Underreporting of Concussion By High School Athletes Continues Despite Increased Education
Reasons for not reporting
Consistent with a 2004 study , the study found that athletes did not report possible concussions because they:
- did not think the injury was serious enough to report (70.2%);
- did not want to be removed from the game (36.5%);
- did not want to let down teammates (27.0%)
- did not want to let down coaches (23.0%);
- did not know the event was a concussion (14.9%); or
- did not want to be removed from practice (13.5%).
By comparison, among college hockey players in a 2013 study  who suspected that they had a concussion during the previous season but did not report their injury:
- fully half (50.6%) stated that they did not report it because they did not know it was a concussion (a much higher rate than the 14.9% of the high school players who cited this a reason for their failure to report);
- 7 out of 10 (69.7%) because they did not think it was serious enough (almost identical to the 70.2% who cited this as their reason for not reporting);
- close to half (48.3%) because they did not want to be pulled out of the game or practice (signficantly higher than the 13.5% and 36.5% of high school athletes who cited not wanting to be pulled from practices or games, respectively, as a reason for not reporting); and
- a third (32.6%) because they did not want to let down their teammates (very close to the 27.0% of high school athletes who gave this as their reason for not reporting)
- While 50% of athletes who believed they had suffered a concussion within the previous 12 months while playing their respective sport stated that they sought medical attention for a presumed concussion at some point, nearly 8 in 10 did not seek medical attention during a game or practice at least once during that same period.
- Similar to past research, the most common reason they gave for not seeking immediate medical attention (55/92) was that they did not feel the concussion was serious/severe and felt they could keep playing with little danger to themselves.
- Nearly half (44 out of 92) did not report because they felt that they would be removed from the game by the medical staff and did not wish that to happen.
- The same percentage failed to report out of fear that being diagnosed with a concussion would result in missing future games.
- More than a third (35 out of 92) said they did not volunteer symptoms because they had experienced similar symptoms of concussion in the past and had no problems.
- 34 out of 92 said they would normally have sought medical attention but the concussion occurred during an important game or at an important time of the season.
- One third (30 out of 92) did not reveal their symptoms at the time of injury because of fear that being diagnosed would affect their standing with their current team or future teams.
- 20 out of 92 did not immediately report out of fear that diagnosis would result in negative repercussions from the coach or coaching staff.
- 15 out of the 92 said that their injury did not occur when any medical personnel were present and they did not have time or desire to go to a medical clinic or hospital to be examined.
The data revealed a wide range of attitudes about concussion. Athletes indicated only moderate agreement with the statement on the questionnaire that concussion symptoms were serious, and many believed reporting concussions may be somewhat embarrassing. “Downplaying concussion symptoms and feelings of embarrassment about reporting them illustrate some of the attitudes towards concussion that need attention,” wrote Register-Mihalik.
While the low reporting rate was disappointing, especially given the concentrated effort in recent years to educate youth and high school athletes about the dangers of concussions, the good news in the study was that, in general, improved athlete knowledge positively affected their willingness to report, with the proportion of those reporting bell-ringer events, and of concussive events during practice, greater with increased athlete knowledge.
Athlete attitude also had positive overall effects on reporting behaviors, researchers found, with higher scores associated with a decrease in athletes reporting that they participated in a game or practice while symptomatic. Register-Mihalik and her colleagues speculated that athletes with a more favorable attitude toward reporting were those with a better understanding of the importance of reporting possible concussion events.
Multi-pronged approach to underreporting recommended
Recognizing that underreporting of concussion is a “multifaceted” and “overwhelming” problem, with knowledge and attitude both appearing to influence reporting behaviors, the study authors recommend taking a multi-pronged approach to improving reporting rates, including:
1. Increasing education about concussion symptoms.
Especially needed is education about less common symptoms, such as nausea (cited as a symptom by 31.4% of high school athletes ) and amnesia (cited as a symptom in 23.4% of concussions in another recent study ). “These symptoms, as well as the other symptoms, should be emphasized in educational efforts,” Register-Mihalik told MomsTEAM, “due to their connection with potential delayed recovery time [as both have been linked in a recent study  with increased risk of prolonged symptoms], as well as the impact that these symptoms have on overall quality of life. [Because] nausea is often associated with other conditions [such as dehydration or overeating before an event], helping young athletes connect this symptom to a potential concussive injury is also important. Amnesia is a difficult symptom, and many young athletes may not fully understand what amnesia as a term actually means, so using age-appropriate terminology when assessing and discussing concussion, such as ‘trouble remembering things’ or ‘memory problems’ may also be helpful.”
Study co-author McLeod agreed that, while all concussion signs and symptoms should be discussed in educational efforts, “We probably could do a better job of educating about the immediate and most prevalent symptoms, but pay equal attention to those that occur less often, may be indicative of decline in [mental] status [which may indicate a more serious brain injury], and those that may be late manifesting so that concussions are not missed by just focusing on a few signs and symptoms. Identifying symptoms that might be predictive of delayed recovery or poorer prognosis is one area of research that I believe will continue to emerge in the coming years;”
2. Fostering increased understanding among clinicians, parents, coaches, and athletes of:
- the serious nature of concussive injuries. “Despite the perception of concussions being mild, high school athletes with mild concussions may experience neurocognitive deficits and symptoms that persist beyond day of injury,” the study notes.
- the need to report bell-ringing events that might be considered so ‘mild’ that they go unreported;
- the risks associated with continuing to play, including delayed recovery  or even catastrophic consequences, such as second impact syndrome.
3. Increasing education of coaches. Such education is especially needed in recognition of the role the coach often plays in initiating medical care in the event an athlete is injured; the fact that, while coaches do not have the same training as medical professionals and reporting to a coach is admittedly very different from reporting to a medical professional, coaches are often the authority figure to whom individuals turn to report a concussion or other injury; and the fact that fewer than half of all U.S. high schools have access to a certified athletic trainer.  [Note: more recent data from the NATA  suggest that the percentage now stands at over 60%].
4. Creating a safe environment which encourages reporting of concussion events by:
- educating the community, coaches, parents, and athletes about concussion;
- helping athletes to understand they are not alone in experiencing concussion;
- providing forums (such as at pre-season concussion education meetings) for individuals, especially those respected in the athletic community, to speak out about concussion and why these injuries should be reported and managed properly; and
- developing awareness programs designed to “create an environment that rewards positive concussion-care seeking behaviors, such as reporting an injury or removing one’s self from play when experiencing concussive symptoms … [such as] the athletic director at the school having medical providers from the community come into the school to talk about concussion or a coach being understanding and supportive when an athlete reports concussive symptoms and is unable to continue playing, especially in front of other athletes.” 
“Clinicians, parents, and coaches should make concussion education and awareness a priority,” concludes Register-Mihalik and her colleagues, “and address factors to provide a more optimal concussion-reporting environment.” Both are needed, because, as acknowledged in the study, “knowledge alone does not equal behavior.” “Individuals may understand and believe that concussion is a serious injury and even a medical concern; however, if they also believe that their peers or coaches will take issue with their reporting their injury or that they may lose substantial playing time, they may still choose not to report the injury.” “Parents also play a key role in driving coaches to be aware and to create this environment at home,” Register-Mihalik told MomsTEAM.
Indeed, a 2014 study  provides support for Register-Mihalik’s conclusions, finding that concussion knowledge was not significantly associated with in-season reporting behavior, and that a better predictor of in-season reporting behavior was intention to report symptoms of a minor concussion, with increasing odds of reporting as additional symptoms were sustained. The study’s authors acknowledged, however, that it was possible that for some populations (eg, younger athletes aor athletes early in their sporting careers), concussion knowledge as it is presently measured may be an important predictor of reporting behavior.
Valovich McLeod agreed with Register-Mihalik that “There is promise to make these changes happen faster with educational efforts and legislation; however, there are still coaches and parents who have an old-school mentality regarding concussions. Pressure to play needs to be taken off kids in order for them to feel comfortable reporting their signs and symptoms of a possible concussion.”