Youth with ADHD appear to be at an increased risk for concussion compared to those without (2/6/25 Newsletter)
This week, our lead article, Youth with ADHD appear to be at an increased risk for concussion compared to those without, is in the Youth category.
In this newsletter: Opportunities, Diagnostics, Therapies Currently Available, Mental Health, and Youth.
We appreciate the Concussion Alliance volunteers and staff who created this edition:
Writers: Myla Hightower, Sravya Valiveti, Fadhil Hussain, and Ella Webster
Editors: Malayka Gormally and Conor Gormally
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Opportunities
Tuesday, February 11, 6 pm EST: A free webinar, Return to Learn after Concussion, presented by Dr. Nick Reed, hosted by the Canadian Concussion Centre. Register in advance.
Thursday, February 13, 4 pm EST: A free webinar, TBI and Sleep Disorders: Pathophysiology and Approaches to Clinical Management, presented by Dr. J. Kent Werner, MD, PhD, hosted by the University of Michigan Concussion Center. Register in advance.
Friday, February 14, 8 am PST: A free webinar, Advancing Brain Health: Innovations in Cognitive and Behavioral Approaches to Measurement, Enhancement, and Scalability, presented by Lori Cook, PhD, CCC-SLP, and hosted by The Center on Brain Injury Research and Training. Register in advance.
Friday, February 21, 9 am - 12 pm PST: A free, remote workshop Supporting First Responders and Justice-Involved Persons, including survivors of intimate partner violence. Hosted by The Center on Brain Injury Research and Training; see their Facebook page for updates about speakers. Register in advance.
Thursday, February 27, 11 am PST: A free online class, Sleep Hygiene with Regee, presented by Regee Costanzo, Survivor Engagement Coordinator, and hosted by Brain Northwest. Register in advance.
Call for study participants: military veterans who have had exposure to blasts, concussions, and/or a traumatic brain injury, including any injury to your head or neck that caused you to lose consciousness or feel dazed/confused/experience a gap in memory. Read our blog post for more information on the Late Effects of TBI (LETBI) study. If you are interested, please contact Julia Kirschenbaum at julia.kirschenbaum@mountsinai.org, call us at 212-241-5152, or sign up online.
Diagnostics
Hidden disruptions in visual pathways linked to mild traumatic brain injury
Chronic mild traumatic brain injury (mTBI) may lead to subtle but significant disruptions in the primary visual pathway, according to a case-control study led by Tonia S. Rex, Ph.D., published in JAMA Ophthalmology. Despite normal results on standard eye exams, 78% of the study participants with mild TBI exhibited measurable visual deficits, including impaired oculomotor function and reduced contrast sensitivity. Advanced imaging and machine-learning analyses also revealed structural changes in the optic radiations (white matter paths that transmit visual information) and occipital lobes (responsible for processing that visual information and helping with spatial memory) of 70% of individuals with mTBI, emphasizing the limitations of routine eye tests in identifying these hidden impairments. These persistent visual symptoms can hinder recovery, even when these deficits are not apparent during standard clinical evaluations.
The study highlights the need for more comprehensive diagnostic tools to assess both functional and structural changes in the visual pathway. Dr. Rex and her colleagues utilized methods like optical coherence tomography (OCT), visual evoked potential tests measured with EEG, and magnetic resonance imaging (MRI) to provide a detailed picture of these changes. These tools offer crucial insights into how even mild traumatic brain injuries can disrupt the visual system at a cellular level.
The research emphasizes that a multimodal approach is essential for diagnosing and treating visual dysfunction in mTBI patients. As Dr. Rex explains, “The combination of a test battery and use of machine-learning algorithms will allow us to reach the necessary specificity and sensitivity to accurately diagnose these patients.” Such diagnostic precision could help clinicians identify hidden impairments while paving the way for targeted rehabilitation strategies to improve quality of life.
Further research is needed to confirm these findings and explore their implications for neurorehabilitation and long-term care in mTBI populations. By enhancing diagnostic protocols, clinicians may better address the hidden visual deficits that complicate recovery, particularly for high-risk groups such as military personnel and athletes.
Therapies Currently Available
Earlier PT rehab for persisting symptoms is better for balance control & reaction times
A study by Campbell et al. published in Physical Therapy highlighted that, for patients with mild traumatic brain injury (mTBI) who were experiencing continued symptoms (beyond four weeks), earlier physical therapy intervention was associated with faster symptom recovery compared to those receiving delayed physical therapy. Notably, for those with persisting symptoms, an early start to a 6-week physical therapy rehabilitation program resulted in improvements in balance control, but delayed physical therapy did not. The earlier physical therapy group showed a faster rate of improvement as well as a beneficial effect in the sensorimotor aspects of balance control. The delayed physical therapy patients had decreases in motor activation (likely due to the delay) that “can be interpreted as a maladaptation,” making patients “less able to resist external disturbances.”
In an OSHU press release, OSHU neurologist Dr. Laurie King notes that up to 30% of those who have a concussion experience lingering symptoms past four weeks post-injury––and that earlier rehab aims to provide more support, facilitate faster recovery and address changes in balance early on. When physical therapy is delayed, the brain appears to over-rely on vision to compensate for dysfunction in the vestibular system, thus creating poorer balance control and reaction times. Dr. King notes that these deficits may lead to patients avoiding physical activity and may also explain why there are “higher rates of re-injury after a first concussion.” She notes that the ideal window to seek physical therapy is within two months of an mTBI event. After that point, patients could experience more prominent deficits in balance and sensorimotor control functions. “There seems to be a window of opportunity within two months,” King said. “After that point, the brain compensates in a way that’s not good.”
The study, administered by physical therapists at OHSU, looked at the ideal physical therapy timing via a randomized control trial, comparing an early start to a 6-week rehabilitation program to a significantly delayed start to the program. 160 Patients were randomly assigned to two groups. The earlier group of mTBI patients started the 6-week rehabilitation program within 1 week of baseline testing (performed at study enrollment) within 2-12 weeks of injury. The later (delayed) rehabilitation group had a 6-week waiting period (after their baseline testing upon enrollment) before commencing the rehabilitation program.
The 6-week program included 8 physical therapy sessions with a physical therapist over six weeks, plus home exercises. Each 60-minute session focused on the cervical spine, cardiovascular, static balance, and dynamic balance. Outcomes were assessed primarily with the Dizziness Handicap Inventory and secondarily with patient-reported measurements of sensorimotor balance control and objective measures of balance.
Delayed physical therapy can negatively affect patient outcomes related to sensorimotor balance and points to a need for more informed guidelines in the primary care setting as well as early physical therapy referral and intervention after mTBI to effectively address any lingering symptoms related to concussion.
Mental Health
Sleep, emotions, and concussion-like symptoms: key factors in return-to-play decisions
An article published by the Sport Information Resource Center detailed a two-part study examining the relationship between sleep dysfunction, emotional functioning, and concussion-like symptoms. The findings from this dissertation, published by the University of Windsor, suggest that inadequate sleep increases the reporting of concussion-like symptoms and that emotional distress further influences this relationship. These results highlight the importance of considering sleep and emotional well-being when assessing concussions and making return-to-play decisions.
In the first part of the study, researchers analyzed retrospective data from 266 healthy undergraduate students to investigate how sleep duration affects concussion-like symptoms. They found that athletes who had slept less than 5.5 hours the previous night reported more concussion-like symptoms than those who'd had adequate sleep.
The second part of the study experimentally restricted participants' sleep to assess its effects on concussion-like symptoms and social factors such as loneliness, social isolation, and emotional support. The results showed that emotional distress—including depression, anxiety, stress, and negative affect—contributed to increased reporting of concussion-like symptoms. However, sleep restriction did not significantly impact social functioning.
These findings have important implications for baseline concussion testing and return-to-play protocols. Athletes typically undergo baseline testing at the start of their season, with post-concussion tests compared against these baselines. Since sleep and emotional functioning influence concussion-like symptoms, clinicians should consider these factors when interpreting test results. Future research could explore whether sleep and emotional health interventions might improve concussion recovery and return-to-play outcomes.
Youth
Youth with ADHD appear to be at an increased risk for concussion compared to those without
A study published in Frontiers found that children and teens with attention-deficit/hyperactivity disorder (ADHD) are nearly twice as likely to have a history of concussion compared to those without ADHD. Dr. Julia Maietta et al. found that the increased risk of concussion in children with ADHD was present as early as age seven and remained consistent throughout childhood and adolescence. Interestingly, boys and girls with ADHD had similar rates of concussion. There was no clear connection between concussion history and the severity of ADHD symptoms or whether a child was taking medication. This suggests that the higher risk of concussion in children with ADHD is not necessarily linked to how severe their symptoms are or whether they are receiving treatment. While the exact reasons for this increased risk are not fully understood, researchers suggest that traits associated with ADHD—such as impulsivity and difficulties with balance—may make injuries more likely.
Researchers analyzed parent-reported data from over 33,000 children in the U.S. using information from the 2021 National Survey of Children's Health. Among the children studied, 4,161 had ADHD, allowing researchers to explore links between ADHD, concussion history, medication use, and severity of symptoms. The study highlights that previous research has focused primarily on adolescent athletes, whereas this study examines a broader age range in the general population. Given the findings, the authors emphasize the importance of further research and suggest that targeted strategies to prevent concussions in children with ADHD could be beneficial, particularly at younger ages when the risk appears to emerge.