Underreporting of Concussion By High School Athletes Continues Despite Increased Education

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  • Lindsey Straus

    Author: Lindsey Straus is an award-winning youth sports journalist, practicing attorney, and has been Senior Editor of SmartTeams since its launch as MomsTEAM in August 2000. She can be reached at lbartonstraus@MomsTEAM.com.

  • Lindsey Straus

Underreporting of Concussion By High School Athletes Continues Despite Increased Education

5. Future research to explore how external factors influence reporting among high school athletes, such as

  • coach, parent, and teammate pressures
  • the influences on reporting among high school athletes (Note: the 2013 study by the same authors involving the same study sample [10] found that coaches and teammates are the strongest influences on an athlete’s intention to report concussion; although the study did not survey parents, the student-athletes surveyed “indicated that what their parents thought about reporting was an important social factor when deciding to report concussive symptoms”);
  • knowledge and attitudes in other high-risk sports, such as ice hockey, basketball, and wrestling.  The combination of the fact that 42.9% of the participants in the current study were football athletes, that the return rate of the survey was low (10%), and was derived from a so-called “convenience” sample, limited generalizing the study’s findings to the general population); and
  • when the athletes reported the event (immediately after injury or at a later time)(a subject explored in a 2014 study.[15]

Bottom up, trickle down, long way to go

“Although our study encompassed only 1 convenience sample of athletes, the major findings illustrated the importance of increased athlete knowledge, more favorable athlete attitude, and context of reporting concussion among high school athletes,” wrote Register-Mihalik.

“We highlighted the importance of addressing multiple factors to increase reporting of possible concussive injuries. In addition, we highlighted the need for multifactorial interventions in the high school setting to address these risky behaviors.”

“We are certainly seeing changes at many levels of sport in the right direction, but still have a long way to go.” Register-Mihalik told MomsTEAM.  “I do think there are things we can continue to do in the here and now that will result in immediate effects, especially when local individuals are advocates for concussion education and sport safety. However, it is true that historically culture change does take years.”

“One approach … is to start at the youngest ages of sport so that individuals carry good attitudes about sports safety and concussion throughout their lives. It is also important that, in addition to this bottom up approach, that we have things trickle down from the top so that information is flowing in both directions, creating a more comprehensive safety network across sport.”

“Now that we have many people attentive to concussion, we need to make sure the right message is getting to the right people, in communities of all types. This involves community networking including parents, coaches, administrators and medical professionals at the local, state, regional and national levels working together,” Register-Mihalik concluded.


Athlete Knowledge of Concussion
Concussion Sign or Symptom? % Answering Correctly
 Amnesia 56.3
 Confusion 92.2
 Dizziness 88,6
 Headache 88.6
 Insomnia 83.8
 Loss of consciousness 76.0
 Nausea 64.1
 Numbness or tingling of arms 67.1
 General knowledge  
 A concussion only occurs if you lose consciousness (false) 84.7
If you are experiencing any signs or symptoms of concussion after a blow to head or sudden movement of the body, you should not return to play (true)  
A concussion is an injury to the ______ (brain) 88.5
Multiple concussions: Of the following, what are the possible complications of having multiple concussions? (check all that apply)   
No complications exist (false) 100.0
Increased risk of further injury (true) 63.5
Brain damage (true) 91.0
Join problems (false) 89.8
I don’t know (false/not checked) 94.0
Memory problems (true) 85.0
Returning to play too soon: Of the following, what are complications of returning to sporting activity while still experiencing possible concussion symptoms? Check all that apply.  
No complications (false)  99.4
Increased risk of further injury (true)  86.8
Paralysis (false)  55.1
Brain damage (true)  86.8
Joint problems (false)  88.0
 I don’t know (false/not checked)  92.0

Athlete Attitude

Rate on a scale of 1-7
How serious you think it is when you experience a headache or dizziness after a blow to your head or body 4.5
How important you think it is to not participate in physical activity (game or practice) when experiencing signs and symptoms of concussion. 5.5
How important you think it is to be informed about how concussions happen 5.9
How important you think it is to be informed about how concussions can be prevented 5.9
How important it is to be informed about what to do if you have a concussion 6.3
How important you think it is to report possible signs and symptoms to a medical professional (eg, doctor, athletic trainer) or coach 6.1
Your level of agreement with the following statement: Athletes are undereducated about concussion 5.1
Check the box (1-7) about how you feel about the following statement for each pair of words listed: For me to report possible signs and symptoms to a coach or a medical professional when I experience them is  
Cowardly/brave 5.1
Embarrasing/pleasant 4.5
Harmful/beneficial 6.2
Extremely difficult/extremely easy 5.0
Bad/good 6.0
Unimportant/Important 6.1
Worthless/valuable 6.1
Athlete attitude total 78.3

1. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW.  Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study.  J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)

2. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004;14(1):13-17.

3. Echlin PS, Tator CH, Cusimano MD, et al. A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.  Neurosurgery Focus. 2010;29(5):E4.

4. Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concuission among university football and soccer players.  Clin J Sport Med 2002;12(6):331-338.

5. Kaut KP, DePompei R, Kerr J, Congeni J. Reports of head injury and symptom knowledge among college athletes: Implications for assessment and educational intervention.  Clin J Sport Med 2003;13:213-221.

6. Valovich-McLeod TC, Schwartz C, Bay RC. Sport-related concussion misunderstanding among youth coaches. Clin J Sport Med. 2007;17(2):140-142.

7. Rosenbaum AM, Arnett PA. The development of a survey to examine knowledge about and atittudes toward concussion in high school students. J Clin Exper. Neuropsych. 2010;32:44-55.

8. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med 2012;40(4):747-755.

9. Chrisman SP, Rivara FP, Schiff MA, Zhou C, Comstock R.D. Risk factors for concussive symptoms 1 week or longer in high school athletes. Brain Injury 2013;27(1):1-9.

10. Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM.  Using theory to understand high school aged athletes’ intentions to report sport-related concussion: Implications for concussion education initiatives.  Brain Injury 2013;27(7-8):878-886.

11. Waxenberg R, Satloff E. Athletic trainers fill a necessary niche in secondary schools.  National Athletic Trainers’ Association: 2009.  Available at: http://www.nata.org/NR031209.

12. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)

13. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.

14. Delaney JS, Lamfookon C, Bloom GA, Al-Kashmiri A, Correa JA.  Why University Athletes Choose Not To Reveal Their Concussion Symptoms During A Practice Or Game.  Clin J Sports Med. 2014;0:1-13; doi: 10.1097/JSM.0000000000000112 (published online ahead of print with post-publication corrections, June 19, 2014).

15. 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. 2014; Post Author Corrections: July 21, 2014
doi: 10.1097/JSM.0000000000000137.

16.  Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, Bauer RM.  “Playing Through It”: Delayed Reporting and Removal From Athletic Activity After Concussion Predicts Prolonged Recovery. J Athl Tr. 2016;51(5):000-00 doi: 10.4085/1062-6050-51.5.02 (published online ahead of print)

17. Pryor RR, Casa DJ, et al. Athletic Training Services in Public Secondary Schools: A Benchmark Study. J Athl Tr. 2015;50(2):156-162.

Most recently revised and updated August 9, 2016


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