Language Matters: Comparisons of Concussion Assessments Among English- and Spanish-Speaking Middle School Athletes

METHODS

Participants

Participants were middle school athletes in a large, socioculturally diverse public school division in Virginia. The George Mason University Institutional Review Board approved the construction of the de-identified database for research purposes and waived assent and consent requirements. Participants were identified from a retrospective observational cohort of middle school athletes between the ages of 11 and 13 years (sixth through eighth grade) who completed baseline Child SCAT5 assessments. As did prior researchers of the Child SCAT3 and Child SCAT5, we administered the Child SCAT5 to all middle school athletes, including 13-year-olds.^3–6 The athletes completed baseline Child SCAT5 assessments between fall 2016 and spring 2021. A total of 2533 athletes were in the dataset. Of the total sample, 73 cases were missing language variables, and 37 were missing preexisting health condition data; therefore, they were removed from the dataset. Because of reported associations of preexisting health conditions with baseline concussion performance (eg, attention-deficit/hyperactivity disorder, migraine status, learning disabilities, dyslexia, and depression), we also removed those cases from the study (n = 777).^8,18 A total of 1646 cases remained in the final dataset, of whom 72 endorsed speaking Spanish at home. These 72 athletes were then individually matched to children speaking English at home (ie, control participants). Matching was completed for the following characteristics: age, gender, sport, school they attended, and concussion history. The final sample comprised 144 athletes, who were grouped by the language they reported speaking at home (Spanish = 72, English = 72). All athletes in the final sample provided 100% matches for all these demographic variables (see Table 1).

Table 1. Demographic and Health History Variables of Sample

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RESULTS

Demographic data for all participants are presented in Table 1. Child SCAT5 scores by Spanish and English groups are provided in Table 2. Athletes whose home language was Spanish scored lower on the SAC-C (P < .01, r = −0.25), Immediate Memory (P < .01, r = −0.45), and total mBESS (P < .01, r = −0.25) than athletes whose home language was English. No statistical differences were found for total symptoms, symptom severity, digits backwards, concentration, or delayed recall (P > .05) by language groups (Figure).

Table 2. Comparisons and Descriptive Data Between Matched English and Spanish Groups on Child Sport Concussion Assessment Tool, Fifth Edition (Child SCAT5), Component Scores^a

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DISCUSSION

The fifth and sixth international consensus statements from the Concussion in Sport Group have called for researchers to better represent sociodemographic variables on concussion assessment tools that are administered to athletes with diverse preferred languages.^22,23 This is the first study to investigate language differences on the Child SCAT5 using a detailed retrospective matched-case control design. As we hypothesized, children whose home language was Spanish had lower baseline scores on cognitive assessments and more errors on the balance assessment when completing the Child SCAT5. Contrary to what we expected, no differences were evident in symptom endorsements between the home language groups. Based on these findings, we recommend that concussion assessment tools for young athletes consider cultural and linguistic variations to obtain valid clinical data.

Currently, limited information is available on the relationship between Child SCAT5 scores and age, sex, health history, and sociocultural factors among middle school age children.^3,6 Research informing concussion management practices for middle school-aged children is important, as their rate of concussion was nearly 3 times that of high school athletes (0.75/1000 athlete exposures [AEs] versus 0.24–0.5/1000 AEs).^24–26 A previous study examined Child SCAT5 component scores among English- and Spanish-speaking groups.⁶ In contrast with our findings, the authors observed that preferred English language speakers endorsed more symptoms than preferred Spanish speakers. Further, those preferring to speak English performed marginally better on cognitive tasks than those preferring to speak Spanish.⁶ Consistent with these outcomes, we noted small differences between the home language groups. However, the median differences on the SAC-C and mBESS were marginal. In addition, athletes whose home language was Spanish scored a median of 1 point lower on the SAC-C than those whose home language was English (Spanish = 21.0, interquartile range [IQR] = 20.0–23.0; English = 22.0, IQR = 20.3–24.0). The differences in SAC-C scores were minimal, likely not clinically meaningful, and still fall within the expected variability of the SAC-C.⁶ Similarly, those with a home language of Spanish committed a median of 1 additional error on the mBESS test as compared with those whose home language was English (Spanish = 5.0, IQR = 3.0–7.0; English = 4.0, IQR = 1.0–6.0). This slight difference in balance scores may be attributable to task cues being conducted in English for both groups, measurement error, and rater reliability limitations rather than a motor control deficit associated with language preference.^3,27 The differences in Immediate Memory generated the highest effect size difference in our study, but the test did not demonstrate a meaningful difference based on median or mean interpretations by home language group (Spanish = 14.0, IQR = 12.0–14.0; English = 14.0, IQR = 14.0–15.0). However, the range of Immediate Memory scores for the Spanish home language group revealed greater variability (range = 9–15) than for the English home language group (range = 12–15). This may suggest a slightly greater acute cognitive burden among athletes whose home language was Spanish rather than English. Conceptually, the task of remembering and subsequently recalling a string of words may pose a distinct challenge, contingent upon the individual’s comfort level and fluency in the English language, particularly for athletes who do not regularly speak English at home. Nonetheless, this finding should be interpreted with caution, given the similar median values per home language groups. Both the Spanish and English home language groups scored within a broadly normal range for all components of the Child SCAT5 when compared with normative reference scores.⁶ Therefore, although statistical differences may exist related to home language, they are not likely to affect the clinical interpretation when using a normative comparison method. This is important, as individual scores of the Child SCAT5 are vulnerable to measurement error, and normative reference value comparisons may better represent meaningful clinical score interpretations.^3,6 Collectively, our results indicate that the differences in Child SCAT5 scores among middle school athletes that were attributable to self-reported Spanish or English home language were minute and unlikely to be clinically meaningful. As such, more research is needed to understand the clinical relevance of the observed differences between the language groups.

Prior authors have compared baseline computerized neurocognitive performance and symptom endorsements among Spanish- and English-speaking athletes.^11–13 Recently, Karr et al used a matched-case control design to compare baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) composite scores among Spanish- and English-speaking adolescent athletes.¹³ Consistent with earlier reports, they determined that adolescent athletes who spoke Spanish endorsed more symptoms and had lower cognitive functioning scores.^11,12 We used a similar design in which we compared English and Spanish home language teammates with the same age, sex, and sport, as well as consistent health history profiles. Our findings generally align with prior research, yet no differences were seen in total symptoms or symptom severity.¹³ The unique terminology and symptoms associated with concussion may present challenges for accurately assessing and managing concussion in languages other than English. This was illustrated by Eirale et al, who identified a lower concussion incidence among Qatari professional football athletes than their European counterparts.²⁸ The authors hypothesized that this difference in incidence may be attributed to differences in knowledge acquisition and symptom recognition among Qatari athletes, possibly due to differences in language and cultural factors. Similarly, Beidler et al showed that concussion awareness and reporting behaviors varied among collegiate athletes from the United States, Ireland, and Jordan.²⁹ According to the results of a validated survey instrument, concussion awareness was highest among US athletes, likely due to concussion education, publicity, and legislation. However, when the survey was translated into Arabic and administered to Jordanian athletes, concussion awareness was lower than their English-speaking counterparts using an English survey. These findings highlight the importance of considering language-specific factors in concussion assessment and management and the need for further research to develop culturally responsive tools for the accurate recognition of and treatment for concussion in diverse populations. Moreover, the current lack of concussion assessment tools and educational materials in languages other than English, such as the Child SCAT5, may contribute to potential disparities in care. This is of particular concern, as reliable Spanish translations of the Child SCAT5 and now the Child SCAT6 are not widely available, thereby presenting a language-based determinant in providing concussion care.³⁰ Supplying reliable language translations is necessary, yet so are efforts to ensure dialect inclusivity so that health care professionals can serve a broader range of individuals and communities globally. The Concussion in Sport Group is creating opportunities to allow professionals to translate and validate the SCAT tools.³¹ Establishing these connections is crucial in addressing health literacy, improving access to care, and accommodating diverse home languages. In the interim, clinicians serving Spanish-speaking communities may benefit from using the established translated patient information produced by the Centers for Disease Control and Prevention to aid in concussion education and managment.³²

CONCLUSIONS

Middle school athletes whose home language was Spanish performed differently on baseline Child SCAT5 assessments than those speaking English; the largest difference was in the Immediate Memory task. Athletes whose home language was Spanish scored slightly lower on cognitive and balance tasks than athletes whose home language was English, but the clinical relevance remains uncertain. Our findings, in conjunction with the prior studies, shed light on the importance of communication in health care and concussion management. Notably, language discordance (ie, incongruent languages between clinicians, assessment tools, and patients) may create a barrier in responsive health care. Further research is warranted to enhance our understanding of the importance of language in concussion assessment performance among a wide range of athletes. This includes but is not limited to diverse age groups, numerous sporting disciplines, athletes with preexisting health conditions, those communicating in various languages, and athletes from diverse environments globally.