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Study Finds Gap Persists in Awareness of Concussion Symptoms, Return-to-Play Practices Following Youth Sports Head Hits

More education needed


Coaches and parents need more training on concussions to avoid making bad calls about when to let a young athlete back in the game, according to a research paper presented at the American Academy of Pediatrics (AAP) National Conference & Exhibition in Washington, DC, in October 2015.[1]

In a survey, more than 40 percent of coaches and 50 percent of parents said they would feel comfortable sending a young athlete back into the game before a doctor's OK, which is not only contrary to medical guidelines on caring for athletes after a head hit (which require that an athlete with suspected concussion not return to play without medical clearance), but the laws of all 50 states.

The results were based on data collected from responses by 506 parents, coaches who are also parents of children aged 18 or younger, and coaches who do not have children 18 or younger, taking an online survey.  

These statistics mean that 20 percent of the time, child athletes lack proper attention after head hits, said lead researcher Edward J. Hass, PhD., director of research and outcomes at the Nemours Center for Children's Health Media. Further, he said, symptoms requiring emergency room treatment would not receive such urgent attention 25 percent to 50 percent of the time.

According to the paper, it's not that parents don't recognize their child has a concussion symptom such as headache, dizziness or vision problems; it's that they don't realize these symptoms mean a possible concussion. Parents in the study were identified as taking one of two approaches to seeking medical attention after a head hit, based on certain symptoms.

"One group's typical response was to `take no chances' and seek immediate medical attention, while the second group was more likely to engage in `watchful waiting' and delay seeking medical attention," Dr. Hass said. "Our research leads us to believe the latter group was not adequately informed about the implications of key symptoms pointing to a possible concussion."

Dr. Hass said the magnitude of these findings is underscored by the fact that tens of millions of children age 18 and younger play some organized sport each year.

"The study shows there are gaps that must be filled to ensure that all youth athletes have an advocate for the safety of their developing brains on the field of play," he said. "These results speak to me as a researcher, parent of a youth athlete, and youth coach."

The researchers also found that news coverage of athlete concussions has made parents of active student athletes more vigilant on their player's behalf.  However, one in four parents whose children do not currently play sports said that such concerns would make them keep their child out of sports.

"While that is certainly acting on the side of caution, it also keeps a child from experiencing the benefits of sports," Dr. Hass said. "We feel that with continued awareness-building on safe return-to-play protocols, sports participation can be enjoyed by all children in as safe a manner as possible."

Prior studies reveal knowledge gaps 

A number of research papers and peer-reviewed studies published or presented in recent years have also revealed persistent gaps in parent and coach knowledge of concussions. 

In a research paper titled "Parental Knowledge of Concussion," presented at the AAP's 2014 national conference in San Diego, 511 a survey of parents of children ages 5-18 years who sought care at a pediatric emergency department within two weeks of their child suffering a head injury revealed that only about half were able to correctly identify a concussion as a brain injury that could lead to symptoms such as headache or difficulty concentrating.  No parental demographics (age, sex, education or prior history of sports participation) significantly predicted parents' knowledge about concussions.

The survey also indicated that almost all parents (92 percent) were aware that they should stop their child from playing and see a physician if they suspected a concussion. Yet only 26 percent were aware of guidelines on when their child could return to sports and school work.

"Our study showed that the vast majority of parents knew what to do if they suspected a concussion in their child and in most cases understood the clinical importance of this injury as a brain injury," said lead author Kirstin D. Weerdenburg, MD, FAAP, pediatric emergency medicine fellow at Hospital for Sick Children, Toronto, Ontario, Canada.

"The study also highlighted the importance of a physician visit shortly after the injury to confirm the diagnosis for parents and to inform parents of return to play/learn guidelines to ensure a proper recovery and prevent a second concussion while the brain is still healing," Dr. Weerdenburg said.

In a second research paper presented at the AAP 2014 conference,  "Parental Misconceptions Regarding Sports-Related Concussion," parents were divided into two groups - 214 parents whose children were evaluated at a sports medicine clinic for musculoskeletal or mild traumatic brain injuries (group 1) and 250 parents of students at a local private school (group 2).

The survey included questions that gauged their knowledge of and attitudes about concussions as well as demographic information.

The majority of parents in both groups did well overall but had several misconceptions:

"Our study highlights the fact that many parents are still in need of education regarding concussion identification and post-injury evaluation. Even those highly educated parents were prone to misconceptions," said senior author Tracy Zaslow, MD, FAAP, medical director of the sports medicine and concussion program at Children's Orthopaedic Center, Children's Hospital Los Angeles. "False perceptions such as the ones pinpointed by our study may impact when medical care is sought after concussion and lead to less than optimal home care."

Does income/education level impact concussion knowledge? 

Using the same data, the researchers reported in a study subsequently published in the journal Sports Health [2] a significant association between concussion knowledge and a parent's ethnicity, household income, marital status, and education level, prompting the authors to suggest that parents with lower income and education levels be targeted for additional education regarding sports-related concussions. 

Interestingly, the researchers found that, contrary to their expectations, parents who had played sports in the past or had a personal history of concussion, did not lead to increased concusson knowledge, perhaps because, when they played sports, concussions were referred to as "dings" or "getting your bell rung" and, unlike today, were perceived and treated as mild injuries. 

Earlier studies: mixed results

Earlier studies of parents' knowledge of concussions have reported mixed results. [3-7]

A 2014 study [3] reporting on the result of a knowledge assessment of sports-related concussion among parents of children aged 5 to 15 years enrolled in a recreational tackle football program, for instance, found that only 13% of parents identified all statements regarding concussion accurately, and no respondent correctly identified all symptoms related to concussion.  

As in the 2014 AAP surveys, parents did not recognize red herring signs and symptoms of concussion, incorrectly identifying numbness in the arms or legs, hearing voices, and weakness in the arms as symptoms, 92%, 80%, and 95%, respectively.

Parents also missed increased irritability or emotional outburst (44%) and sleeping difficulty (28%) as symptoms of concussion.  Two-thirds of parents failed to recognize that a concussion is considered a form of mild TBI, and 42% had difficulty identifying that a concussion can be caused by something other than a direct blow to the head.

A 2010 study of parents of athletes aged 13 to 14 years [4] also found many parents unable to recognize the red herring signs and symptoms, with nearly half incorrectly identifying hearing voices and lower pulse rate as true signs and symptoms of concussion.

A second 2010 study [5] surveying parents of children of children 5 to 7 years old who were seen and discharged from a pediatric emergency department with TBI found that most (69.5%) initially stated that their child was asymptomatic, but when asked about each symptom specifically, 46.6% of these parents identified one or more symptoms.

A 2010 survey [6] by C.S. Mott Children's Hospital and the University of Michigan of parents of children age 12 to 17 years playing school sports also reported a surprising lack of knowledge by parents of concussion risks; more than half of those surveyed did not know if their child's school had a policy about returning to sports after a concussion; only a third (36%) were aware that their child's school had such a policy.

On the other hand,  in a 2014 study [7], researchers at the University of Washington found that, a year after enactment in Washington State of its groundbreaking Zackery Lystedt Law, 96% of respondents (parents, coaches, and other persons involved in athletics) understood that concussion was a form of traumatic brain injury, and that 90% would delay an athlete's return to play when neurological symptoms were present.  Fewer individuals understood return-to-play guidelines, including the requirement of written clearance (73%), or that a parent could not clear the athlete for RTP (88%).    

For the most comprehensive information about sports-related concussions, visit MomsTEAM's pioneering concussion safety center

Source: American Academy of Pediatrics 

1.   Research Paper. "Post-Head Hit Return to Play Awareness in Parents and Coaches." Hass HJ, Cronan KM, Izenberg N, Bratsis ME, Moffitt D, Presented at American Academy of Pediatrics National Conference and Exhibition, Washington, D.C. October 24-27, 2015 

2.  Lin AC, et. al. Assessment of Parental Knowledge and Attitudes Toward Pediatric Sports-Related Concussions. Sports Health: A Multidisp. Approach. 2015;7(2):124-129. 

3.   Mannings S, Kalynych C, Joseph M, Smotherman C, Kraemer DF. Knowledge assessment of sports-related concussion among parents of children aged 5 years to 15 years enrolled in a recreational tackle football program.  J Trauma Acute Care Surg 2014;77(3) Supp. 1, S18-S22.

4.  Coughlin C, Myles B, Howitt S. The ability of parents to accurately report concussion occurence in their bantam-aged minor league hockey league children.  J Can Chiropr Assoc. 2009;53:233-250.

5. Stevens P, Penprase B, Kepros J, Duneback J. Parental recognition of postconcussive symptoms in children. J Trauma Nurs. 210;17:178-182.

6. C.S. Mott Children's Hospital National Poll on Children's Health, Vol. 10, Issue 1 (June 14, 2010)

7.  Shenouda C, Hendrickson P, Davenport K, Barber J, Bell KR.  The effects of concussion legislation one year later - what we have learned: a descriptive pilot survey of youth soccer player associates.  PM R 2012;4:427-435