Rugby is a popular sport in South Africa, and has been played by young boys from as early as seven years old (South African Rugby Union [SARU], 2011). Despite various physical health benefits, it carries a high risk for injury, especially head injury, and consequently has a high incidence of concussion (Alexander, 2009; Laubscher, 2006; Shuttleworth-Edwards, Smith & Radloff, 2008). It is common for 12 to 13 per cent of adolescent rugby players to report mild traumatic brain injury or concussion per season (Laubscher, 2006; Shuttleworth-Edwards et al., 2008). The true incidence is however considered to be higher, even as high as 70.4% (Shuttleworth-Edwards et al., 2008). Concussion, otherwise known as mild traumatic brain injury (mTBI) is described as a traumatically induced alteration in mental status, or traumatically induced cerebral dysfunction (Kraus, McArthur, Silvermand & Jayaraman, 1996) which may, or may not involve loss of consciousness (Quality Standards Subcommittee, American Academy of Neurology [AAN], 1997). The nature of concussion has traditionally been considered to be transient, and symptoms are usually resolved within a few days or weeks (Kirkwood et al., 2008; Taylor et al., 2010). However, when concussions are not fully resolved prior to players returning to the game, they may be vulnerable to second impact syndrome. This syndrome causes herniation and brain oedema, which may result in death (Patel, 2005), as has been reported in South African press (Alexander, 2009; South African Press Association [SAPA], 2012). Even without second impact syndrome, repeated concussions may render the brain neurocognitively vulnerable, leading to an array of short- and long-term cognitive symptoms (Alexander, 2009; Shuttleworth-Edwards et al., 2008). Short-term problems include difficulties with attention, focus and concentration; following multi-step instruction, engaging in mental problem-solving; verbal expression, receiving and processing verbal and visual information; maintaining effective levels of mental and physical energy; controlling mood; suppressing impulsive behaviours; initiating and maintaining productive interpersonal relationships with peers; engaging in meaningful conversation and participating in group activities (Jantz & Coulter, 2007). Short-term cognitive impairments due to repeated concussion have also been found, and include amongst the former symptoms, also problems with delayed memory, learning, social functioning, and abstract thinking (Anderson, Brown, Newitt & Hoile, 2011; Laubscher, 2006). Long-term sequelae follow when children did not return to their baseline level of functioning after three months (Kirkwood et al., 2008; Taylor et al., 2010). Long-term sequelae include problems with memory, visuo-motor processing, executive functioning, learning and abstract thinking (Anderson, 2002; Anderson et al., 2010; Horton et al., 2010; Lezak et.al., 2004; Shuttleworth-Edwards & Radloff, 2008). As mTBI is traditionally thought to be of transient nature, researchers tend to investigate moderate to severe TBI, rather than mTBI (Alexander, 2009; Anderson et al., 2010; Patel, 2005). This could easily lead to important facts about mTBI being missed or not acknowledged. Nevertheless, recent investigations are uncovering facts about mTBI that could transform the way in which we understand mTBI, providing increasing evidence that mTBI is more serious than widely believed (Blakemore, 2012; Maxwell, 2011; Toleda et al., 2012). However, there remains a lack of research investigating mTBI from a single cause. Considering the above information, the current study provides unique information about mTBI. It specifically investigated the long-term effects of mTBI on adolescents from a homogenous cause, which makes results more comparable. The importance of this study is highlighted in the face of evidence for the long-term effects of multiple concussions, that were sustained during school rugby, on academic achievement (Alexander, 2009; Laubscher, 2006).In the light of grey areas in existing research, the aim of this current study was to investigate whether there is a significant difference in academic achievement within and between two groups of adolescents that had either played rugby and sustained multiple concussions, or had not played rugby nor sustained any concussions, when measured at four points in time over six years. A retrospective data-analysis was performed on matched, controlled, prospective longitudinal data, which was obtained from a study that evaluated the impact of repeated mTBI on the cognitive and academic functioning of early adolescent rugby players over time (Alexander, 2009). This study elaborates on a subset of the previous data, adding the gr. 12 results for academic aggregate scores, to the previously reported academic dataset. Participants were selected from Alexander‟s study (2009), and had either played rugby and obtained two or more concussions (Rugby/Concussed (RC- group); n=17), or did not play rugby nor sustained any concussions (Non-rugby/Non-concussed (NRC-group); n=13). Academic aggregate scores from baseline (gr. 7) through gr. 12 were analysed using quantitative statistical measures. A normal probability plot determined that the data was distributed normally. Descriptive statistics were reported, where after repeated measures ANOVA‟s were conducted to determine the statistical significance of differences in academic scores between and within the groups over time. These results indicated that the NRC-group displayed statistically significant increase in academic achievement over time (p = .000), whereas the RC-group did not display any significant differences, despite displaying a downwards trend in achievement. The difference between the two groups was measured at its highest in gr. 12 (p = .003), indicating that the NRC-group performed statistically significantly better than the RC-group over time. However, a Pearson‟s correlation test revealed that the estimated IQ (Vocabulary subscale of the WISC-III) (Wechsler, 1991) had a positive correlation on academic achievement [r(34) = .54, p < .05)]. To control for the effect that this correlation had on the academic results, an ANCOVA was conducted. This analysis indicated a statistically significant difference in academic achievement between the two groups in gr.12 (p = .004), with a large effect size (d = 1.41), implicating practical significance. Findings consequently confirmed our hypothesis. The significant increase in academic achievement observed within the NRC-group over time, is consistent with what could be expected if the brain is allowed to develop normally without disruption such as mTBI (Blakemore, 2012; Horton et al., 2010). The finding that the RC group did not display statistically significant intra-group differences in academic achievement when measured over time, but that academic achievement followed a downward trend, is difficult to substantiate in the literature. The few research studies on the effect of cumulative concussion on young athletes do not isolate academic achievement as a variable (Iverson et al., 2004; Shuttleworth-Edwards et al., 2008). Further research into intra-group differences in this specific area of enquiry and population group is therefore necessary. Normal cognitive and brain development, maintains that the brain develops in a posterior to anterior direction, and the prefrontal regions which are vulnerable to concussion, develop last (Anderson, 2010; Blakemore, 2012; Lezak, 2004). Whereas the primary motor and sensory areas and areas for receptive and expressive language are fully developed by the age of ten years, the prefrontal brain areas that are responsible for more complex and abstract thought repertoires only start maturing in early adolescence and this development continues up to the age of 24 and even into the early 30s (Toleda et al., 2012). Injury to the developing brain at this critical stage of maturation may adversely affect the development of cognitive skills, preventing the child from acquiring the effective cognitive strategies needed for normal academic functioning and adequate academic achievement after TBI (Horton et al., 2010). However, if there is no insult to the brain, cognitive functions are expected to develop normally as a result of synaptic pruning and increased white-matter volume in the prefrontal cortex (Blakemore, 2012), making it likely that the maturation of these abilities will lead to greater cognitive and academic ability (Blakemore & Choudhury, 2006), such as seen for the NRC-group in this study. Limitations for this study include a small sample size and the testing of only one variable. It is therefore recommended that future studies include more variables, and aim at creating a larger, randomized sample size, possibly providing a more representative pool of participants to study this phenomenon in South African context. It is also advised that future studies consider using neuropsychological measures to test cognitive functioning. As previous studies have indicated specific impairment in executive functioning after TBI, it may be worth researching the effect of concussion on executive functioning more thoroughly (Anderson, 2002; Anderson et al., 2010; Horton et al., 2010). Further it may be valuable to consider using functional MRI studies to broaden existing knowledge about the interaction between pathophysiology and cognitive functioning This study also highly recommends that schools and rugby clubs catering for child and adolescent players reconsider the importance of implementing proper return to play protocols after players obtain concussions. / Thesis (MA (Clinical Psychology))--North-West University, Potchefstroom Campus, 2013

Rugby is a popular sport in South Africa, and has been played by young boys from as early as seven years old (South African Rugby Union [SARU], 2011). Despite various physical health benefits, it carries a high risk for injury, especially head injury, and consequently has a high incidence of concussion (Alexander, 2009; Laubscher, 2006; Shuttleworth-Edwards, Smith & Radloff, 2008). It is common for 12 to 13 per cent of adolescent rugby players to report mild traumatic brain injury or concussion per season (Laubscher, 2006; Shuttleworth-Edwards et al., 2008). The true incidence is however considered to be higher, even as high as 70.4% (Shuttleworth-Edwards et al., 2008). Concussion, otherwise known as mild traumatic brain injury (mTBI) is described as a traumatically induced alteration in mental status, or traumatically induced cerebral dysfunction (Kraus, McArthur, Silvermand & Jayaraman, 1996) which may, or may not involve loss of consciousness (Quality Standards Subcommittee, American Academy of Neurology [AAN], 1997). The nature of concussion has traditionally been considered to be transient, and symptoms are usually resolved within a few days or weeks (Kirkwood et al., 2008; Taylor et al., 2010). However, when concussions are not fully resolved prior to players returning to the game, they may be vulnerable to second impact syndrome. This syndrome causes herniation and brain oedema, which may result in death (Patel, 2005), as has been reported in South African press (Alexander, 2009; South African Press Association [SAPA], 2012). Even without second impact syndrome, repeated concussions may render the brain neurocognitively vulnerable, leading to an array of short- and long-term cognitive symptoms (Alexander, 2009; Shuttleworth-Edwards et al., 2008). Short-term problems include difficulties with attention, focus and concentration; following multi-step instruction, engaging in mental problem-solving; verbal expression, receiving and processing verbal and visual information; maintaining effective levels of mental and physical energy; controlling mood; suppressing impulsive behaviours; initiating and maintaining productive interpersonal relationships with peers; engaging in meaningful conversation and participating in group activities (Jantz & Coulter, 2007). Short-term cognitive impairments due to repeated concussion have also been found, and include amongst the former symptoms, also problems with delayed memory, learning, social functioning, and abstract thinking (Anderson, Brown, Newitt & Hoile, 2011; Laubscher, 2006). Long-term sequelae follow when children did not return to their baseline level of functioning after three months (Kirkwood et al., 2008; Taylor et al., 2010). Long-term sequelae include problems with memory, visuo-motor processing, executive functioning, learning and abstract thinking (Anderson, 2002; Anderson et al., 2010; Horton et al., 2010; Lezak et.al., 2004; Shuttleworth-Edwards & Radloff, 2008). As mTBI is traditionally thought to be of transient nature, researchers tend to investigate moderate to severe TBI, rather than mTBI (Alexander, 2009; Anderson et al., 2010; Patel, 2005). This could easily lead to important facts about mTBI being missed or not acknowledged. Nevertheless, recent investigations are uncovering facts about mTBI that could transform the way in which we understand mTBI, providing increasing evidence that mTBI is more serious than widely believed (Blakemore, 2012; Maxwell, 2011; Toleda et al., 2012). However, there remains a lack of research investigating mTBI from a single cause. Considering the above information, the current study provides unique information about mTBI. It specifically investigated the long-term effects of mTBI on adolescents from a homogenous cause, which makes results more comparable. The importance of this study is highlighted in the face of evidence for the long-term effects of multiple concussions, that were sustained during school rugby, on academic achievement (Alexander, 2009; Laubscher, 2006).In the light of grey areas in existing research, the aim of this current study was to investigate whether there is a significant difference in academic achievement within and between two groups of adolescents that had either played rugby and sustained multiple concussions, or had not played rugby nor sustained any concussions, when measured at four points in time over six years. A retrospective data-analysis was performed on matched, controlled, prospective longitudinal data, which was obtained from a study that evaluated the impact of repeated mTBI on the cognitive and academic functioning of early adolescent rugby players over time (Alexander, 2009). This study elaborates on a subset of the previous data, adding the gr. 12 results for academic aggregate scores, to the previously reported academic dataset. Participants were selected from Alexander‟s study (2009), and had either played rugby and obtained two or more concussions (Rugby/Concussed (RC- group); n=17), or did not play rugby nor sustained any concussions (Non-rugby/Non-concussed (NRC-group); n=13). Academic aggregate scores from baseline (gr. 7) through gr. 12 were analysed using quantitative statistical measures. A normal probability plot determined that the data was distributed normally. Descriptive statistics were reported, where after repeated measures ANOVA‟s were conducted to determine the statistical significance of differences in academic scores between and within the groups over time. These results indicated that the NRC-group displayed statistically significant increase in academic achievement over time (p = .000), whereas the RC-group did not display any significant differences, despite displaying a downwards trend in achievement. The difference between the two groups was measured at its highest in gr. 12 (p = .003), indicating that the NRC-group performed statistically significantly better than the RC-group over time. However, a Pearson‟s correlation test revealed that the estimated IQ (Vocabulary subscale of the WISC-III) (Wechsler, 1991) had a positive correlation on academic achievement [r(34) = .54, p < .05)]. To control for the effect that this correlation had on the academic results, an ANCOVA was conducted. This analysis indicated a statistically significant difference in academic achievement between the two groups in gr.12 (p = .004), with a large effect size (d = 1.41), implicating practical significance. Findings consequently confirmed our hypothesis. The significant increase in academic achievement observed within the NRC-group over time, is consistent with what could be expected if the brain is allowed to develop normally without disruption such as mTBI (Blakemore, 2012; Horton et al., 2010). The finding that the RC group did not display statistically significant intra-group differences in academic achievement when measured over time, but that academic achievement followed a downward trend, is difficult to substantiate in the literature. The few research studies on the effect of cumulative concussion on young athletes do not isolate academic achievement as a variable (Iverson et al., 2004; Shuttleworth-Edwards et al., 2008). Further research into intra-group differences in this specific area of enquiry and population group is therefore necessary. Normal cognitive and brain development, maintains that the brain develops in a posterior to anterior direction, and the prefrontal regions which are vulnerable to concussion, develop last (Anderson, 2010; Blakemore, 2012; Lezak, 2004). Whereas the primary motor and sensory areas and areas for receptive and expressive language are fully developed by the age of ten years, the prefrontal brain areas that are responsible for more complex and abstract thought repertoires only start maturing in early adolescence and this development continues up to the age of 24 and even into the early 30s (Toleda et al., 2012). Injury to the developing brain at this critical stage of maturation may adversely affect the development of cognitive skills, preventing the child from acquiring the effective cognitive strategies needed for normal academic functioning and adequate academic achievement after TBI (Horton et al., 2010). However, if there is no insult to the brain, cognitive functions are expected to develop normally as a result of synaptic pruning and increased white-matter volume in the prefrontal cortex (Blakemore, 2012), making it likely that the maturation of these abilities will lead to greater cognitive and academic ability (Blakemore & Choudhury, 2006), such as seen for the NRC-group in this study. Limitations for this study include a small sample size and the testing of only one variable. It is therefore recommended that future studies include more variables, and aim at creating a larger, randomized sample size, possibly providing a more representative pool of participants to study this phenomenon in South African context. It is also advised that future studies consider using neuropsychological measures to test cognitive functioning. As previous studies have indicated specific impairment in executive functioning after TBI, it may be worth researching the effect of concussion on executive functioning more thoroughly (Anderson, 2002; Anderson et al., 2010; Horton et al., 2010). Further it may be valuable to consider using functional MRI studies to broaden existing knowledge about the interaction between pathophysiology and cognitive functioning This study also highly recommends that schools and rugby clubs catering for child and adolescent players reconsider the importance of implementing proper return to play protocols after players obtain concussions. / Thesis (MA (Clinical Psychology))--North-West University, Potchefstroom Campus, 2013