.png"},{"id":14411013,"identity":"813cbcb9-e398-4afd-b080-550d0b9a7d64","added_by":"auto","created_at":"2021-10-11 14:44:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":62548,"visible":true,"origin":"","legend":"Receiver operator curves for the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) scores. Note: Dashed line is reference line demonstrating equitable sensitivity and specificity.\n\n","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-957510/v1/d5c5be0e83560847d2203552.png"},{"id":42662844,"identity":"28dff9eb-e72b-41b6-8b36-d8fb235a70b8","added_by":"auto","created_at":"2023-09-05 19:28:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":518562,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-957510/v1/e147d2e5-57e6-4377-911e-d0982ee85404.pdf"}],"financialInterests":"","formattedTitle":"Symptoms are the Most Effective Child SCAT5 Component for Recognizing Concussion on the Day of Injury","fulltext":[{"header":"Key Points","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eConcussed middle school athletes endorsed more symptoms, reported greater symptom severity, and had worse balance performance as compared to middle school athletes who were not diagnosed with a concussion on the same day as the suspected injury.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe number and severity of self-endorsed symptoms were effective at recognizing concussed middle school athletes on the same day as their suspected injury.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHighly variable diagnostic properties were observed for the individual assessment of symptoms, neurocognition, and balance when administered to middle school athletes on the same day as a suspected concussion.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eThere are approximately 12.3 million middle school (grade level 6-8) age children in the United States and an estimated 36% (\u0026asymp;4.4 million) will participate in organized intramural or interscholastic sport annually.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Participation in organized sport for children under 14 years of age is the leading cause of concussion (43%)[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and has been associated with a six times greater risk of concussion as compared to other leisure physical activities.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Limited on-site medical coverage of school-sanctioned sports[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] contributes to a majority (86%) of children seeking medical care from healthcare professionals in direct access settings (e.g., emergency department, outpatient clinics)[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] where follow up visits are uncommon (1-3%).[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSeveral governing bodies[\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] recommend the implementation of a multimodal assessment for the evaluation of children following a suspected concussion. The Sport Concussion Assessment Tool 5th edition (SCAT5)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and the Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] are two of the most commonly used multimodal assessments.[\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] The Child SCAT5 is a modified version of the SCAT5 which was developed for administration to children between 5-12 years of age.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Previous literature has demonstrated poor psychometric (e.g., test-retest reliability) and diagnostic properties (e.g., sensitivity, specificity, predictive value, likelihood ratios) for the individual components of prior iterations of the SCAT[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and the Child SCAT 3rd Edition (Child SCAT3)[\u003cspan additionalcitationids=\"CR42 CR43\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Despite consensus recommendation and wide adoption, scant evidence exists regarding the psychometric and diagnostic properties of the Child SCAT5.[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe lack of empirical evidence regarding the Child SCAT5 necessitates that healthcare professionals rely upon their subjective interpretation of Child SCAT5 scores to inform acute clinical management. An approach which may contribute to misdiagnosis and inconsistent treatment for those children acutely evaluated for concussion using the Child SCAT5.[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] Therefore, the purpose of our study was to evaluate for differences and assess the diagnostic properties of Child-SCAT5 scores on the same day as a suspected concussion among middle school children who were (\u0026ldquo;concussed\u0026rdquo;) or were not (\u0026ldquo;non-concussed\u0026rdquo;) subsequently diagnosed with a concussion. We hypothesized that (i) the concussed children would endorse significantly more symptoms and report a significantly higher symptom severity as compared to the non-concussed children; (ii) the concussed children would score lower on the SAC-C and commit significantly more errors on the mBESS as compared to the non-concussed children; and (iii) the symptom evaluation (total symptoms endorsed, symptom severity) would demonstrate better diagnostic properties than the SAC-C or mBESS on the same day as the suspected concussion.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Settings\u003c/h2\u003e \u003cp\u003eThe Advancing Healthcare Initiatives for Underserved Students (ACHIEVES) Project provided on-site medical care to sixteen middle schools within a large socio-demographically diverse school district in Virginia, USA.[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] The George Mason University Institutional Review Board approved the construction of the deidentified database for research purposes as part of the ACHIEVES Project and waived assent and consent. All participants in our study competed in school-sanctioned sports between the 2017-2018 and 2019-2020 academic years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eOur sample originally consisted of 186 (103 concussed, 83 non-concussed) middle school children that were evaluated for a suspected concussion (Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Exclusion criteria were set to ensure that injury and assessment data was available from the concussion assessment that was administered at the time of the suspected concussion. Participants were excluded if their suspected concussion occurred outside of sport, the initial assessment was not completed on the same day as the suspected concussion, or there were any missing data elements from the Child SCAT5 (Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After applying all of our exclusion criteria, our final sample consisted of 78 (34 concussed, 44 non-concussed) middle school children that were evaluated for a suspected concussion while participating in school-sanctioned sports.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eTesting Procedures\u003c/h2\u003e \u003cp\u003eConsistent with the school system\u0026rsquo;s concussion management protocol, the Child SCAT5 was administered to middle school children after removing them from participation in school-sanctioned sports due to the suspicion of a concussion. The children in our study were allocated into groups dependent on whether they were (\u0026ldquo;concussed\u0026rdquo;) or were not (\u0026ldquo;non-concussed\u0026rdquo;) subsequently diagnosed with a concussion. The definition of a concussion was consistent with the most recent international consensus statement on concussion in sport.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Regardless of their Child SCAT5 scores, the children were not permitted to return to sport participation on the same day as the suspected concussion which is in alignment with international consensus statements, several governing bodies, and the state law of Virginia.[\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe administration and scoring of each component of the Child SCAT5 (symptom evaluation, child version of the Standardized Assessment of Concussion [SAC-C], modified version of the balance error scoring system [mBESS]) are described in detail elsewhere.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] For the symptom evaluation, the total number of symptoms endorsed (range=0\u0026ndash;21) and the total symptom severity (range=0\u0026ndash;63) endorsed by the children were calculated. For the SAC-C, points earned for the immediate memory (range=0\u0026ndash;15 points), concentration (range=0\u0026ndash;6 points), and delayed recall (range=0\u0026ndash;5 points) domains were recorded and summed to calculate a composite score (range=0\u0026ndash;26 points). For the mBESS, errors committed (range=0\u0026ndash;10) during each stance (double leg, single leg, tandem) were recorded and summed to calculate the total score (range=0\u0026ndash;30). Lower scores on the SAC-C and higher scores on the mBESS were indicative of worse performance on the respective components of the Child SCAT5.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cp\u003eNonparametric analyses were performed due to the non-normal distribution (Shapiro-Wilk=0.78-0.94, \u003cem\u003ep\u003c/em\u003e\u0026rsquo;s\u0026lt;0.05) of the Child SCAT5 scores. Mann-Whitney U-tests were used to assess for differences between the concussed and non-concussed children for each Child SCAT5 score. Nonparametric effect sizes[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(r=\\frac{Z}{\\sqrt{N}}\\)\u003c/span\u003e\u003c/span\u003e) were calculated and interpreted as small (\u003cem\u003er=\u003c/em\u003e0.10\u0026ndash;0.30), moderate (\u003cem\u003er=\u003c/em\u003e0.30\u0026ndash;0.50), or large (\u003cem\u003er\u0026ge;\u003c/em\u003e0.50).[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eReceiver operator curve analyses were performed to calculate the diagnostic accuracy (area under the curve [AUC]) of each Child SCAT5 score.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53 CR54\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] Youden\u0026rsquo;s Index (\u003cem\u003eJ\u003c/em\u003e)[\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] was calculated to determine the cutoff score that optimized the combination of sensitivity (Sn) and specificity (Sp) for each Child SCAT5 score.[\u003cspan additionalcitationids=\"CR58 CR59\" citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] Values closer to 1.0 for the Youden Index are indicative of a greater combination of sensitivity and specificity.[\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe sensitivity and specificity values of each Child SCAT5 score was used to calculate their positive (PPV) and negative (NPV) predictive values, positive (+LR) and negative (-LR) likelihood ratios, and diagnostic odds ratios (DOR). Positive and negative predictive values that are closer to 1.0 are indicative of a more valid test result.[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] Higher positive likelihood ratios indicate a greater likelihood that the patient has the test condition (e.g., concussed) while lower negative likelihood ratios indicate a greater likelihood that the patient does not have the test condition (e.g., not concussed).[\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] Higher diagnostic odds ratios indicate that the test result has a greater ability to differentiate between patients with (e.g., concussed) and without (e.g., non-concussed) the test condition. All analyses were performed using SPSS (Version 27, IBM Corp., NY, USA). Alpha was set \u003cem\u003ea priori\u003c/em\u003e at \u003cem\u003ep\u003c/em\u003e\u0026lt;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOur sample consisted of 34 concussed (21 male [62%], age=12.8\u0026plusmn;0.86 years) and 44 non-concussed (31 male [70%], age=12.4\u0026plusmn;0.76 years) middle school children who participated in a variety of school-sanctioned sports including football, wrestling, baseball, softball, volleyball, cheerleading, basketball, soccer, and track (Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe concussed children endorsed significantly more symptoms (median=6.0 [range=1-20] vs. median=2.0 [range=0-19], \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003er\u003c/span\u003e\u003c/span\u003e=0.45) and reported greater symptom severity (median=7.5 [range=1-47] vs. median=3.0 [range=0-31], \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003er\u003c/span\u003e\u003c/span\u003e=0.44) than the non-concussed group (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The total number and severity of endorsed symptoms resulted in the highest diagnostic accuracy (AUC=0.76-0.77) and negative predictive values (NPV=0.84-0.88) and the lowest negative likelihood ratios (-LR=0.22-0.31) of the Child SCAT5 scores (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, Figure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eA).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDescriptive statistics for the Child Sport Concussion Assessment Tool \u0026ndash; 5\u003csup\u003eth\u003c/sup\u003e Edition (Child SCAT5) scores.\u003c/p\u003e\n \u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" width=\"31.386861313868614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eConcussed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" width=\"31.386861313868614%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-Concussed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"13.138686131386862%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup Comparisons\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003e\u003cstrong\u003eChild SCAT5 Component\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u003cstrong\u003eM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMd\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u003cstrong\u003eM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMd\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003er\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eTotal Number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e1-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e5.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e4-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e0-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e3.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e3.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eTotal Severity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e1-47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e5-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e0-31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e6.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e1-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSAC-C\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eImmediate Memory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e6-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e13-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e9-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e13-15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e.582\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eConcentration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e2-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e4-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e2-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e3-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e.896\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eDelayed Recall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e2-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e3-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e3-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e.684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eComposite Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e13-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e21.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e2.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e20-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e16-26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e22.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e19-23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e.542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003e\u003cstrong\u003emBESS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eDouble Leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e0-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0-0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e.046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eSingle Leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e1-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e3.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e3-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e0-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e2.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e2-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eTandem Leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e0-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e2.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e0-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e.398\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.708029197080293%\"\u003e\n \u003cp\u003eTotal Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e1-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e4.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e4-11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.299270072992701%\"\u003e\n \u003cp\u003e1-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e4.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.839416058394161%\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e2-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.18978102189781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.569343065693431%\"\u003e\n \u003cp\u003e.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"6.569343065693431%\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"15\" width=\"99.87834549878346%\"\u003e\n \u003cp\u003eNote. SAC-C = Standardized Assessment of Concussion - Child Version, mBESS = Modified Balance Error Scoring System, M = mean, SD = standard deviation, Md = median, IQR = interquartile range (25\u003csup\u003eth\u003c/sup\u003e to 75\u003csup\u003eth\u003c/sup\u003e percentile), \u003cem\u003er\u003c/em\u003e = Pearson correlation coefficient.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0.12165450121654502%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab2\"\u003e\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNone of the SAC-C scores were not significantly different between the concussed and non-concussed children (\u003cem\u003ep\u0026rsquo;s\u003c/em\u003e\u0026ge;.542) and had the lowest diagnostic accuracy values (AUC=0.51\u0026ndash;0.54) of the Child SCAT5 scores (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, Figure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eB).\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eDiagnostic properties for the Child Sport Concussion Assessment Tool 5\u003csup\u003eth\u003c/sup\u003e Edition (Child SCAT5) scores.\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.00826446280992%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome Measure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.426997245179063%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCutoff Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSn\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSp\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eJ\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.851239669421488%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAUC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.43801652892562%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePPV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.575757575757576%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNPV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.988980716253444%\"\u003e\n \u003cp\u003e\u003cstrong\u003e+LR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.6115702479338845%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-LR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.43801652892562%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.00826446280992%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTotal Endorsed\u003c/p\u003e\n \u003cp\u003eTotal Severity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.426997245179063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ge; 3 symptoms\u003c/p\u003e\n \u003cp\u003e\u0026ge; 5 points\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.851239669421488%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.43801652892562%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.575757575757576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.988980716253444%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.90\u003c/p\u003e\n \u003cp\u003e2.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.6115702479338845%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.43801652892562%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8.60\u003c/p\u003e\n \u003cp\u003e7.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.00826446280992%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSAC-C\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eImmediate Memory\u003c/p\u003e\n \u003cp\u003eConcentration\u003c/p\u003e\n \u003cp\u003eDelayed Recall\u003c/p\u003e\n \u003cp\u003eComposite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.426997245179063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026le; 12 points\u003c/p\u003e\n \u003cp\u003e\u0026le; 4 points\u003c/p\u003e\n \u003cp\u003e\u0026le; 1 point\u003c/p\u003e\n \u003cp\u003e\u0026le; 18 points\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.851239669421488%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.43801652892562%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.575757575757576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.988980716253444%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.73\u003c/p\u003e\n \u003cp\u003e1.21\u003c/p\u003e\n \u003cp\u003e6.39\u003c/p\u003e\n \u003cp\u003e1.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.6115702479338845%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.43801652892562%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.95\u003c/p\u003e\n \u003cp\u003e2.43\u003c/p\u003e\n \u003cp\u003e7.32\u003c/p\u003e\n \u003cp\u003e2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.00826446280992%\"\u003e\n \u003cp\u003e\u003cstrong\u003emBESS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDouble Leg\u003c/p\u003e\n \u003cp\u003eSingle Leg\u003c/p\u003e\n \u003cp\u003eTandem\u003c/p\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.426997245179063%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026ge; 1 error\u003c/p\u003e\n \u003cp\u003e\u0026ge; 7 errors\u003c/p\u003e\n \u003cp\u003e\u0026ge; 2 errors\u003c/p\u003e\n \u003cp\u003e\u0026ge; 9 errors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.887052341597796%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.851239669421488%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.43801652892562%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.575757575757576%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.988980716253444%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e88.00\u003c/p\u003e\n \u003cp\u003e2.37\u003c/p\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003cp\u003e3.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.6115702479338845%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.43801652892562%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e96.39\u003c/p\u003e\n \u003cp\u003e3.45\u003c/p\u003e\n \u003cp\u003e1.53\u003c/p\u003e\n \u003cp\u003e5.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003eSAC-C = child version of the Standardized Assessment of Concussion, mBESS = modified version of the balance error scoring system, Sn = sensitivity, Sp = specificity, \u003cem\u003eJ\u003c/em\u003e = Youden Index, AUC = area under the curve, PPV/NPV = positive and negative predictive values, +LR/-LR = positive and negative likelihood ratios, DOR = diagnostic odds ratios.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe concussed children committed significantly more errors in the double leg (median=0.0 [range=0-2] vs median=0.0 [range=0-0], \u003cem\u003ep\u003c/em\u003e=0.046, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(r\\)\u003c/span\u003e\u003c/span\u003e=0.23) and single leg (median=5.5 [range=1-10] vs median=3.0 [range=0-10], \u003cem\u003ep\u003c/em\u003e=0.035, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(r\\)\u003c/span\u003e\u003c/span\u003e=0.24) stances of the mBESS as compared to the non-concussed children (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Significantly higher total scores on the mBESS (median=7.5 [range=1-20] vs median=5.0 [range=1-20], \u003cem\u003ep\u003c/em\u003e=0.022, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(r\\)\u003c/span\u003e\u003c/span\u003e=0.26) were observed for the concussed children as compared to the non-concussed children (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Committing at least one error in the double leg stance resulted in the highest specificity (Sp=1.00) but the lowest sensitivity (Sn=0.09; Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) values. A total mBESS score of at least nine errors had higher diagnostic accuracy (AUC=0.64) than interpretation of the individual stances (AUC=0.54\u0026ndash;0.63; Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e, Figure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eC).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study evaluated for differences in Child SCAT5 scores, and their subsequent diagnostic properties, among concussed and non-concussed middle school children on the day that they were evaluated for a suspected concussion. Our findings demonstrate that concussed children endorse a greater number and severity of symptoms and suggest that the symptom evaluation is the most effective component of the Child SCAT5 for differentiating between concussed and non-concussed children on the same day as a suspected concussion. The concussed children also committed significantly more errors on the mBESS than the non-concussed children, however, the magnitude of these differences were relatively small as supported by the effect sizes. Our data suggests that the SAC-C is the least meaningful component of the Child SCAT5 as no significant differences were observed between the concussed and non-concussed children which resulted in poor diagnostic accuracy values. Overall, our study reinforces the importance of the symptom evaluation as an integral part of the clinical assessment of children on the same day as a suspected concussion.\u003c/p\u003e \u003cp\u003eSelf-reported symptomology has been a cornerstone of concussion evaluation and remains the key component for informing clinical judgement.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Our data demonstrates that concussed middle school children endorse a significantly greater number and severity of symptoms than children who are not diagnosed with a concussion. Specifically, the concussed children in our sample endorsed nearly double the number of symptoms (8.0\u0026plusmn;5.50 vs. 3.7\u0026plusmn;3.97) and symptom severity (12.1\u0026plusmn;10.5 vs. 12.1\u0026plusmn;10.9) as compared to the non-concussed children. Previous literature has demonstrated that concussed children evaluated in the emergency department using the Child SCAT3 endorsed significantly more symptoms and greater severity than non-concussed children, which is alignment with our results.[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] Our findings also align well with previous literature that have reported elevated endorsement and severity of symptoms in older athletic populations (e.g., high school, collegiate) following a diagnosed concussion as compared to preinjury (baseline) data or matched comparisons.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] We did not incorporate baseline assessments or matched comparisons, thus, we encourage future research to investigate these differences in symptom reporting of middle school children following a suspected concussion.\u003c/p\u003e \u003cp\u003eOur study also observed that concussed children committed significantly more errors in two stances (double leg, single leg) of the mBESS and had significantly higher mBESS total scores as compared to the non-concussed children. Furthermore, our mBESS total scores for the concussed children (7.8\u0026plusmn;4.53 errors) were slightly elevated compared to normative reference values for this population (5.0\u0026plusmn;3.7 errors).[\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] However, the small effect sizes (\u003cem\u003er\u003c/em\u003e=0.23\u0026ndash;0.26) calculated for the concussed versus non-concussed comparisons suggest that the differences may not be clinically meaningful. Findings from our sample of middle school children align well with extensive literature that have reported that concussed high school and collegiate athletes perform worse on the BESS than non-concussed athletes.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] Collectively, our findings and those of previous literature that assessed older athletic populations suggest that balance assessment following a suspected concussion may elicit subtle deficits to inform clinical diagnosis and management.\u003c/p\u003e \u003cp\u003eThe concussed children in our study did not perform significantly different on any component of the SAC-C as compared to the non-concussed children on the same day as the suspected concussion. The SAC-C composite scores were also not significantly different between the concussed and non-concussed groups in our sample and the values for each group align within the \u0026ldquo;broadly normal\u0026rdquo; interpretation of normative reference values for this population.[\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] The lack of significant findings between the concussed and non-concussed groups is different than previous literature that evaluated older athletic populations.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] Possible rationales for the lack of significant differences in SAC-C scores include discrepancies in the age of the participants in our study (middle school children) as compared to those of previous literature study populations (high school or collegiate athletes) and different ranges of composite scores for the SAC (range=0-25) and SAC-C (range=0-26).[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTo our knowledge, our study is the first to provide evidence of the diagnostic properties of the Child SCAT5 in the population for which it was designed. The total number and severity of endorsed symptoms were found to have the highest levels of diagnostic accuracy (AUC=0.76\u0026ndash;0.77) and sensitivity (Sn=0.79\u0026ndash;0.88) of the Child SCAT5 scores. Based on the calculated cutoff scores, children who endorse less than four symptoms or report a severity less than six points on the same day as the suspected concussion were less likely (-LR=0.22\u0026ndash;0.31) to be diagnosed with a concussion. As mentioned previously, it is important to note that none of the children assessed for a suspected concussion were permitted to return to sport participation on the same day as the assessment regardless of their Child SCAT5 scores. This is in alignment with the recommendations from the leading international consensus group on concussion in sport,[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] position statements from several governing bodies,[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and the legal requirements of state laws[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe highest positive predictive values and likelihood ratios were observed for interpretation of the double leg stance of the mBESS followed by the delayed recall domain of the SAC-C. However, inordinately low thresholds for a positive test result (e.g., diagnosed concussion) for the double leg stance of the mBESS (\u0026le;1 error) and the delayed recall domain of the SAC-C (\u0026le;1 point) yielded high specificity values (Sp=0.98\u0026ndash;1.00) which artificially elevated the calculated positive predictive values and likelihood ratios. Therefore, we caution healthcare professionals from independent interpretation of the double leg stance of the mBESS or the delayed recall domain of the SAC-C in their clinical decision-making at this time. Future research is warranted to validate our findings related to the diagnostic properties of the individual components (symptom evaluation, SAC-C, mBESS) of the Child SCAT5 in an independent sample of children on the same day as a suspected concussion.\u003c/p\u003e \u003cp\u003eThe calculated diagnostic properties of the Child SCAT5 scores in our study align with those reported for previous iterations of the SCAT and the Child SCAT3.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] More specifically, the values of sensitivity, specificity, and diagnostic accuracy observed in our study are similar to those calculated for the individual components of the SCAT for the assessment of older athletes.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] A similar methodology as our study has been implemented to evaluate for differences and assess the diagnostic properties of Child SCAT3 scores among children who were evaluated for a suspected concussion in the emergency department.[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] The authors of this prior study reported similar diagnostic accuracy values for Child SCAT3 scores to those observed in our study which utilized the Child SCAT5.[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] Overall, our findings support those of previous literature[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e] which suggest that the symptom evaluation has the best combination of diagnostic properties and is the most effective component of the Child SCAT for differentiating between concussed and non-concussed children.\u003c/p\u003e \u003cp\u003eHealthcare professionals in direct access settings (e.g., emergency department, outpatient clinics) may be the first to evaluate a child following a suspected concussion[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and likely will not have access to preinjury (baseline) scores for comparison. It is vital that healthcare professionals in direct access settings are equipped with age-appropriate assessment tools that can effectively differentiate between those who are and are not concussed in order to appropriately inform patient care. Our findings reinforce the importance of the symptom evaluation of the Child SCAT5 and suggest that healthcare professionals can be confident in the clinical interpretation of acute symptom reporting of children following a suspected concussion. The poorer diagnostic accuracy of the SAC-C and mBESS highlights the inability of these assessments to adequately differentiate between concussed and non-concussed children which limits their clinical utility on the same day as a suspected concussion. Future research should investigate alternative assessment tools (e.g., tandem gait test[\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]) or strategies (e.g., the dual task paradigm[\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]) for the acute evaluation of children following a suspected concussion. Findings from this future research may provide additional objective data to assist in the evaluation of children with a suspected concussion.\u003c/p\u003e \u003cp\u003eWe recognize that our study is not without limitations. All of the children in our study were participating in school-sanctioned sports at middle schools within a single county in the northern Virginia which limits our generalizability. However, the middle school student population in our study has a unique socio-demographic profile including students of diverse racial backgrounds (e.g., 36.7% Hispanic, 27.8% White/Caucasian, 20.7% Black/African-American) and high academic achievement (e.g., less than a 2% course failure rate overall).[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] Another limitation is the variability in the time between the removal from sport and the concussion evaluation, however, all participants were evaluated on the same day as the suspected concussive event. Lastly, the diagnosis of a concussion was made by the on-site healthcare professional using their own clinical decision-making which improves the external validity of our study. The healthcare professionals participating in the ACHIVES Project also completed annual training on concussion assessment using the Child SCAT5 and followed an established concussion management protocol which limited variability in their clinical evaluation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe concussed middle school children endorsed more symptoms, reported greater symptom severity, and committed more errors during administration of the mBESS on the same day as the suspected concussion than children who were not diagnosed with a concussion. Clinical interpretation of the total quantity and severity of the endorsed symptoms resulted in the greatest combination of diagnostic properties as supported by the best sensitivity, diagnostic accuracy, negative predictive values, and negative likelihood ratios. Our data does not support the clinical interpretation of the SAC-C on the same day as a suspected concussion due to the lack of significant differences observed between the concussed and non-concussed groups and highly variable diagnostic properties. Overall, our findings demonstrate that the symptom evaluation may be the most effective component of the Child SCAT5 for differentiating between concussed and non-concussed middle school children on the day of a suspected concussive event.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cem\u003eEthics Approval:\u003c/em\u003e\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Additionally, our study was approved by the George Mason University Institutional Review Board.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eConsent to Participate:\u003c/em\u003e\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eParticipants signed informed consent regarding publishing their data.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eConsent for Publication:\u003c/em\u003e\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eAvailability of Data and Materials:\u003c/em\u003e\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eCompeting Interests:\u003c/em\u003e\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors have no competing interests to disclose.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eFunding:\u003c/em\u003e\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eDr. Shane V. Caswell has received funding from the Virginia Department of Health (Grant #709I832700) and the Centers for Disease Control and Prevention (Grant #NU17CE924832) as well as support from the Prince William County Public Schools.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eAuthor\u0026rsquo;s Contributions:\u003c/em\u003e\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eDr. Nicholas K. Erdman conceptualized the design of the study, carried out the initial analyses, drafted the initial manuscript, and revised the manuscript. Dr. Patricia M. Kelshaw conceptualized the design of the study, designed the data collection instruments, collected data, and critically reviewed the manuscript for important intellectual content. Ms. Samantha Hacherl designed the data collection instruments, collected data, and critically reviewed the manuscript for important intellectual content. Dr. Shane V. Caswell conceptualized the design of the study, designed the data collection instruments, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchool Enrollment in the United States. October 2018 - Detailed Tables [Internet]. 2019 [cited 2021 Jan 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.census.gov/content/census/en/data/tables/2018/demo/school-enrollment/2018-cps.html\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanters MA, Bocarro JN, Edwards MB, Casper JM, Floyd MF. School Sport Participation Under Two School Sport Policies: Comparisons by Race/Ethnicity, Gender, and Socioeconomic Status. 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Are Divided Attention Tasks Useful in the Assessment and Management of Sport-Related Concussion? Neuropsychol Rev [Internet]. 2013 [cited 2019 May 17];23:300\u0026ndash;13. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://link.springer.com/\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11065-013-9238-1\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neurocognitive, balance, symptomology, children, diagnostic accuracy","lastPublishedDoi":"10.21203/rs.3.rs-957510/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-957510/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5) was developed to evaluate children between 5-12 years of age for a suspected concussion. However, limited empirical evidence exists demonstrating the value of the Child SCAT5 for acute concussion assessment. Therefore, the purpose of our study was to examine differences and assess the diagnostic properties of Child SCAT5 scores among concussed and non-concussed middle school children on the same day as a suspected concussion.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Our participants included 34 concussed (21 boys, 13 girls; age=12.8±0.86 years) and 44 non-concussed (31 boys, 13 girls; age=12.4±0.76 years) middle school children who were administered the Child SCAT5 upon suspicion of a concussion. Child SCAT5 scores were calculated from the symptom evaluation (total symptoms, total severity), child version of the Standardized Assessment of Concussion (SAC-C), and modified Balance Error Scoring System (mBESS). The Child SCAT5 scores were compared between the concussed and non-concussed groups. Non-parametric effect sizes (r=z/√n) were calculated to assess the magnitude of difference for each comparison. The diagnostic properties (sensitivity, specificity, diagnostic accuracy, predictive values, likelihood ratios, and diagnostic odds ratio) of each Child SCAT5 score were also calculated.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Concussed children endorsed more symptoms (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001, r=0.45), higher symptom severity (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001, r=0.44), and had higher double leg (\u003cem\u003ep\u003c/em\u003e=0.046, r=0.23), single leg (\u003cem\u003ep\u003c/em\u003e=0.035, r=0.24), and total scores (\u003cem\u003ep\u003c/em\u003e=0.022, r=0.26) for the mBESS than non-concussed children. No significant differences were observed for the SAC-C scores (\u003cem\u003ep’s\u003c/em\u003e≥0.542). The quantity and severity of endorsed symptoms had the best diagnostic accuracy (AUC=0.76–0.77), negative predictive values (NPV=0.84–0.88), and negative likelihood ratios (-LR=0.22–0.31) of the Child SCAT5 scores.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The symptom evaluation was the most effective component of the Child SCAT5 for differentiating between concussed and non-concussed middle school children on the same day as a suspected concussion.\u003c/p\u003e","manuscriptTitle":"Symptoms are the Most Effective Child SCAT5 Component for Recognizing Concussion on the Day of Injury","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-10-11 14:41:31","doi":"10.21203/rs.3.rs-957510/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revision","date":"2022-03-15T19:31:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-10-22T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2021-10-17T06:04:23+00:00","index":0,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-10-17T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-10-14T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-10-06T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-10-05T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-10-05T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2021-10-05T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sports-medicine-open","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"smoa","sideBox":"Learn more about [Sports Medicine-Open](http://sportsmedicine-open.springeropen.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/smoa/default.aspx","title":"Sports Medicine-Open","twitterHandle":"@SpringerOpen","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"599e5b49-5397-4b45-b1cd-5604c238bfec","owner":[],"postedDate":"October 11th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":7768464,"name":"Sports Medicine and Kinesiology"}],"tags":[],"updatedAt":"2023-09-05T19:28:33+00:00","versionOfRecord":{"articleIdentity":"rs-957510","link":"https://doi.org/10.1186/s40798-022-00499-8","journal":{"identity":"sports-medicine-open","isVorOnly":false,"title":"Sports Medicine-Open"},"publishedOn":"2022-08-13 00:00:00","publishedOnDateReadable":"August 13th, 2022"},"versionCreatedAt":"2021-10-11 14:41:31","video":"","vorDoi":"10.1186/s40798-022-00499-8","vorDoiUrl":"https://doi.org/10.1186/s40798-022-00499-8","workflowStages":[]},"version":"v1","identity":"rs-957510","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-957510","identity":"rs-957510","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}