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Measuring Dynamic Symptom Response in Concussion

Children's Exertional Effects Rating Scale

Sady, Maegan D., PhD; Vaughan, Christopher G., PsyD; Gioia, Gerard A., PhD

The Journal of Head Trauma Rehabilitation: March/April 2019 - Volume 34 - Issue 2 - p E35–E44
doi: 10.1097/HTR.0000000000000424
Pediatric TBI 2019

Objective: To introduce and evaluate a measure of momentary symptom response to cognitive activity, a core feature of concussion.

Setting: Concussion clinic at a large regional children's hospital.

Participants: Individuals aged 5 to 18 years, comprising 3 clinical groups: uninjured (n = 590), recently concussed but clinically recovered (n = 160), and recently concussed but not yet recovered (n = 570).

Design: Participants completed pretest symptom ratings, underwent neurocognitive assessment and completion of questionnaires, and then completed posttest ratings. An exertional effects index was computed by subtracting pretest from posttest ratings.

Main Measures: Children's Exertional Effects Rating Scale, which includes 4 symptoms (Headache, Fatigue, Concentration Problems, and Irritability) rated pre- and postactivity.

Results: Children's Exertional Effects Rating Scale was found to have adequate reliability and validity. There were negligible differences in ratings (pretest and exertional effects) between the Uninjured and Recovered groups, while individuals who were Not Recovered rated higher levels of pretest and exertional effects. Base rates showed that an exertional effects index of 4 or more points is rare in individuals who do not have a current concussion.

Conclusion: Children's Exertional Effects Rating Scale is a psychometrically sound scale for evaluating momentary symptom increase in response to cognitive activity. Clinicians can use this scale as part of a multimodal battery for concussion assessment and treatment.

Division of Pediatric Neuropsychology, Children's National Health System, and Departments of Pediatrics & Psychiatry and Behavioral Sciences, George Washington University School of Medicine, Washington, District of Columbia.

Corresponding Author: Maegan D. Sady, PhD, Division of Pediatric Neuropsychology, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010 (

The authors thank the research team in the SCORE Program at Children's National Health System including faculty members Catherine McGill, PsyD, and Julie B. Newman, PhD; former postdoctoral fellows Alison Burns, PhD, and Danielle Ransom, PsyD; and former research assistants Elyssa Gerst, PhD, Lincoln Pratson, and Divya Sriram. The authors also thank Grant Iverson, PhD, for consultation regarding the concepts behind the paper.

This work was supported in part by the Centers for Disease Control and Prevention (U17/CCU323352 to G.G.); and the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) (M01RR020359 to G.G.).

The authors declare no conflicts of interest.

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