Contact and collision sports at all levels are characterized by what some call a “culture of resistance” by athletes to honest self-reporting of concussion symptoms.
From an early age, and throughout an athlete’s career, they have likely been under pressure – sometimes subtle, often explicit – from parents, teammates, and coaches to play hurt.
Some coaches believe that playing with concussion symptoms – at the risk to an athlete’s health – is not only acceptable, but expected; and may criticize, penalize, or ostracize an athlete who doesn’t follow these team and cultural norms.
Up to now concussion education has focused almost exclusively on teaching coaches, athletes, and parents about how to recognize the signs and symptoms of concussion and providing information about the health risks of concussion and repetitive head trauma, in the hopes that an athlete, knowing the symptoms of concussion, and knowing the risks from continuing to play, won’t be willing to risk further injury and will report their symptoms to you or an athletic trainer right away.
Unfortunately, such education hasn’t worked to change the concussion reporting behavior of athletes, with between 40 and 60 percent of all concussions – and a much higher percentage of so-called “bell-ringer” events – still going unreported.
Even though most athletes probably now recognize that continuing to play while concussed puts their health at risk, many athletes continue to hide concussion symptoms in order to keep playing.
Research over the last decade reveals that the top ten reasons athletes consistently give for not immediately reporting concussion symptoms are that:
- They did not think they suffered a concussion;
- They did not believe, if it was a concussion, that it was serious enough to report;
- They were not aware of the potential negative health consequences from continuing to play with concussion;
- They believed that they could safely delay disclosure until their removal was less likely to affect game or practice play, or until the symptoms got so bad they could no longer be ignored;
- They did not want to be removed from the game or practice;
- They did not want to disappoint coaches, teammates, parents, and fans by coming out of the game;
- They felt pressure from coaches, teammates, parents, and fans to play injured;
- They believed that coaches, teammates, parents, and fans expected them to play injured;
- They feared suffering negative consequences if they reported concussion symptoms, such as loss of playing time or position as a starter, or having their toughness questioned;
- They thought, if they had a positive attitude toward concussion symptom reporting, was such attitude wasn’t shared by the coach, medical staff, and teammates, so that they hid their symptoms for fear of social disapproval.
What is striking about this list is that fully half of the ten have nothing to do with knowledge of concussion signs and symptoms or the health risks of concussions, but have everything to do with an athlete’s attitudes and beliefs about concussion reporting, what they think might happen to them if they report, and what they think are – and, in many cases, actually turn out to be – the negative attitudes of coaches, teammates, parents, and fans have towards concussion reporting.
Research also shows that:
- Athletes who perceive that are receiving less support from coaches for appropriate concussion symptom reporting are more likely to continue playing with symptoms of concussion;
- One in four college athletes experienced pressure from a teammate, coach, parent or fan to continue to play after a head impact during the previous season, with the greater the number of groups of stakeholders from whom an athlete experienced such pressure the less likely they were to report symptoms of a future suspected concussion;
- That few coaches explicitly support playing through injury does not mean that athletes do not experience an implicit message that playing through injury is behavior they value because coaches can influence reporting behavior indirectly by shaping team attitudes about concussion safety, such as through their communications with team members about the importance of concussion safety, and through by their control over playing time, what athletes they pick as starters, and, at the Division I college level, over scholarships; and
- A substantial majority (77%) of college athletes in one recent study perceived their own reporting attitudes to be safer than those of their teammates.
Attitude Adjustment Time
Based on this research, SmartTeams™ is trying something different – or, in the parlance of American football, trying a new game plan – to increase the rate at which athletes report concussion symptoms, one which recognizes that chronic under-reporting is not so much a result of an athlete’s lack of knowledge about concussion symptoms and the health risks of continuing to play with symptoms, as (1) a belief that they are expected to play through injury (even a head injury); (2) a belief that the coach, teammates, parents, and fans would be disappointed if they didn’t shake off the injury and stay in the game, and, (3) even if they thought reporting was the safer course, a belief that they would be violating the team’s code of silence and wouldn’t be viewed as a good teammate if they reported.
Like the Centers for Disease Control, and a growing consensus of concussion experts, SmartTeams™ believes that the best way to increase the rate at which athletes report concussion symptoms, either their own or their teammates, is for coaches, parents, medical staff to work as a team to change reporting behavior, to reshape the culture around concussions by changing individual and team reporting attitudes and norms and by creating a climate in which athletes feel comfortable reporting their symptoms.
The #TeamUp4ConcussionSafety™ program, developed by SmartTeams™ with a Mind Matters grant from the National Collegiate Athletic Association and Department of Defense, and through the additional, generous support of our sponsors and underwriters, aims to increase reporting by athletes of concussion symptoms by engaging you, your athletes, your team’s medical staff, and parents in a season-long program which emphasizes that immediate reporting of concussion symptoms not only reduces the risk of further injury – or, in rare cases, even death – but is actually helps your team’s chances of performing better and winning, not just that game, but, by giving athletes the best chance to return as quickly as possible from concussion, in future games, and by instilling in athletes a belief that honest reporting is a valued team behavior.
The SmartTeams™ #TeamUp4ConcussionSafety™ program consists of five steps:
1. Testing Knowledge and Attitudes
A growing body of scientific research leads SmartTeams™ to believe that athletes will be more likely to immediately and honestly report experiencing concussion symptoms, both their own and their teammates, if coaches, athletes, and parents know more, not just about concussions, but their own attitudes towards and beliefs about symptom reporting. (How, after all, can one’s attitudes be changed if one doesn’t know what they are in the first place?)
To find out what what you know about concussions, and, more importantly, whether you view concussion symptom reporting in a positive or negative light, we ask that you take a series of quizzes (the results of which will NOT be shared with anyone, but which you, of course, can share if you want to via social media):
- Do You Know The Concussion Basics?
- Do You Know The Signs and Symptoms Of Concussion?
- Coaches: Does Concussion Safety Or Winning Come First?
2. Completing a Concussion Safety Course
While knowledge and awareness of concussion has increased substantially over the sixteen years that MomsTEAM/SmartTeams™ has been engaged in concussion education, research shows that there are still important gaps which need to be filled.
To fill in those gaps and continue the concussion education process, and in the belief that Smart Teams Play Safe,™ you are asked in Step Two of the #TeamUp4ConcussionSafety™ program to:
- take an online concussion education course;
- watchThe Smartest Team documentary (streaming free on this website); and
- learn more about concussion safety best practices and the latest in head injury research by accessing our extensive library of concussion articles and videos.
3. Leading a Concussion Safety Meeting
Because studies show that one-off concussion education isn’t enough to change concussion symptom reporting behavior, Step Three in the SmartTeams™ #TeamUp4 ConcussionSafety™ game plan calls for you, along with your athletic trainer and team doctor, to hold a mandatory concussion safety meeting before every sports season at which athletes (and, at the high school level and below, parents) can learn in detail about your commitment to creating a climate in which athletes feel comfortable about reporting concussion symptoms, both their own and their teammates, and how immediate concussion symptom reporting not only minimizes the risks concussions pose to an athlete’s short- and long-term health, but may actually increase the chances for individual and team success, both by ensuring that the concussed athlete does not compromise the team’s overall performance, not only in that game, but by minimizing the time the concussed athlete miss away from the team before being cleared to return to contact and the chances of a prolonged recovery, in future games as well.
4. Taking a Concussion Safety Pledge
Anecdotal evidence from NCAA Division I football programs suggests that the signing by athletes of pledges acknowledging their responsibility to report concussion symptoms may increase the rate of reporting by athletes, both of their own symptoms and those of teammates. Because SmartTeams™ views improving concussion safety as a team effort, we believe that all those with a stake in concussion safety should sign pledges, including coaches.
Step Four of our new concussion safety game plan thus asks athletes, coaches, and parents to sign a concussion safety pledge at or shortly after the pre-season concussion safety meeting so as to demonstrate in a tangible way your shared commitment to creating a culture in which immediate reporting of concussion symptoms by athletes is considered a valued team behavior and an important responsibility of every team member. We ask that you provide a copy of your signed pledge to each member of the team, and also, if you are coaching at the high school level and below, to their parents.
5. Staying Involved/Sharing Success Stories
We know that change is not going to happen over night. Because prevailing attitudes towards concussion symptom reporting and reporting behavior are deeply entrenched in our sports culture, SmartTeams™ strongly encourages all stakeholders to continue working together over the course of the sports season, and beyond, towards creating and maintaining an environment in which athletes feel comfortable in immediately reporting concussion symptoms (both their own and their teammates) and in which immediate symptom reporting is considered a valued team behavior.
You can do that by sharing and reinforcing positive messages about the importance of immediate concussion symptom reporting with your team before every game, during team meetings and via social media (we encourage sharing success stories and positive messages @SmartTeams on Twitter, the SmartTeams Facebook page, via YouTube, and/or your favorite social media smartphone app, and by maintaining open lines of communication and engaging in an ongoing dialog with athletes and parents about concussion safety throughout the season.
Four Key Takeaway Messages
The goals of the SmartTeams™ #Teaming Up4Concussion Safety™ program are to instill the following four key messages:
- In honestly and immediately self-reporting concussion symptoms, and encouraging teammates to do the same, athletes are not letting the coach, teammates, parents, and fans down, but are helping the team’s chances of success;
- Honestly and immediately self-reporting concussion symptoms, and encouraging teammates to do the same, are hallmarks of a good team player;
- Delaying the reporting of concussion symptoms – or hiding them completely – puts an athlete’s health and even those of their teammates at risk by exposing their already injured brain to further damage, potentially even death; by prolonging the time it takes for them to recover by almost a week; and by doubling their chances of needing 8 or more days to be cleared to return to contact practice; and
- Not honestly and immediately reporting concussion symptoms can hurt an individual’s and the team’s performance, not just in the game in which the athlete sustains a concussion, but in future games in which the athlete is unable to play as a result of a prolonged recovery.
With consistent messaging and constant reinforcement of the value of immediate concussion reporting in achieving your team’s performance goals, and by making athletes feel comfortable in reporting, we believe that, not only will attitudes and beliefs about concussion reporting begin to change, but the concussion reporting behavior of your athletes will start to change as well, and that, over time, the culture of resistance to concussion symptom reporting will be replaced by a sports culture of concussion safety.
Because this is a pilot program, we invite your feedback, comments, suggestions, and constructive criticism (emphasis on the word “constructive”) so we can make the program the best it can be.