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\"During the past several decades, interest in children's psychological disorders has grown steadily within the research community, resulting in a burgeoning knowledge base. The majority of the attention and funding, not surprisingly, has focused on the more prevalent and well-known conditions. Although this raises the odds that young people with more well-known disorders such as ADHD, autism, and learning disorders will receive much-needed professional assessment and intervention, children with less frequently encountered disorders may experience a higher risk of misdiagnosis and inappropriate treatment\"--Back cover.

Although high rates of injury occur in youth ice hockey, disagreements exist about the risks and benefits of permitting bodychecking. We sought to evaluate associations between experience with bodychecking and rates of injury and concussion among ice hockey players aged 15–17 years. We obtained data from a prospective cohort study of ice hockey players aged 15–17 years in Alberta who played in leagues that permitted bodychecking. We collected data over 3 seasons of play (2015/16–2017/18). We compared players based on experience with bodychecking (≤ 2 v. ≥ 3 yr), estimated using local and national bodychecking policy and region of play. We used validated methodology of ice hockey injury surveillance to identify all injuries related to ice hockey games and defined concussions according to the Consensus Statement on Concussion in Sport. We included 941 players who contributed to 1168 player-seasons, with 205 players participating in more than 1 season. Compared with players with 2 years or less of bodychecking experience, those with 3 or more years of experience had higher rates of all injury (adjusted incidence rate ratio [IRR] 2.55, 95% confidence interval [CI] 1.57–4.14), injury with more than 7 days of time loss (adjusted IRR 2.65, 95% CI 1.50–4.68) and concussion (adjusted IRR 2.69, 95% CI 1.34–5.42). Among ice hockey players aged 15–17 years who participated in leagues permitting bodychecking, more experience with bodychecking did not protect against injury. This provides further support for removing bodychecking from youth ice hockey.

ObjectivesTo examine factors associated with rates of game-related concussion in youth ice hockey.DesignFive-year prospective cohort.SettingCanadian ice hockey rinks.Participants4419 male and female ice hockey players (6585 player-seasons) participating in Under-13 (ages 11–12), Under-15 (ages 13–14), and Under-18 (ages 15–17) age groups were recruited.Assessment of Risk FactorsBody checking policy, age group, year of play, level of play, lifetime concussion history, sex, player weight, and position of play.Outcome MeasuresAll game-related concussions were identified using validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician for diagnosis and management.Main ResultsCrude concussion rates were 1.82 concussions/1000 game-hours (95% CI: 1.44–2.30) for Under-13s, 3.47 (95% CI: 3.00–4.02) for Under-15s, and 3.61 (95% CI: 3.06–4.27) for Under-18s. Based on multiple multilevel Poisson regression analysis including multiple imputation of missing covariates, female players (IRRFemale/Male=1.72; 95% CI: 1.21–2.46) and players with a previous concussion history (IRR=1.81; 95% CI: 1.51–2.17) had higher rates of game-related concussion. Policy disallowing body checking in games (IRR=0.55; 95% CI: 0.41–0.73) and being a goaltender (IRRGoaltenders/Forwards=0.64; 95% CI: 0.44–0.95) were protective against game-related concussion.ConclusionsIn the largest Canadian youth ice hockey longitudinal cohort study to date, female players (despite policy disallowing body checking) and players with a concussion history had higher rates of concussion. Goalies and players in leagues where policy disallowed body checking had lower rates of concussion. Policy prohibiting body checking continues to be the most effective concussion prevention strategy in youth ice hockey.

Patients with concussion commonly present to the emergency department (ED) for assessment. Misdiagnosis of concussion has been documented in children and likely impacts treatment and discharge instructions. This study aimed to examine diagnosis of concussion in a general adult population. Patients >17years old presenting meeting the World Health Organization's definition of concussion were recruited in one academic (Hospital 1) and two community (Hospitals 2 and 3) EDs in a Canadian city. A physician questionnaire and patient interviews documented recommendations given by emergency physicians. Bi-variable comparisons are reported using chi-square tests, t-tests or Mann-Whitney tests, as appropriate. Multivariate analyses were performed using logistic regression methods. Overall, the study enrolled 250 patients. The median age was 35 (IQR: 23 to 49) and 52% were female. A variety of concussion causes were documented. Forty-one (16%) patients were not diagnosed with a concussion despite meeting criteria. Concussion diagnosis was less likely with a longer ED length of stay (OR=0.71; 95% CI: 0.60 to 0.83), presenting to the non-academic centers (Hospital 2: OR=0.21, 95% CI: 0.08 to 0.58; Hospital 3: OR=0.07, 95% CI: 0.02 to 0.24), or involvement in a motor vehicle collision (OR=0.11; 95% CI: 0.03 to 0.46). One in six patients with concussion signs and symptoms were misdiagnosed in the ED. Misdiagnosis was related to injury mechanism, length of stay, and enrolment site. Closer examination of institutional factors is needed to identify effective strategies to promote accurate diagnosis of concussion.

Background: The identification of factors associated with clinical recovery in youth after sports-related concussion could improve prognostication regarding return to play (RTP). Purpose: To assess factors associated with clinical recovery after concussion in youth ice hockey players. Study Design: Cohort study; Level of evidence, 2. Methods: Participants were part of a larger longitudinal cohort study (the Safe to Play study; N = 3353). Included were 376 ice hockey players (age range, 11-17 years) from teams in Calgary and Edmonton, Canada, with 425 physician-diagnosed ice hockey–related concussions over 5 seasons (2013-2018). Any player with a suspected concussion was referred to a sports medicine physician for diagnosis, and a Sport Concussion Assessment Tool (SCAT) form was completed. Time to clinical recovery was based on time between concussion and physician clearance to RTP. Two accelerated failure time models were used to estimate days to RTP clearance: model 1 considered symptom severity according to the SCAT3/SCAT5 symptom evaluation score (range, 0-132 points), and model 2 considered responses to individual symptom evaluation items (eg, headache, neck pain, dizziness) of none/mild (0-2 points) versus moderate/severe (3-6 points). Other covariates were time to physician first visit (≤7 and >7 days), age group (11-12, 13-14, and 15-17 years), sex, league type (body checking and no body checking), tandem stance (modified Balance Error Scoring System result ≥4 errors out of 10), and number of previous concussions (0, 1, 2, and ≥3). Results: The complete case analysis (including players without missing covariates) included 329 players (366 diagnosed concussions). The median time to clinical recovery was 18 days. In model 1, longer time to first physician visit (>7 days) (time ratio [TR], 1.637 [95% confidence interval (CI), 1.331-1.996]) and greater symptom severity (TR, 1.016 [95% CI, 1.012-1.020]) were significant predictors of longer clinical recovery. In model 2, longer time to first physician visit (TR, 1.698 [95% CI, 1.399-2.062]), headache (moderate/severe) (TR, 1.319 [95% CI, 1.110-1.568]), and poorer tandem stance (TR, 1.249 [95% CI, 1.052-1.484]) were significant predictors of longer clinical recovery. Conclusion: Medical clearance to RTP was longer for players with >7 days to physician assessment, poorer tandem stance, greater symptom severity, and moderate/severe headache at first visit.

ObjectiveTo identify whether early referral to a multidisciplinary health care team improves total symptom duration and reduces treatment duration following a diagnosis of sport-related concussion (SRC).DesignRetrospective chart audit.SettingCommunity based tertiary multidisciplinary medical clinic; Patients seen between January 2013 and August 2016.Participants53 patients with SRC were analyzed.Outcome MeasuresTreatment duration and total symptom duration.Main ResultsMean age of participants was 19.5 years (32% female), mean duration prior to SRC assessment was 27.8 days for all groups, mean treatment duration was 66.1 days and mean total symptom duration was 94.0 days. Three groups were made based on time of assessment (0–14 days, 15–42 days, and 43–90 days). A MANOVA test was performed to compare treatment duration and symptom duration between each of the groups. Group 1 was found to have significantly shorter symptom duration compared to groups 2 and 3 (p<0.05); group 2 was also statistically different from group 3 (p<0.05). Group 1 was found to have significantly shorter treatment duration than group 3 (p<0.05); groups 1 and 2 were not statistically different, nor were groups 2 and 3.ConclusionsThese findings show that individuals seen earlier following their SRC have a shorter total symptom duration. It also demonstrates that individuals seen earlier (<14 days) have a shorter treatment duration than those seen later (43–90 days). We would recommend an early referral to a multidisciplinary concussion clinic after the diagnosis of SRC is made.

ObjectiveShort sleep duration has been shown to affect baseline neurocognitive screening scores in high school and college athletes, but no studies have shown a similar effect in professional athletes. We hypothesized that Canadian Football League (CFL) athletes with a shorter sleep duration the night prior to baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) would have lower neurocognitive scores and higher post concussion symptom scores (PCSS).DesignRetrospective cross-sectional.SettingCanada-wide outpatient.Participants1438 male CFL athletes ages 22–40 were included. Exclusion criteria included no self-reported sleep duration, failure to meet ImPACT internal validity measures, history of learning disabilities, ADD, ADHD, or psychiatric illness.Interventions (or Assessment of Risk Factors)Participants were assigned to three groups based on sleep duration, short (<7 hours), intermediate (≥ 7 to ≤ 9) or long (>9).Outcome MeasuresWe compared the overall ImPACT neurocognitive scores, sub-category scores, and PCSS between groups.Main ResultsPairwise comparison showed lower visual memory scores for the short sleep duration group compared to intermediate (p<0.001) and long (p=0.009). Comparison of PCSS showed higher symptom scores for the short sleep duration group when compared to intermediate (p<0.001) and long (p=0.009).ConclusionsCFL athletes with short sleep duration performed worse on 1 of 4 ImPACT domains and reported more concussion symptoms. Clinicians must be cautious in using return to baseline symptom and neurocognitive screening scores as the sole determinant in return to play decisions, especially in athletes who slept <7 hours prior to baseline testing.

Family caregivers are the main source of support for survivors of traumatic brain injury (TBI) while they transition from pediatric to adult care service and support systems. Yet there is little research that examines the needs of these caregivers during the transition phase. The aim of this qualitative phenomenological study was to examine the lived experiences of family caregivers of young adults with TBI who had recently transitioned from services for children and adolescents to adult care service and supports. The study sample comprised 15 family caregivers of young adult TBI survivors who had transitioned to adult services in the last 5 years. They were recruited from two large hospitals and a caregiver support center in a city in Western Canada. Semistructured interviews were conducted with the caregivers and the data were analyzed using Colaizzi’s approach in developing an essential structure of the phenomenon of caregiving. Fifteen themes emerged from the analysis and these are discussed under two broad domains: (a) caregivers’ experiences and challenges with their relative at the time of transition; (b) caregivers’ challenges with services and supports systems during transition. Findings suggest that there is a wide gap between what caregivers need and what is available to them to support their young adult relative through the transition process and beyond. Most caregivers reported that the transition phase is overwhelming and has a profound and pervasive impact on their lives. Implications of the findings and recommendations for policy and practice are discussed.

Sideline assessment tools are an important component of concussion evaluations. To date, there has been little data evaluating the clinical utility of these tests in professional football. The purpose of this study was to evaluate the clinical utility of the King-Devick (K-D) test in evaluating concussions in professional football players. Baseline data was collected over two consecutive seasons in the Canadian Football League as part of a comprehensive medical baseline evaluation. A pilot study with the K-D test began in 2015 with 306 participants and the next year (2016) there were 917 participants. In addition, a sample of 64 participants completed testing after physical exertion (practice or game). Participants with concussion demonstrated significantly higher (slower) results compared with baseline and the exercise group (F[2,211] = 5.94; p = 0.003). The data revealed a specificity of 84% and sensitivity of 62% for our sample. Reliability from season to season was good (intraclass correlation coefficient [ICC] 2,1 = 0.88; 95% confidence interval [CI]: 0.83, 0.91). On average, participants improved performances by a mean of 1.9 sec (range, -26.6 to 23.8) in subsequent years. High reliability was attained in the exercise group. (ICC2,1 = 0.93; 95% CI: 0.89, 0.96). The K-D test presents as a reliable measure although sensitivity and specificity data from our sample indicate it should be used in conjunction with other measures for diagnosing concussion. Further research is required to identify stability of results over multiple usages.

ObjectiveTo compare head impact rates in a modified 9-on-9 Bantam (13–15 years old) Canadian football season to a traditional 12-on-12 season using video-analysis.DesignProspective cohort.SettingFootball fields (Calgary, Canada).ParticipantsIn 2020, 384 youth football players (N=18 teams) and in 2021, 500 players (N=12 teams) participated. Video-analysis data was anonymized.Interventions (or Assessment of Risk Factors)Adhering to provincial COVID-19 cohort restrictions, the number of on-field players was reduced to 9-a-side in 2020, returning to 12-a-side in 2021. Independent variables included the number of on-field players, game type (i.e., regular season, playoffs), play type, player position, player role, impact location, and impact object (e.g., helmet, ground).Outcome MeasuresHead impacts (HI) were analyzed using Dartfish video-analysis software. HIs were stratified by team unit (e.g., offensive, defensive, kicking team, receiving team). Using negative binomial regression, HI rates (/100 player-plays and/10 gameplay-minutes) and incidence rate ratios (IRR) were estimated to examine differences between years.Main ResultsNo differences were identified between 9-on-9 and 12-on-12 seasons for offense HI (IRRPlays=0.92, 95% CI; 0.75–1.12, IRRGameMins=0.90, 95% CI; 0.75–1.15) or any other team unit. The offensive team unit, however, experienced a significantly higher HI rate in the 12-on-12 format during playoffs versus the 12-on-12 regular season (IRRPlays=1.33, 95% CI; 1.07–1.65, IRRGameMins=1.26, 95% CI; 1.03–1.56).ConclusionsNo differences in HI were found between the 9-on-9 and 12-on-12 seasons for any team unit. Future research should consider field player-density and combining HI accelerometry, video-analysis, and injury surveillance.