Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study

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1 Journl of Athletic Trining 2013;48(5): doi: / Ó y the Ntionl Athletic Triners Assocition, Inc originl reserch Knowledge, Attitude, nd Concussion-Reporting Behviors Among High School Athletes: A Preliminry Study John K. Register-Mihlik, PhD, LAT, ATC* ; Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM ; Tmr C. Vlovich McLeod, PhD, ATC, FNATA ; Lur A. Linnn, ScD ; Frederick O. Mueller, PhD ; Stephen W. Mrshll, PhD *Emergency Services Institute, WkeMed Helth nd Hospitls, Rleigh, NC; Mtthew Gfeller Sport-Relted Trumtic Brin Injury Reserch Center, Deprtment of Exercise nd Sport Science, University of North Crolin t Chpel Hill; Athletic Trining Progrm, A.T. Still University, Mes, AZ; Deprtment of Helth Behvior nd Helth Eduction, Deprtment of Epidemiology, nd Injury Prevention Reserch Center, University of North Crolin t Chpel Hill Context: Mny thletes continue to prticipte in prctices nd gmes while experiencing concussion-relted symptoms, potentilly predisposing them to susequent nd more complicted rin injuries. Limited evidence exists out fctors tht my influence concussion-reporting ehviors. Ojective: To exmine the influence of knowledge nd ttitude on concussion-reporting ehviors in smple of high school thletes. Design: Cross-sectionl study. Setting: Prticipnts completed vlidted survey instrument vi mil. Ptients or Other Prticipnts: A totl of 167 high school thletes (97 mles, 55 femles, 5 sex not indicted; ge ¼ yers) prticipting in footll, soccer, lcrosse, or cheerleding. Intervention(s): Athlete knowledge nd ttitude scores served s seprte predictor vriles. Min Outcome Mesure(s): We exmined the proportion of thletes who reported continuing to prticipte in gmes nd prctices while symptomtic from possile concussion nd the self-reported proportion of reclled concussion nd ell-ringer events disclosed fter possile concussive injury. Results: Only 40% of concussion events nd 13% of ellringer reclled events in the smple were disclosed fter possile concussive injury. Incresed thlete knowledge of concussion topics (increse of 1 stndrd devition ¼ 2.8 points) ws ssocited with incresed reporting prevlence of concussion nd ell-ringer events occurring in prctice (prevlence rtio [PR] ¼ 2.27, 95% confidence intervl [CI] ¼ 1.60, 3.21) nd the reporting prevlence of ell-ringer-only events overll (PR ¼ 1.87, 95% CI ¼ 1.38, 2.54). Athlete ttitude scores (increse of 1 stndrd devition ¼ 11.5 points) were ssocited with decreses in the proportion of thletes stting they prticipted in gmes (PR ¼ 0.74, 95% CI ¼ 0.66, 0.82) nd prctices (PR ¼ 0.67, 95% CI ¼ 0.59, 0.77) while symptomtic from concussions. Conclusions: Most reclled concussion events in our study were not reported to supervising dult. Clinicins should e wre tht knowledge nd ttitude influence concussion reporting. Clinicins nd dministrtors should mke concussion eduction priority nd encourge n optiml reporting environment to etter mnge nd prevent concussive injuries in young thletes. Key Words: eduction, rin injuries, cre seeking Key Points Athlete knowledge nd ttitude influenced concussion-reporting ehviors in some contexts. A lrge proportion of reclled concussion events ws not reported mong the smple of high school thletes. Incresing knowledge of concussion symptoms, improving the culture of sport, nd incresing the understnding of the seriousness of concussive injuries should e trgets for future interventions. Progrms should e implemented to increse wreness, promote reporting, nd crete sfe reporting environment. Cererl concussion is physiologic injury tht is difficult to identify nd mnge. 1 Unidentified concussive injuries, specificlly mong young popultion, crry risk of dditionl nd more complicted injuries to the rin 2 4 tht my result in delyed recovery or even ctstrophic consequences, such s second-impct syndrome. 5,6 Despite the perception of concussions eing mild, high school thletes with mild concussions my experience neurocognitive deficits nd symptoms tht persist eyond the dy of injury. 7 Thus, understnding the fctors influencing concussion reporting in thletes is importnt, prticulrly in high-school ged thletes in whom the rin is continuing to develop. 8 Reserchers hve suggested tht more thn 50% of concussions re unreported McCre et l 9 instructed thletes to complete survey t the end of 1 seson of high Journl of Athletic Trining 645

2 school footll, wheres Echlin et l 10 exmined concussions oserved y trined monitor nd concussions reported y dolescent-ged ice-hockey plyers or identified y n thletic triner or thletic therpist. Delney et l 11 instructed thletes to complete survey fter 1 full yer of prticiption in university-level footll or soccer. Mny thletes often do not recognize common symptoms ssocited with concussion nd often report not knowing tht their injuries could hve een concussions. 5,9,12,13 McCre et l 9 noted resons commonly cited y thletes who do not report concussions included they did not think the injuries were serious enough to report, did not wnt to leve gme, did not know the injuries were concussions, nd did not wnt to let temmtes down. However, the resons for not reporting concussions my differ depending on the level of ply (professionl versus college versus high school) s motivtions, nd vlues re different cross these ge groups. Among high-school ged individuls, peer cceptnce 14 nd coch support/mindset 15 re 2 importnt motivtors in sport. For collegite thletes, considertions include scholrships, peer cceptnce, coch support, 16 nd longer period in which they my plce gret mount of their identities in their sports. However, few, if ny, reserchers hve ddressed these motivtions concerning concussion reporting mong these popultions. Across ll sports, the desire to continue to prticipte is strong motivtor, ut the given fctors my differ in how they influence this desire. Furthermore, internl or intrinsic fctors, such s knowledge nd ttitude, my influence concussion-reporting motivtions. Knowledge nd ttitude re oth chngele fctors tht my contriute to concussion-reporting nd cre-seeking ehviors. 17 Furthermore, improvements in these fctors hve een linked to improvements in other helth ehviors. 18 Knowledge lone does not equl ehvior. However, etter understnding, specificlly considertion y n individul tht he or she ctully my hve concussion, is importnt in the decision to report potentil concussive injury. Attitude is n importnt fctor in mny ehviors, 19 with more fvorle ttitudes often linked to the preferred ehvior. 20 Attitude consists of 2 sic components: elief tht prticulr ehvior leds to certin outcome nd person s evlution of the outcome of tht ehvior. 19 Thus, individuls who hve more positive perception of the ehviors out reporting concussion nd not just out concussion s n injury my e more likely to report. For exmple, individuls my understnd nd elieve tht concussion is serious injury nd even medicl concern; however, if they lso elieve tht their peers or coches will tke issue with their reporting the injury or tht they my lose sustntil plying time, they my still choose not to report the injury. This highlights negtive (less fvorle) ttitude out reporting the injury, which is the ehvior of interest. These concepts provide the frmework for not only incresing knowledge nd wreness ut lso ddressing ttitudes. Despite the overwhelming prolem of underreporting concussion, few reserchers hve exmined the influence of concussion knowledge on reporting frequency. In ddition, no one concurrently hs exmined overll ttitudes concerning concussion nd reporting of possile concussions mong high school thletes. Therefore, the primry purpose of our study ws to exmine the influence of knowledge nd ttitude on concussion reporting mong smple of high school thletes. We hypothesized tht etter knowledge nd ttitude scores would e ssocited with incresed reporting prevlence. METHODS Reserch Design We conducted cross-sectionl survey study of high school thletes in 6 sports. We collected dt from Novemer 2008 to Ferury The survey instrument cptured dt on thletes knowledge, ttitudes, nd eliefs regrding concussion. It lso sked thletes to recll previous concussion nd concussion-like events nd to indicte whether they reported the events to coch or medicl professionl. Smple nd Prticipnts A convenience smple of 28 high schools in 9 sttes greed to prticipte in the study, with survey dt returned from 25 schools. Fifteen of the 25 respondent schools hd dily ccess to certified thletic triner (AT), nd 10 hd no ccess. A totl of 167 (10%) of 1669 thletes (97 mles, 55 femles, 5 sex not indicted; ge ¼ yers, rnge ¼ yers) returned the survey. Athlete descriptive nd demogrphic dt re included in Tle 1. An thlete ws included if he or she ws listed on the roster s n thlete for vrsity footll, cheerleding, oys soccer, girls soccer, oys lcrosse, or girls lcrosse. All prticipnts nd their prents provided written informed ssent nd consent, respectively, nd the Institutionl Review Bord of the University of North Crolin t Chpel Hill pproved the study. Instrument A single survey served s the instrument for the study. This instrument ws pretested for fce vlidity y 3 content experts. Test-retest greement ws ssessed with 50 high school thletes completing the survey instrument t 2 test times tht were 30 minutes prt nd in different order. The greement cross test times for ll knowledge (yes/no) items used on the questionnires rnged from 0.60 to For Likert scle ttitude questions, the men difference ws less thn 0.4 (mximum score for ech item ¼ 7) on the survey instrument. We clculted the Cronch for knowledge construct (Cronch ¼ 0.72) nd ttitude constructs (Cronch ¼ 0.80) on the survey instrument. Athlete knowledge ws ssessed with series of 35 questions concerning symptom recognition, complictions relted to multiple concussions, nd generl knowledge of concussion. Athlete ttitude ws ssessed with 14 7-point Likert-scle questions ddressing overll ttitude towrd concussion, concussion eduction, nd concussion reporting. Totl knowledge score for ech thlete ws clculted y summing the numer of correct nswers out of the 35 knowledge questions (possile rnge ¼ 0 35). Totl ttitude score ws clculted y summing the responses to 14 Likert-scle (rnge ¼ 1 7) ttitude questions (possile rnge ¼ 14 98). A higher score represented more fvorle ttitude towrd concussion nd concussion reporting. 646 Volume 48 Numer 5 Octoer 2013

3 Tle 1. Athlete Demogrphics (N ¼ 167) Chrcteristic (No. Reporting) Frequency (%) Sex (n ¼ 162) Mle 98 (60.5) Femle 64 (39.5) Rce (n ¼ 164) Africn Americn 17 (10.4) White 138 (84.1) Hispnic 5 (3.0) Asin 4 (2.4) Current sport (n ¼ 154) Footll 66 (42.9) Boys soccer 20 (13.0) Girls soccer 18 (11.7) Boys lcrosse 10 (6.5) Girls lcrosse 9 (5.8) Cheerleding 31 (20.1) Concussion eduction discussion? (n ¼ 167) Yes 130 (77.8) No 37 (22.2) Certified thletic triner ccess? (n ¼ 165) Yes 81 (49.1) No 84 (50.9) History of concussion? (n ¼ 167) Yes 44 (26.3) No 123 (73.7) History of ell ringer/ding? (n ¼ 167) Yes 81 (48.5) No 86 (51.5) Indictes some percentges re rounded. Indictes 2 prticipnts did not indicte school nd their scores were not included in the totl. To ssess reclled concussion events nd reporting during the respondents high school yers, multiple reporting vriles were used (Tle 2). Athletes were sked out concussion events they reclled s experienced nd reported during their high school yers during gmes nd prctices. The items on the survey ddressing concussion events nd reporting were worded s follows: (1) In your high school yers, how mny concussions do you think you hve experienced? nd (2) How mny of the possile concussions you experienced in high school did you report to medicl professionl (doctor, thletic triner, etc) or coch? Athletes lso were sked out ell-ringer events they reclled s experienced nd reported during their high school yers during gmes nd prctices. The items on the survey ddressing ell-ringer/ding events nd reporting of these events were worded s follows: (1) In your high school yers, how mny times hve you hd your ell rung or een dinged? nd (2) How mny of the possile concussions you experienced in high school did you report to medicl professionl (doctor, thletic triner, etc) or coch? The term ell ringer ws employed s mens of ssessing when possile concussions occurred nd to ssess reclled events tht thletes considered ell ringer. No forml definition for the term ell ringer ws given to prticipnts ecuse the study ws sed on personl perceptions. Athletes commonly use the term to descrie rief, trnsient ltertions in neurologic function. Wheres not ll of these events my hve een true concussions, they wrrnt exmintion efore n individul returns to prticiption. In ddition, thletes were sked out ever continuing to prticipte in prctices nd gmes while experiencing concussion signs nd symptoms. Procedures Approvl from ech school ws otined efore initition of the study. After school pprovl, school informtion forms were completed y designted school contct (thletic director, AT, or dministrtor) serving s reserch ssistnt t ech school. The school contcts rrnged questionnire-distriution meetings for the thletes. The primry investigtor or the designted school contct conducted these meetings. The meetings were performed using stndrdized script to ensure similr instructions for ll possile prticipnts. Only questions pertining to logistics of completing the questionnire were nswered during the meeting. During these meetings, the study ws explined, nd ech thlete ws issued study pcket tht included n instruction letter, ssent nd consent documents, the survey instrument, nd postge-pid return envelope. Athletes were instructed to tke the pcket home, complete the survey instrument, nd return it directly to the primry investigtor vi mil. Upon return, survey instruments were logged nd entered into the study dtset. Sttisticl Anlyses Generl descriptive sttistics were used to exmine thlete knowledge scores, ttitude scores, nd concussion-reporting ehviors. Reporting wsdefinedsreclledeventsindicted y the thlete s reported to coch or medicl professionl. Seprte inomil regression models were used to estimte the prevlence rtio (PR) for ech of the 6 reporting outcomes (Tle 1). Binomil regression estimtes the chnge in the prevlence, or PR, sed on chnges in the predictor vriles. Predictors included thlete knowledge totl scores (AKT) nd thlete ttitude totl scores (AAT). A totl of 12 inomil regression models were used (2 Tle 2. Six Reporting Outcome Mesures nd Portion of Smple Included in Anlysis Reporting Outcome Anlysis Unit Portion of Smple Included in Anlysis Reporting of reclled concussion or ell-ringer events in gmes Reclled events Only prticipnts with t lest 1 reclled concussion or ell-ringer event in gme Reporting of reclled concussion or ell-ringer events in prctices Reclled events Only prticipnts with t lest 1 reclled concussion or ell-ringer event during prctice Reporting of reclled concussion-only events Reclled events Only prticipnts with t lest 1 reclled concussion event Reporting of reclled ell-ringer only events Reclled events Only prticipnts with t lest 1 reclled ell-ringer event Prticiption in gmes with concussion signs nd People Entire smple symptoms Prticiption in prctices with concussion signs nd symptoms People Entire smple Journl of Athletic Trining 647

4 Tle 3. Athlete Knowledge Items nd Descriptives Athlete Knowledge Item Frequency Answering Correctly (%) Plese indicte (y checking the ox eside the question) which of the following you would consider to e sign or symptom of concussion. Check ll tht pply. (n ¼ 167) Anorml sense of smell (flse) 151 (90.4) Anorml sense of tste (flse) 153 (91.6) Amnesi (true) 94 (56.3) Joint stiffness (flse) 152 (91.0) Blurred vision (true) 147 (88.0) Blck eye (flse) 149 (89.2) Bleeding from the er (flse) 130 (77.8) Bleeding from the mouth (flse) 152 (91.0) Bleeding from the nose (flse) 145 (86.8) Confusion (true) 154 (92.2) Fever (flse) 157 (94.0) Dizziness (true) 148 (88.6) Hedche (true) 148 (88.6) Insomni (true) 140 (83.8) Loss of consciousness (true) 127 (76.0) Nuse (true) 107 (64.1) Numness or tingling of rms (true) 113 (67.7) Skin rsh (flse) 167 (100.0) Shrp urning pin in neck (flse) 113 (67.7) Wekness in neck movements (flse) 91 (54.5) Generl knowledge A concussion only occurs if you lose consciousness (flse) (n ¼ 163) 138 (84.7) If you re experiencing ny signs nd symptoms of concussion fter low to the hed or sudden 134 (82.2) movement of the ody, you should not return to ply (true) (n ¼ 163) A concussion is n injury to the. (rin) (n ¼ 165) 146 (88.5) Multiple concussions: Of the following, wht re possile complictions of hving multiple concussions? Check ll tht pply. (n ¼ 167) No complictions exist (flse) 167 (100.0) Incresed risk of further injury (true) 106 (63.5) Brin dmge (true) 152 (91.0) Joint prolems (flse) 150 (89.8) I don t know (flse/not checked) 157 (94.0) Memory prolems (true) 142 (85.0) Returning to ply too soon: Of the following, wht re complictions of returning to sporting ctivity while still experiencing possile concussion symptoms? Check ll tht pply. (n ¼ 167) No complictions exist (flse) 166 (99.4) Incresed risk of further injury (true) 145 (86.8) Prlysis (flse) 92 (55.1) Brin dmge (true) 145 (86.8) Joint prolems (flse) 147 (88.0) I don t know (flse/not checked) 154 (92.2) Indictes the correct response for ech question is indicted in prentheses. Indictes the frequencies nd percentges represent the proportion of the smple responding correctly to ech question. predictors 3 6 outcomes). The level ws set priori t.05. The level ws djusted for multiple comprisons performed for ech predictor (0.05/6 [numer of nlyses for ech predictor ¼ 0.008]). The PRs represent the chnge in the prevlence of reclled concussion nd ell-ringer events ssocited with chnges in AKT nd AAT. We chose this method to exmine the reltionship mong knowledge, ttitude, nd reporting of concussion events from crosssectionl dt. To estimte the PRs ssocited with knowledge nd ttitude, n increse of 1 stndrd devition (SD) from our smple men in thlete knowledge (1 SD ¼ 2.8 points, possile points ¼ 0 35) nd ttitude score (1 SD¼ 11.5 points, possile points ¼ 14 98) ws selected. Thus, the PRs presented in the Results section represent the chnge in reporting prevlence tht occurs for every 1 SD increse in knowledge or ttitude score. The unlnced smple size cross nlyses is explined y the following: (1) when people reporting concussions or ell ringers re the nlysis unit, only individuls reclling concussion or ell-ringer event re included; (2) when exmining involvement in gmes or prctices while symptomtic, ll prticipnts nswering the question re included; nd (3) to e included in the nlyses, ll questions forming the independent nd dependent vriles hd to e nswered. RESULTS Athlete Knowledge nd Attitude Descriptives Athlete knowledge totl scores rnged from 20 to 34 (men ¼ ; Tle 3). Higher scores indicted incresed knowledge. The overll AAT towrd concussion 648 Volume 48 Numer 5 Octoer 2013

5 Tle 4. Athlete Attitude Items nd Descriptives Athlete Attitude Item Men (SD) Rte on scle of 1 7 How serious you think it is when you experience hedche or dizziness fter low to your hed or ody 4.5 (1.5) How importnt you think it is to not prticipte in physicl ctivity (gme or prctice) when experiencing signs nd 5.5 (1.6) symptoms of concussion How importnt you think it is to e informed out how concussions hppen 5.9 (1.4) How importnt you think it is to e informed out how concussions cn e prevented 5.9 (1.5) How importnt it is to e informed out wht to do if you hve concussion 6.3 (1.2) How importnt you think it is to report possile signs nd symptoms to medicl professionl (eg, doctor, thletic 6.1 (1.2) triner) or coch Your level of greement with the following sttement: Athletes re undereducted out concussion. 5.1 (1.5) Check the ox (1 7) out how you feel out the following sttement for ech pir of words listed: For me to report possile signs nd symptoms to coch or medicl professionl when I experience them is Cowrdly/rve 5.1 (1.6) Emrrssing/plesnt 4.5 (1.7) Hrmful/eneficil 6.2 (1.3) Extremely difficult/extremely esy 5.0 (1.6) Bd/good 6.0 (1.4) Unimportnt/importnt 6.1 (1.4) Worthless/vlule 6.1 (1.3) Athlete ttitude totl 78.3 (11.5) Indictes 1 ws eside the word presented on the left nd 7 ws eside the word presented on the right. rnged from 40 to 98 (men ¼ ). Higher scores indicted more fvorle ttitude (Tle 4). Athlete Reporting Behvior Descriptives A totl of 89 thletes (53.3%) reclled hving t lest 1 possile concussion or ell-ringer event. Of these 89, only 15 (16.9%) indicted reporting ll experienced concussive/ ell-ringer events to coch or medicl professionl. Prticipnts reclled 84 concussions, nd in only 41 (48.8%) of these events, the respondent indicted tht he or she hd reported the event to coch or medicl professionl. In ddition, prticipnts reclled 584 ellringer events, nd in only 72 (12.3%), the respondent indicted he or she hd reported the event to coch or medicl professionl. Overll, the most common resons for not reporting concussion or ell-ringer event were tht the thlete did not think it ws serious enough to report (52/ 74, 70.2%), did not wnt to e removed from gme (27/ 74, 36.5%), did not wnt to let down temmtes (20/74, 27.0%), nd did not wnt to let down coches (17/74, 23.0%). Not knowing the event ws concussion (11/74, 14.9%) nd not wnting to e removed from prctice (10/ 74, 13.5%) were the remining resons cited for not reporting the reclled event. In gmes only, prticipnts reclled totl of 320 concussion nd ell-ringer events nd indicted tht they reported only 73 (22.8%) of these events to coch or medicl professionl. For prctices only, prticipnts reclled totl of 348 concussion nd ell-ringer events nd indicted reporting only 40 (11.5%) of these events to coch or medicl professionl. In ddition, 37.7% (n ¼ 63) of the thlete smple indicted they hd continued prticipting in prctice or gme t lest once while experiencing signs nd symptoms of concussion. Influence of Athlete Knowledge nd Attitude Incresed AKT ws not ssocited with the prevlence of thletes indicting they continued to prticipte in gme or prctice while experiencing concussion symptoms (Tle 5). The AAT ws ssocited with decrese in thletes reporting to prticipte in gme while symptomtic (PR ¼ 0.74), wheres the prevlence of thletes reporting tht they continued prticipting in prctice while symptomtic lso decresed (PR ¼ 0.67; Tle 6). The AKT nd AAT were not ssocited with reporting of reclled concussion or ell-ringer events during gmes (Tles 5 nd 6). Alterntively, 1-SD (2.8-point) increse in AKT ws ssocited with n incresed prevlence of reporting these reclled events in prctices y 2.27 times. A 1-SD (11.5-point) increse in AAT lso ws ssocited with 1.38-times incresed prevlence of reclled event reporting during prctices. However, when ccounting for Tle 5. Athlete Knowledge Influence on Reporting Prevlence Rtios, Stndrd Errors, nd Confidence Limits Predictor 2.8-Point Increse Prevlence Rtio Stndrd Error 95% Confidence Limits v 2 P Vlue Knowledge nd reporting of concussion nd ell-ringer events in gmes (n ¼ 58) , Knowledge nd reporting of concussion nd ell-ringer events in prctices (n ¼ 56) 2.27 c , ,.001 Knowledge nd reporting of reclled concussion events (n ¼ 40) , 1.32, Knowledge nd reporting of reclled ell-ringer events (n ¼ 69) 1.87 c , ,.001 Knowledge nd reporting continuing in gme while symptomtic (n ¼ 129) , Knowledge nd reporting continuing in prctice while symptomtic (n ¼ 128) , Indictes reclled events were the unit of nlysis. Indictes people were the unit of nlysis. c Indictes n ssocition. Journl of Athletic Trining 649

6 Tle 6. Athlete Attitude Influence on Reporting Prevlence Rtios, Stndrd Errors, nd Confidence Limits Predictor 11.5-Point Increse Prevlence Rtio Stndrd Error 95% Confidence Limits v 2 P Vlue Attitude nd reporting of concussion nd ell-ringer events in gmes (n ¼ 61) , Attitude nd reporting of concussion nd ell-ringer events in prctices (n ¼ 55) 1.45 c , Attitude nd reporting of reclled concussion events (n ¼ 40) , 1.29, Attitude nd reporting of reclled ell-ringer events (n ¼ 69) 1.48 d , Attitude nd reporting continuing in gme while symptomtic (n ¼ 129) 0.74 d , ,.001 Attitude nd reporting continuing in prctice while symptomtic (n ¼ 128) 0.67 d , ,.001 Indictes reclled events were the unit of nlysis. Indictes people were the unit of nlysis. c Indictes trend. d Indictes n ssocition. the djusted level, this increse ws not different. The AKT nd AAT were not ssocited with reporting reclled concussion-only events. Alterntively, oth AKT nd AAT were ssocited with reporting ell-ringer only events ecuse the reporting prevlence of these events incresed y more thn 1.8 times with 1-SD (2.8-point) increse in AKT nd 1.4 times with 1-SD (11.5-point) increse in AAT. A summry of the overll influence of knowledge nd ttitude on reporting ehviors is presented in Tle 7. DISCUSSION The most importnt findings in our study re tht most reclled concussions sustined y high school thletes were not reported nd tht concussion knowledge nd ttitudes oth ply role in concussion-reporting ehviors. Although this informtion ws self-reported, it suggested tht lrge proportion of possile concussion events re never reported to coch or medicl professionl nd tht knowledge nd ttitude my ply sustntil roles in these reporting decisions. Athletes in the study smple clssified most of these events s ell ringers. The difference etween the proportion of thletes reclling concussions nd ell ringers highlights the misunderstnding concerning the use of these terms nd thletes lck of ssocition etween the term ell ringer nd concussive injury. We employed the term ell ringer in our study to exmine the numer of these events tht thletes would clssify s occurring. However, ccording to Guskiewicz et l, 21 the term should not e used in clinicl, thletic, or eductionl settings ecuse it minimizes the serious nture of possile concussion. All of these ell-ringer events my not hve een true concussions, ut these events should hve een reported nd evluted y clinicins to mke the determintion out whether concussions did occur. If these events re not reported, thletes re more likely to continue to ply in potentilly vulnerle stte. In ddition, our findings provide insight into the importnce of incresed knowledge nd incresed ttitude on the ehvior of concussion reporting mong high school thletes. A summry of the influences of these fctors on reporting mesures included in the study is shown in Tle 7. Overll Knowledge, Attitude, nd Concussion- Reporting Behviors The AKT indicted n verge of 7 (out of 35) questions missed, illustrting tht gp still exists in wht thletes should know concerning concussion concepts, such s common signs nd symptoms. The most common questions missed were those concerning less frequent symptoms, such s nuse nd mnesi. 22,23 These findings were similr to those reported y Vlovich McLeod et l, 13 lthough they ddressed youth coches. Nuse is symptom ssocited with mny conditions, such s dehydrtion or overeting efore n event. Young thletes nd coches 13 my hve difficulty recognizing tht this symptom is ssocited with concussion or rin injury. The findings in our smple suggest thletes re reltively knowledgele out the generl signs nd symptoms of concussion (Tle 3). Student-thletes knowledge out concussions, specificlly out signs nd symptoms, hs een reported to e lower thn wht we oserved. 12 The incresed knowledge of concussion symptoms my e due to recent eductionl nd socil inititives to increse concussion wreness. 24 However, future efforts lso should emphsize the less common symptoms, such s nuse, to help young thletes etter recognize potentil concussive injuries. Attitude (overll ttitude out concussion) hd wide rnge of scores, illustrting the disprity in perceptions of concussion cross the thletic popultion. Mny of the thletes indicted only moderte greement (men ¼ 4.5/7) Tle 7. Summry of Chnges in Reporting Behviors Reporting (Reclled) Outcome Athlete Knowledge 10-Point Increse Athlete Attitude 10-Point Increse Gme events Increse Prctice events Increse Increse Concussion only Bell-ringer only Increse Increse (trend) Prticiption in gmes with symptoms Decrese (positive ehvior) Prticiption in prctice with symptoms Decrese (positive ehvior) Indictes reclled events were the nlysis unit. Indictes people were the nlysis unit. 650 Volume 48 Numer 5 Octoer 2013

7 with the sttement on the questionnire tht concussion symptoms were serious. In ddition, mny elieved reporting concussion my e somewht emrrssing (men ¼ 4.5/7). Downplying concussion symptoms nd feelings of emrrssment out reporting them illustrte some of the ttitudes towrd concussion nd reporting tht need ttention. Few reserchers hve ddressed ttitudes concerning concussion nd concussion reporting mong thletes despite ttitude eing one of the fctors tht my modify ehvior. 17,25 A etter understnding of the role of ttitude out concussion-relted ehviors is needed. The issues concerning concussion in the high school thletic setting re further highlighted in our smple y gross underreporting of reclled concussion events. In ddition, lrge proportion of the study smple indicted continuing to prticipte in oth gmes nd prctices while experiencing concussion signs nd symptoms. McCre et l 9 oserved the prevlence of underreporting mong high school footll plyers to e s high s 50%. Delney et l 26 lso reported tht mny college-ged footll nd soccer thletes do not recognize potentil concussion events. More recently, reserchers hve highlighted tht relying on selfreport nd even single medicl provider my result in underrecognition of concussive injuries. 10 We used different methods to investigte nd explin this phenomenon, ut we oserved n underreporting rte of pproximtely 40% for perceived concussions. More strikingly, thletes only indicted reporting 13% of events they considered ell ringers, which likely were concussive injuries. Athletes not reporting these ell-ringer events my hve continued to prticipte or returned to prticiption too erly, predisposing them to further injury. 3,27 This illustrtes the need for clinicins, prents, coches, nd thletes to etter recognize tht these mild events should e reported nd ddressed. Reporting to coch is very different from reporting to medicl professionl; however, not ll schools or thletes in our study hd ccess to n AT, which models the relity tht mny high school thletes lso do not hve ccess to n AT, especilly during thletic prticiption. The Ntionl Athletic Triners Assocition 28 reported tht only 42% of high schools hve ccess to n AT. The purpose of reporting to n uthorittive figure is to cknowledge potentil concussion nd to seek dditionl help. McCrory et l 29 identified the role of the coch s inititing medicl cre in the event n thlete is injured. Coches do not hve the sme trining s medicl professionls, ut when no medicl professionl is present, they re often the people to whom individuls report concussion or other injury. The most common reson thletes cited for not reporting possile concussions ws not thinking the injury ws serious enough to report, followed y not wnting to e removed from gme. These resons re similr to those tht McCre et l 9 reported. In contrst to McCre et l, 9 letting down temmtes nd coches ws prioritized in our smple over lck of concussion wreness s possile resons for not reporting. Wheres reporting ehviors in our study smple were sed on reclled events, they suggest the ehvior of underreporting possile concussion events is prevlent. 10 Continuing to prticipte in the presence of concussive injury is risky given the possile negtive outcomes 3,4,27,30 33 ssocited with the ehvior. Our study highlights the risk-tking ehviors of thletes, which hve een suggested in other literture. 34 Athlete Knowledge nd Attitude Influence on Reporting of Reclled Events In generl, improved thlete knowledge positively ffected reporting, s the proportion of people reporting ell-ringer events, proportion of events reported during prctice, nd proportion of ell-ringer events reported were greter with incresed thlete knowledge. Increses in knowledge encompss recognition of signs nd symptoms. This possile increse in recognition my hve resulted in more knowledgele thletes recognizing the signs nd symptoms of these events s needing to e reported ecuse the primry reson for not reporting events in our smple ws not thinking the injury ws serious enough to report. Improved knowledge out concussions my result in thletes recognizing these injuries re possile concussions nd reporting them to someone in uthority. This lso my explin why findings relted to concussion-only events nd continued prticiption while symptomtic were not ssocited with increses in knowledge. Vlovich McLeod et l 35 oserved tht, when sked out concussion history using the terms concussion nd ell ringer, greter proportion of the high school prticipnts reported hving sustined ell ringer thn hving sustined concussion. Our study further supports these findings, underscoring the issue tht young thletes often elieve tht ell ringers re not concussions. Athlete ttitude lso hd overll positive effects on reporting ehviors, with n incresed proportion of reported ell-ringer events in gmes nd prctices. Athletes with more fvorle ttitude towrd reporting concussive injury my hve etter understnding out the importnce of reporting possile concussion events. An increse in this ttitude score my help thletes elieve they re more cple of ccurtely reporting with the incresed understnding of the injury. 9,12 Limittions The low return (10%) mong the prticipnts is concerning nd limits generlizility. Our results cnnot e generlized to the generl popultion ecuse the study smple ws one of convenience. In ddition, the ehvior we ssessed (reporting/not reporting) ws not oserved directly ut ws self-reported, yielding results sed lrgely on thlete perceptions. In ddition, 42.9% (n ¼ 66) of the smple were footll thletes (Tle 1). This my hve led to is towrd findings reltive to footll. Our crosssectionl study cn only provide insight on the 1 point in time when the survey instrument ws completed. In ddition, time of reporting in proximity to the concussion or ell-ringer event ws not otined. Therefore, we do not know if the thletes reported the event immeditely fter injury or t lter time, which will e importnt to know in future reserch. Wheres we cknowledge other fctors externl to the thlete my influence thlete self-reporting, we investigted the influence of fctors t the thlete level. In the future, reserchers should investigte how externl fctors, such s coch, prent, nd temmte pressures, influence reporting of concussion mong high school thletes. They lso should include dditionl high-risk Journl of Athletic Trining 651

8 sports, such s ice hockey, sketll, nd wrestling. Furthermore, potentil recruitment strtegies, such s hving prent thlete meeting t which prents cn consent nd thletes cn complete the questionnire in single session in contrst to sking high school thletes to tke forms home to hve them signed, my e useful in future reserch to increse return. During the study period, sustntil mount of medi ttention ws given to concussion in sport, which my hve resulted in the reltively high knowledge scores in our smple. CONCLUSIONS Underreporting of concussion is multifceted prolem, s evidenced y the influence of the fctors ddressed in our study. Knowledge nd ttitude oth pper to influence reporting ehviors in some contexts. Our most striking finding ws the lrge proportion of reclled concussion events tht this smple of high school thletes did not report. In ddition, our findings suggest tht incresing knowledge of concussion symptoms, improving the culture of sport, nd incresing the understnding of the serious nture of concussive injuries should e trgets for future interventions. Furthermore, our findings support policies for educting oth coches nd thletes. In ddition, they support implementtion of progrms incresing wreness, promoting reporting, nd creting sfe reporting environment. Clinicins cn work to crete this sfe environment y educting the community, coches, prents, nd thletes out concussion; helping others to see they re not lone in their experiences; nd providing pltforms for individuls, especilly those respected in the thletic community, to spek out out concussion nd why these injuries should e reported nd mnged properly. These efforts cn e used to increse tolernce nd helth litercy, oth of which potentilly my increse reporting nd creseeking for concussive injury. Our study is lso 1 of the first to encompss the constructs of knowledge, ttitude, nd self-report ehvior into single study imed t understnding concussion-reporting ehviors mong young thletes. Although our study encompssed only 1 convenience smple of thletes, the mjor findings illustrted the importnce of incresed thlete knowledge, more fvorle thlete ttitude, nd context of reporting concussion mong high school thletes. We highlighted the importnce of ddressing multiple fctors to increse reporting of possile concussive injuries. In ddition, we highlighted the need for multifctoril interventions in the high school setting to ddress these risky ehviors. Clinicins, prents, nd coches should mke concussion eduction nd wreness priority nd ddress fctors to provide more optiml concussion-reporting environment. In turn, increses in reporting my led to decreses in recurrent injuries in this young popultion. In the future, reserchers should ddress the influence of incresing knowledge nd ttitude on reporting concussions nd recurrent concussions in lrge prospective studies. ACKNOWLEDGMENTS This study ws funded y Ntionl Footll Legue Chrities Medicl Reserch Grnt (New York, NY). REFERENCES 1. Lovell MR, Fzio V. Concussion mngement in the child nd dolescent thlete. Curr Sports Med Rep. 2008;7(1): Collins MW, Lovell MR, Iverson GL, Cntu RC, Mroon JC, Field M. Cumultive effects of concussion in high school thletes. Neurosurgery. 2002;51(5): Guskiewicz KM, McCre M, Mrshll SW, et l. Cumultive effects ssocited with recurrent concussion in collegite footll plyers: the NCAA Concussion Study. JAMA. 2003;290(19): Moser RS, Schtz P, Jordn BD. Prolonged effects of concussion in high school thletes. Neurosurgery. 2005;57(2): Boden BP, Tcchetti RL, Cntu RC, Knowles SB, Mueller FO. Ctstrophic hed injuries in high school nd college footll plyers. Am J Sports Med. 2007;35(7): Cntu RC. Second-impct syndrome. 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Belief, Attitude, Intention, nd Behvior: An Introduction to Theory nd Reserch. Reding, MA: Addison- Wesley Pulishing Compny; Rudsepp L, Viir R, Hnnus A. Prediction of physicl ctivity intention nd ehvior in longitudinl smple of dolescent girls. Percept Mot Skills. 2010;110(1): Guskiewicz KM, Bruce SL, Cntu RC, et l. Ntionl Athletic Triners Assocition position sttement: mngement of sportrelted concussion. J Athl Trin. 2004;39(3): Frommer LJ, Gurk KK, Cross KM, Ingersoll CD, Comstock RD, Sli SA. Sex differences in concussion symptoms of high school thletes. J Athl Trin. 2011;46(1): Volume 48 Numer 5 Octoer 2013

9 23. Guskiewicz KM, Ross SE, Mrshll SW. Posturl stility nd neuropsychologicl deficits fter concussion in collegite thletes. J Athl Trin. 2001;36(3): Srmiento K, Mitchko J, Klein C, Wong S. Evlution of the Centers for Disese Control nd Prevention s concussion inititive for high school coches: Heds Up: Concussion in High School Sports. J Sch Helth. 2010;80(3): Rosenum AM, Arnett PA. The development of survey to exmine knowledge out nd ttitudes towrd concussion in highschool students. J Clin Exp Neuropsychol. 2010;32(1): Delney JS, Lcroix VJ, Ggne C, Antoniou J. Concussions mong university footll nd soccer plyers: pilot study. Clin J Sport Med. 2001;11(4): Zemper ED. Two-yer prospective study of reltive risk of second cererl concussion. Am J Phys Med Rehil. 2003;82(9): Ntionl Athletic Triners Assocition. Athletic triners fill necessry niche in secondry schools. 2009; NR Accessed April 7, McCrory P, Meeuwisse W, Johnston K, et l. Consensus sttement on Concussion in Sport 3rd Interntionl Conference on Concussion in Sport held in Zurich, Novemer Clin J Sport Med. 2009;19(3): Guskiewicz KM, Mrshll SW, Biles J, et l. Recurrent concussion nd risk of depression in retired professionl footll plyers. Med Sci Sports Exerc. 2007;39(6): Co S, Bttin B. Second-impct syndrome. J Sch Nurs. 2004;20(5): Register-Mihlik J, Guskiewicz KM, Mnn JD, Shields EW. The effects of hedche on clinicl mesures of neurocognitive function. Clin J Sport Med. 2007;17(4): Register-Mihlik JK, Mihlik JP, Guskiewicz KM. Assocition etween previous concussion history nd symptom endorsement during preseson seline testing in high school nd collegite thletes. Sports Helth. 2009;1(1): Bumert PW Jr, Henderson JM, Thompson NJ. Helth risk ehviors of dolescent prticipnts in orgnized sports. J Adolesc Helth. 1998;22(6): Vlovich McLeod TC, By RC, Heil J, McVeigh SD. Identifiction of sport nd recretionl ctivity concussion history through the preprticiption screening nd symptom survey in young thletes. Clin J Sport Med. 2008;18(3): Address correspondence to John K. Register-Mihlik, PhD, LAT, ATC, 3024 New Bern Avenue, Suite G01, Rleigh, NC Address e-mil to jmihlik@wkemed.org. Journl of Athletic Trining 653