Changing Attitudes About Concussion Reporting: More Than Legislation Needed
Now that all 50 U.S. states and the District of Columbia have youth concussion laws in place, we have jumped the biggest hurdle, right? Then why is that there is still a BIG problem in concussion reporting? Why is it that athletes still continue to play in a game when they are concussed? In reality, changing state laws may be a phenomenal feat; however changing the culture of sport and attitudes about concussion is even harder.
Concussion education programs are step one in changing the culture and attitudes. A research 2014 study published by Johna Register-Mihalik and co-authors revealed that only 40% of concussion events and 13% of “bell-ringer recalled events” were disclosed by high school athletes. (1) That means that more than half of these injuries were not reported. Importantly, in this study, reporting by athletes was associated with “increased knowledge” about concussion.
But a 2015 study by Emily Kroshus and co-authors found that it is not just knowledge about concussion that makes the difference in an athlete reporting concussion. (2) Rather, measuring an athlete’s “intention to report” symptoms is more strongly associated with reporting than just knowledge alone. In other words, it is the athlete’s attitude before a concussion which better predicts if the athlete will report the concussion. The implications of this study are that we should not just focus on increasing knowledge, but also strongly focus on doing what we can to change athletes’ attitudes about reporting.
Yet, focusing only on the athlete is not enough. Pressure from coaches, teammates, fans and parents can also strongly influence the athlete to continue playing rather than reporting the concussion. A second study by Kroshus and colleagues in 2015 (3) revealed that more than 25% of the 328 college athletes they studied admitted that they had experienced pressure from a coach, teammate, parent, or even fan, and that such pressure, especially where it came from more than one group, increased the likelihood that the athlete would continue to play after a head impact.
Even if we target coaches and educate them, athletes continue to not report. In a 2014 study by Rivara and colleagues, 69% of concussed athletes reported that they played with symptoms. (4) Indeed, 40% of them admitted that their coaches did not know they had sustained a concussion. In fact, just because a coach had been educated about concussion did not mean that he or she was more aware of the occurrence of concussion in their athletes.
Taken together, these four studies remind us that changing the culture of sport and changing the attitudes about concussion takes more than just legislation. We need to consider myriad factors that may contribute to an athlete’s not reporting concussion, some of which may still need to be identified. Concussion education is the first step, but it must occur in the context of a multifactorial, complex psychosocial system that includes numerous “players,” not just the athletes.
1. Register-Mihalik JK, Guskiewicz KM, McLeod TC, Linnan LA, Mueller FO, Marshall SW. Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study. J Athl Train. 2013. Sep-Oct;48(5):645-53. doi: 10.4085/1062-6050-48.3.20. Epub 2013 Jul 12.
2. Kroshus E, Baugh CM, Daneshvar DH, Nowinski CJ, Cantu RC. Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education. Clin J Sport Med. 2015 May;25(3):243-7. doi: 10.1097/JSM.0000000000000137.
3. Kroshus E, Garnett B, Hawrilenko M, Baugh CM, Calzo JP. Concussion under-reporting and pressure from coaches, teammates, fans, and parents. Soc Sci Med. 2015 Jun;134:66-75. doi: 10.1016/j.socscimed.2015.04.011. Epub 2015 Apr 20.
4. Rivara FP, Schiff MA, Chrisman SP, Chung SK, Ellenbogen RG, Herring SA. The effect of coach education on reporting of concussions among high school athletes after passage of a concussion law. Am J Sports Med. 2014 May;42(5):1197-203. doi: 10.1177/0363546514521774. Epub 2014 Feb 25.