Improving post-concussion discharge education for families seeking emergency department care: intervention development

BACKGROUND

Pediatric emergency departments (ED) are where many families receive post-concussion medical care and thus an important context for helping parents build skills to support their child after discharge.

OBJECTIVE

Develop a strategy for increasing parent provision of emotional and instrumental support to their child after discharge and conduct a pilot test of this strategy's acceptability.

METHODS

In a large pediatric ED in the United States, we partnered with parents (n = 15) and clinicians (n = 15) to understand needs and constraints related to discharge education and to operationalize a strategy to feasibly address these needs. This produced a brief daily text message intervention for parents for 10 days post-discharge. We used a sequential cohort design to assess the acceptability this intervention and its efficacy in changing parenting practices in the 2-weeks post-discharge (n = 98 parents).

RESULTS

Parents who received the messaging intervention rated it as highly acceptable and had meaningfully higher scores for emotionally supportive communication with their child in the two weeks post-discharge than parents in the control condition (Cohen's d = 0.65, p = 0.021).

CONCLUSIONS

This brief messaging intervention is a promising strategy for enhancing discharge education post-concussion that warrants further evaluation.

Developing and implementing survivor-centred approaches for college student-athletes: perspectives from athletic department, Title IX, and campus advocacy personnel

ABSTRACTBackground: Sexual violence (SV) is a persistent issue on US college campuses, particularly among college student-athletes. Strategies to address SV are urgently needed. Yet, prior research shows that many university practices can be more harmful than helpful to SV survivors and necessitates a reimagination of how institutions support SV survivors. Survivor-centred approaches may be one way to effectively address SV for students, including student-athletes, across college campuses.Objective: This qualitative study explored campus personnel experiences with and perceptions of survivor-centred SV prevention and intervention policies and practices on college campuses and examined how these approaches serve SV survivors, including college student-athletes.Methods: As part of a larger study on campus SV and student-athletes across four institutions, semi-structured interviews with 22 representatives from athletic departments, campus advocacy, and Title IX were conducted. Guided by phenomenology, a thematic analysis approach was used to identify key patterns in survivor-centred SV prevention and intervention policies and practices. Participant demographic data were analysed descriptively.Results: Most participants identified as white (72.2%), heterosexual (63.6%), women (68.2%), and were an average of 41.8 years old (SD = 10.2). The majority were in positions associated with athletic departments (63.6%), and they had been in their role for an average of 5.6 years (SD = 6.6). Through thematic analysis, three main themes were identified: (1) education & accessibility; (2) interpersonal relationships & individual well-being; and (3) campus and societal norms.Conclusions: The findings from this study highlight clear policy and practice recommendations for survivor-centred SV prevention and intervention on college campuses, such as accessible, applicable SV training and the implementation of survivor-centred approaches. Further research is needed to understand existing survivor-centred practices and the facilitators and barriers to their implementation across institutions and within athletic departments.

Stakeholder-Engaged Development of a Theory-Driven, Feasible, and Acceptable Approach to Concussion Education

Concussion education is widely mandated and largely ineffective. Recent consensus guidance on concussion education asserts the importance of (1) theory-driven programming that targets the team as a system and (2) working with end users throughout the development process, and considering issues such as feasibility, acceptability, and sustainability. Consistent with this guidance, and in collaboration with youth sport stakeholders in two regions of the United States, we developed a novel approach to concussion education: Pre-game safety huddles. Safety huddles have the following two core components: (1) athletes, coaches, and other stakeholders come together before the start of each game and (2) opinion leaders (coaches, referees) affirm the importance of care seeking for suspected concussion. The aim of this article is to provide an overview of the collaborative process through which we refined the safety huddle concept into an acceptable and feasible intervention with potential for sustainable implementation in diverse youth sports settings with minimal resource demands. In describing our process and discussing challenges and opportunities, we hope to provide an example for others seeking to develop and implement injury prevention interventions in youth sports settings.

Optimizing Concussion Care Seeking: Connecting Care-Seeking Behaviors and Neurophysiological States Through Blood Biomarkers

BACKGROUND

Timely and appropriate medical care after concussion presents a difficult public health problem. Concussion identification and treatment rely heavily on self-report, but more than half of concussions go unreported or are reported after a delay. If incomplete self-report increases exposure to harm, blood biomarkers may objectively indicate this neurobiological dysfunction.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare postconcussion biomarker levels between individuals with different previous concussion diagnosis statuses and care-seeking statuses. It was hypothesized that individuals with undiagnosed concussions and poorer care seeking would show altered biomarker profiles.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Blood samples were collected from 287 military academy cadets and collegiate athletes diagnosed with concussion in the Advanced Research Core of the Concussion Assessment, Research and Education Consortium. The authors extracted each participant's self-reported previous concussion diagnosis status (no history, all diagnosed, ≥1 undiagnosed) and whether they had delayed or immediate symptom onset, symptom reporting, and removal from activity after the incident concussion. The authors compared the following blood biomarkers associated with neural injury between previous concussion diagnosis status groups and care-seeking groups: glial fibrillary acidic protein, ubiquitin c-terminal hydrolase-L1 (UCH-L1), neurofilament light chain (NF-L), and tau protein, captured at baseline, 24 to 48 hours, asymptomatic, and 7 days after unrestricted return to activity using tests of parallel profiles.

RESULTS

The undiagnosed previous concussion group (n = 21) had higher levels of NF-L at 24- to 48-hour and asymptomatic time points relative to all diagnosed (n = 72) or no previous concussion (n = 194) groups. For those with delayed removal from activity (n = 127), UCH-L1 was lower at 7 days after return to activity than that for athletes immediately removed from activity (n = 131). No other biomarker differences were observed.

CONCLUSION

Individuals with previous undiagnosed concussions or delayed removal from activity showed some different biomarker levels after concussion and after clinical recovery, despite a lack of baseline differences. This may indicate that poorer care seeking can create neurobiological differences in the concussed brain.

Project nature: promoting outdoor physical activity in children via primary care

BACKGROUND

Families face a range of barriers in supporting their children's active play in nature including family circumstances, environmental constraints, and behavioral factors. Evidence-based strategies to address these barriers are needed. We aimed to develop and pilot test a primary care-based family-centered behavioral intervention to promote active outdoor play in 4-10 year-old children.

METHODS

Project Nature, a provider-delivered intervention that provides informational resources and an age-appropriate toy for nature play, was initially developed for children ages 0-3. With stakeholder input, we adapted existing materials for 4-10 year-olds and conducted usability testing at an urban clinic serving families from diverse backgrounds. Subsequently, we conducted a mix-methods pilot study to evaluate intervention feasibility and acceptability. Parents of 4-10 year-olds completed pre- and post-surveys (n = 22), and a purposive subset (n = 10) completed qualitative interviews. Post-intervention, pediatric providers (n = 4) were interviewed about their implementation experiences.

RESULTS

The majority (82%) of parents liked the information provided and the remaining (18%) were neutral. Qualitatively, parents reported that: the toy provided a tangible element to help children and parents be active, they did not use the website, and they wished the intervention emphasized strategies for physical activity during cold and wet seasons. Providers felt the materials facilitated discussion about behavior change with families. There were no statistically significant changes in PA and outdoor time pre- and post-intervention.

CONCLUSIONS

Project Nature was welcomed by providers and families and may be a practical intervention to promote outdoor active play during well-child visits. Providing an age-appropriate nature toy seemed to be a critical component of the intervention, and may be worth the additional cost, time and storage space required by clinics. Building from these results, Project Nature should be revised to better support active outdoor play during suboptimal weather and evaluated to test its efficacy in a fully-powered trial.

Improving concussion education: do athletic trainer opinions match expert consensus?

CONTEXT

The NCAA-DoD Mind Matters Challenge created "useful and feasible" consensus recommendations to improve concussion care-seeking behavior in collegiate athletes and military cadets. Given athletic trainers' (ATs') role as providers of concussion education and medical care, it is important to understand if they agree with the expert panel that the recommendations are useful and feasible.

OBJECTIVE

To describe and compare secondary school (SS) and collegiate setting ATs' perceptions of the utility and feasibility of the NCAA-DoD Mind Matters Challenge recommendations on improving concussion education.

DESIGN

Cross-sectional study.

SETTING

Electronic survey.

PATIENTS OR OTHER PARTICIPANTS

Five hundred and fifteen (515) ATs (age 40.7±12.4, 53.1% female gender) practicing in the SS (60.6%) or collegiate (38.4%) setting.

MAIN OUTCOME MEASURE(S)

An online survey asked participants about their awareness of the statement followed by 17 pairs of Likert-item questions regarding each recommendation's utility and feasibility with responses ranging from No (1) to Yes (9). Mimicking the consensus process, we defined consensus as a mean rating ≥7.00. We compared utility and feasibility rating responses between SS and collegiate setting participants using Mann-Whitney U tests with ι=.05.

RESULTS

Two-thirds (66.6%) of participants were unaware of the consensus statement. Participants felt all recommendations were useful (all means≥7.0); however, 4 recommendations related to collaborating with stakeholders did not meet the feasibility cutoff (mean range=6.66-6.84). SS ATs rated lower feasibility related to educational content (p-value range=.001-.014), providing patient education throughout recovery (p=.002), and promoting peer intervention (p=.019), but higher utility (p=.007) and feasibility (p=.002) for providing parent education compared to collegiate ATs.

CONCLUSIONS

The NCAA-DoD Mind Matters Challenge recommendations require further dissemination. ATs rated collaboration with stakeholders as a feasibility barrier. SS ATs require more resources for educational content, messaging, and promoting peer intervention, but find educating athletes' parents more useful and feasible than collegiate ATs.

Youth intentions to provide social support to a peer with a concussion

OBJECTIVES

1) To describe demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion and 2) to examine if demographic factors and concussion knowledge are associated with components of the Theory of Planned Behavior.

METHODS

The survey was completed between October 2018 and February 2019 by 200 youth (M = 15.30 years, SD = 1.52). Questions were designed for athletes and non-athletes and inquired about various types of social support. Data analysis included descriptive statistics, Wilcoxon Rank Sum Tests and Spearman's Rank-Order Correlation Coefficients.

RESULTS

More favorable attitudes and intentions to provide social support were observed among females (W = 2576, p ≤ 0.001; W = 2411, p ≤ 0.001), older youth (rho = 0.32, p ≤ 0.001; rho = 0.41, p ≤ 0.001) and those with higher concussion knowledge (rho = 0.29, p ≤ 0.001; rho = 0.22; p ≤ 0.001). Participating in sports with a high-risk of concussion was associated with lower attitudes and intentions to provide social support (W = 6677; p ≤ 0.001; W = 6721; p ≤ 0.001). Self-reported concussion history or knowing someone with a concussion history was not significantly associated with social support intentions.

CONCLUSION

This study identified characteristics of youth who had positive intentions to provide social support. These findings identify individuals who may model providing social support to a peer, as well as opportunities for future concussion education.

Driving characteristics of young adults prior to and following concussion

OBJECTIVES

This study sought to examine whether young adults who sustain concussions have different driving histories and pre-injury driving styles than uninjured peers. In addition, we assessed whether modifications were made to driving behavior in the acute period following concussion.

METHODS

Self-reported driving and demographic information was collected from 102 16- to 25-year-old drivers. Half of the sample had recently sustained concussions and the other half comprised a matched comparison group.

RESULTS

The groups reported similar pre-injury driving behaviors and styles. However, the recently injured group had more driving citations, higher rates of psychiatric disorders, and greater likelihood of having sustained a prior concussion. Self-reported driving habits postconcussion suggested that most drivers did not modify their driving behavior following concussion, though they were less likely to drive at night or with others in the car.

CONCLUSION

Results highlight the need for postconcussion driving guidelines and support for returning to driving safely.

Development of a Measure of Parent Concussion Management Knowledge and Self-Efficacy

Abstract Assessing parent readiness to support their child's post-concussion management requires valid and reliable measures. Therefore, the objective of this study was to develop and conduct preliminary tests of reliability and validity of survey measures of parent concussion management knowledge and self-efficacy. Additionally, we tested the hypothesis that among parents of youth who had sustained a concussion, higher scores on measures of knowledge and self-efficacy would predict greater likelihood of engaging in recommended concussion management behaviors during their child's recovery. Measure development occurred with reference to parenting behaviors included in the Center for Disease Control and Prevention's Pediatric Mild Traumatic Brain Injury (mTBI) Management Guidelines. A multi-stage mixed- methods approach was employed, including expert review, cognitive interviews with parents, quantitative item reduction, and tests of reliability and validity. All participants were English-speaking parents of school-aged children in the United States. A stepwise measure development process was followed, with different participant groups across steps (including opt-in web-based survey panels and in-person recruitment from the population of parents of pediatric patients seen in a large pediatric emergency department). In total, 774 parents participated in study activities. The final knowledge index had 10 items, and the final self-efficacy scale had 13 items across four subscales (emotional support, rehabilitation support, monitoring, and external engagement). Internal consistency reliability was 0.63 for the knowledge index and 0.79-0.91 for self-efficacy sub-scales, and validation tests were in the hypothesized directions. In a test of predictive validity, we observed that among parents of youth patients with recent concussion, higher self-efficacy scores at the time of discharge from the pediatric emergency department were positively correlated (r = 0.12) with greater likelihood of engaging in recommended support behaviors at 2-week follow-up. There was no association between concussion management knowledge at discharge and parenting behaviors at follow-up. Parents have the potential to play an important role in concussion management. The measures of knowledge and self-efficacy developed in this study can help identify parent needs and evaluate interventions aiming to support parenting post-concussion.

Structural and social determinants of mental health inequities among collegiate athletes during the COVID-19 pandemic

OBJECTIVES

To characterise psychological distress during the COVID-19 pandemic among collegiate athletes and assess whether racial and ethnic differences in psychological distress are attenuated when accounting for inequitable exposure to structural and social determinants of health.

METHODS

Participants were collegiate athletes on teams competing in the National Collegiate Athletic Association (n=24 246). An electronic questionnaire was distributed by email, open for completion 6 October to 2 November 2020. Multivariable linear regression models were used to assess the cross-sectional associations between meeting basic needs, death or hospitalisation due to COVID-19 of a close contact, race and ethnicity, and psychological distress.

RESULTS

Athletes racialised as Black had higher levels of psychological distress than their white peers (B=0.36, 95% CI 0.08 to 0.64). Psychological distress was higher among athletes who had more difficulties meeting basic needs, and who had a close contact die or be hospitalised with COVID-19. After adjusting for these structural and social factors, Black athletes experienced less psychological distress than white peers (B=-0.27, 95% CI -0.54 to -0.01).

CONCLUSIONS

The present findings provide further evidence of how inequitable structural and social exposures are associated with racial and ethnic differences in mental health outcomes. Sports organisations should ensure the mental health services available for their athletes are appropriate for meeting the needs of individuals experiencing complex and traumatic stressors. Sports organisations should also consider whether there are opportunities to screen for social needs (eg, related to food or housing insecurity), and to connect athletes with resources to help meet those needs.

Randomized Evaluation of Centers for Disease Control and Prevention HEADS UP Concussion Education Materials for Youth Sport Coaches

The Centers for Disease Control and Prevention (CDC) HEADS UP youth sports coach materials are the most widely adopted form of concussion education for coaches across the United States-reaching millions of youth sports coaches over the last decade. These materials focus on concussion symptom identification, response, and management (e.g., return to school and sports), while also addressing the importance of communicating to athletes and their families about concussion safety. The purpose of this study was to assess the effectiveness of CDC HEADS UP materials on coach knowledge and communication with youth athletes about concussion safety. This is the first randomized control study of the CDC HEADS UP materials in real world youth sport conditions. Participants were 764 coaches at 15 YMCA associations. Cluster randomization was used to assign branches within associations to intervention (CDC HEADS UP) and control (treatment as usual) conditions. Coaches completed surveys prior to and at the end of the competitive season. Communication with athletes about concussion increased among coaches in the intervention group (adjusted risk ratio [aRR] = 1.24, 95% confidence interval [CI] = 1.14, 1.36) but not the control group (aRR = 1.09, 95% CI = 0.90, 1.31), in multi-variate analyses controlling for coach demographic characteristics and baseline communication practices. Concussion symptom knowledge and communication intentions also significantly increased in the intervention group but not in the control group. This study provides evidence that CDC HEADS UP materials increase the likelihood that youth sport coaches communicate with their athletes about concussion safety. As youth sports organizations increasingly mandate concussion education for coaches, CDC HEADS UP materials may be considered a leading resource for adoption and setting-relevant implementation.

Developing a conceptual model of coach concussion communication by adapting the theory of planned behavior and the social ecological model

Objective: Acknowledging that coach communication about concussion increases the likelihood of athletes reporting concussive symptoms, the goal of this study was to examine factors affecting such communication, in order to develop a conceptual model that would inform the design of future educational interventions.Participants: Division I contact sport coaches.Methods: We conducted structured qualitative interviews with coaches and analyzed interviews using Thematic Analysis, viewed through the lens of the Theory of Planned Behavior nested within the Social Ecological Model.Results: Coaches had good knowledge of concussion and understood the dangers of playing with symptoms. However, they also discussed the lack of objective criteria for concussion diagnosis, and pressure to win in order to remain employed, both of which created barriers to concussion communication. Ultimately, most coaches reported not engaging in significant concussion communication as they did not feel this was their role, instead deferring to medical staff.Conclusions: Educational interventions might benefit from a focus on the importance of coach concussion safety-supportive coach communication, with a goal of increasing the likelihood of athlete concussion reporting.

Cognitive Impairment and Driving Skills in Youth After Concussion

Abstract Concussions can impact cognitive processes necessary for driving. Young adults, a group who are more likely to engage in risky behaviors, have limited driving experience and a higher rate of motor vehicle collisions; they may be at higher risk for driving impairment after concussion. There are no clear guidelines for return-to-driving following a concussion. We sought to examine the simulated driving performance of young drivers after receiving medical care following a concussion, compared with a similar control population, to examine the association of driving performance with performance on neuropsychological tests. We evaluated 47 drivers, 16- to 25-year-old, within 3 weeks of sustaining a concussion and 50 drivers with similar characteristics who had not sustained concussions. Participants completed demographic questionnaires, the Sport Concussion Assessment Tool-5 (SCAT-5), and a brief set of neurocognitive tests, including the National Institutes of Health (NIH) Toolbox Cognition Battery and the Trail Making Test, and a simulated driving assessment. At various times during simulated driving, participants were asked to respond to tactile stimuli using the tactile detection response task (TDRT), a validated method of testing cognitive load during simulated driving. The concussion group reported significantly higher symptoms on the SCAT-5 than the comparison group. Performance on crystallized neurocognitive skills was similar between groups. Performance on fluid neurocognitive skills was significantly lower in the concussion than comparison group, although scores were in the normal range for both groups. Simulated driving was similar between groups, although there was a small but significant difference in variation in speed as well as TDRT miss rate, with worse performance by the concussion group. Symptom report on the SCAT-5 was significantly associated with TDRT miss rate. In addition, neurocognitive test scores significantly predicted TDRT reaction time and miss count with medium to large effect sizes. Results suggest that neurocognitive screening may be a useful tool for predicting capacity to return to drive. However, further research is needed to determine guidelines for how neuropsychological tests can be used to make return to driving recommendations and to evaluate effects of concussion on real world driving.

Effect of RISE bundle implementation on school adoption of a student-centered return-to-learn program in Washington state

BACKGROUND

Appropriate concussion care in school is vital for full recovery, but school return-to-learn (RTL) programs are lacking and vary in quality. Establishing student-centered RTL programs may reduce disparities in RTL care.

OBJECTIVE

To examine the effect of RISE Bundle (Return to Learn Implementation Bundle for Schools) implementation on high school adoption of a student-centered RTL program.

METHODS

A convenience sample of fourteen (4 rural and 10 urban) small and large Washington (WA) State public high schools were enrolled in a stepped-wedge study with baseline, end of study, and monthly measures over the 2021-2022 academic year. Schools identified an RTL champion who led RISE Bundle implementation in 6-week steps. Concussion knowledge and impact of RTL program on concussion care were examined.

RESULTS

Ten schools (71.4%) successfully completed RISE Bundle implementation and established a functional RTL program. Self-reported concussion knowledge from RTL Champions increased post intervention. Establishing RTL programs facilitated provision of tailored accommodations, and perceived variation and inequities in RTL care were reduced.

CONCLUSION

RISE Bundle implementation proved feasible, supported the establishment of a functional RTL program, and perceived to reduce disparities in concussion care in rural and urban WA State public high schools of varying sizes.

Structural Inequities in Self-compassion and Parental Burnout

Objectives

When parenting-related stressors and coping resources are chronically imbalanced, there is risk of parental burnout, and consequent negative impact on parent and child wellbeing. The objective of this study was to determine the relations between structural and social determinants of health inequities, self-compassion (a theoretically indicated coping practice), and parental burnout during the COVID-19 pandemic.

Method

Participants were parents (n = 2324) with at least one child aged 4-17 in the household recruited from NORC's AmeriSpeak Panel (a probability-based panel providing coverage of 97% of the US household population). Parents completed an online or telephone questionnaire in English or Spanish in December 2020. Structural equation modeling was used to test a system of relations between income, race and ethnicity, parental burnout, and parent and child mental health. Indirect effects and moderation by self-compassion were also tested.

Results

On average, parents experienced symptoms of burnout several days per week. Symptoms were the most frequent among parents with the least income, as well as female-identified and Asian parents. More self-compassion was associated with less parental burnout, and fewer parent and child mental health difficulties. Black and Hispanic parents were more self-compassionate compared to white parents, helping to explain similar levels of parental burnout and relatively better mental health outcomes, despite comparatively more stressors.

Conclusions

Self-compassion is a potentially promising target for interventions aiming to address parental burnout; however, such efforts must not detract from critical structural changes to reduce parenting stressors, particularly those impacting parents experiencing systemic racism and other forms of socioeconomic disadvantage.

Preregistration

This study is not preregistered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-023-02104-9.

Feasibility and acceptability of at-home play kits for middle school physical activity promotion during the COVID-19 pandemic

BACKGROUND

Schools are central to providing opportunities for youth physical activity (PA), however such opportunities were limited during the COVID-19 pandemic. Identifying feasible, acceptable, and effective approaches for school-based PA promotion amid pandemic-related barriers can inform resource allocation efforts in future circumstances necessitating remote instruction. The aims of this study were to: (1) describe the pragmatic, stakeholder-engaged and theory-informed approach employed to adapt one school's PA promotion efforts to pandemic restrictions, leading to the creation of at-home "play kits" for students, and (2) assess the feasibility, acceptability, and preliminary effectiveness of this intervention.

METHODS

Intervention activities occurred in one middle school (enrollment: 847) located in a Federal Opportunity Zone in the Seattle, WA area, with control data from a nearby middle school (enrollment: 640). Students at the intervention school were eligible to receive a play kit during the quarter they were enrolled in physical education (PE) class. Student surveys were completed across the school year (n = 1076), with a primary outcome of days/week that the student engaged in ≥ 60 min of PA. Qualitative interviews (n = 25) were conducted with students, staff, parents, and community partners, and focused on play kit acceptability and feasibility.

RESULTS

During remote learning play kits were received by 58% of eligible students. Among students at the intervention school only, students actively enrolled in PE (versus not enrolled) reported significantly more days with ≥ 60 min of PA in the previous week, however the comparison between schools was not statistically significant. In qualitative interviews, most students reported the play kit motivated them to participate in PA, gave them activity ideas, and made virtual PE more enjoyable. Student-reported barriers to using play kits included space (indoors and outdoors), requirements to be quiet at home, necessary but unavailable adult supervision, lack of companions to play outdoors, and inclement weather.

CONCLUSIONS

A pre-existing community organization-school partnership lent itself to a rapid response to meet student needs at a time when school staff and resources were highly constrained. The intervention developed through this collaborative response-play kits-has potential to support middle school PA during future pandemics or other conditions that necessitate remote schooling, however modifications to the intervention concept and implementation strategy may be needed to improve reach and effectiveness.

Improving inclusion and well-being of trans and gender nonconforming collegiate student-athletes: foundational concepts from the National Collegiate Athletic Association Summit on Gender Identity and Student-Athlete Participation

The National Collegiate Athletic Association (NCAA) Summit on Gender Identity and Student-Athlete Participation was convened to identify institutional/athletic department strategies that may support the well-being of trans and gender nonconforming (TGNC) collegiate student-athletes in the USA. The Summit's purview did not include policy-level changes to eligibility rules. A modified Delphi consensus process was used to identify strategies for supporting collegiate TGNC student-athlete well-being. Key steps included an exploration phase (learning, generating ideas), and an evaluation phase (rating ideas in terms of their utility and feasibility). Summit participants (n=60) included individuals meeting at least one of the following criteria: current or former TGNC athlete, academic or healthcare professional with topical expertise, collegiate athletics stakeholder who would be involved in implementing potential strategies, representative from leading sports medicine organisation, or representative from relevant NCAA membership committee. Summit participants identified strategies in the following domains: healthcare practices (patient-centred care and culturally sensitive care); education for all stakeholders involved in athletics; and administration (inclusive language, quality improvement processes). Summit participants also proposed ways that the NCAA, through its existing committee and governance structures, could help support the well-being of TGNC athletes. NCAA-focused concepts were in the following domains: policy making processes; eligibility and transfer processes; resource development and dissemination; and visibility and support for TGNC athletes. The strategies developed represent important and relevant approaches that member institutions, athletic departments, NCAA committees, governance bodies and other stakeholders might consider in their efforts to support TGNC student-athlete well-being.

Differences in American adolescent sport participation during the COVID-19 pandemic by learning mode: A national survey

This study aimed to examine the relation between learning mode with sport participation and compare participation prevalence in different settings by learning mode among United States adolescents during the COVID-19 pandemic. A cross-sectional, national survey was conducted by a market research company (December 2021-January 2022) among parents whose child participated in sports pre-pandemic. Parents were asked about their child's learning mode (in-person, online, hybrid); sports participation (yes/no) during the pandemic; and participation setting (school, community, club/elite). Weighted logistic regression models examined the relation between learning mode with sport participation. Weighted prevalence estimates of participation setting were compared by learning mode. Among youth included in the analysis (n = 500; Mean_age = 14.0 years), 71.0% played sports during the pandemic. Learning mode was significantly associated with participating (versus not participating) among adolescents attending school online (aOR = 0.09; 95% CI: 0.04-0.18) and in a hybrid modality (aOR = 0.30; 95% CI: 0.15-0.58) versus those attending in-person. Those attending school online (versus in-person or hybrid) had significantly lower participation prevalence in community, school, and club/elite sports. Findings may reflect parents opting out of in-person activities or schools canceling organized sport opportunities. To inform engagement strategies, research is needed to understand reasons for declined participation and extent to which participation resumed.

Concussion education for youth athletes using Pre-Game Safety Huddles: a cluster-randomised controlled trial

OBJECTIVES

Determine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes.

METHODS

A cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9-14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season.

RESULTS

Of 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen's d=0.35).

CONCLUSIONS AND RELEVANCE

Pre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting.

TRIAL REGISTRATION NUMBER

NCT04099329.

Addressing mental health needs of NCAA student-athletes of colour: foundational concepts from the NCAA Summit on Diverse Student-Athlete Mental Health and Well-Being

We sought to identify concepts that may facilitate National Collegiate Athletic Association efforts to assist member institutions in addressing the mental health needs of student-athletes of colour. A two-step process was followed to generate and refine concepts, guided by Delphi methodology. First, a scoping review was conducted, including original peer-reviewed research articles that quantified or qualitatively described determinant(s) of racial or ethnic differences in athlete mental health or mental healthcare. Next, a multiday virtual meeting was facilitated to review the results of the scoping review, discuss lived experiences and generate potential concepts. Participants included a racially and ethnically diverse group of student-athletes, medical and mental health professionals, athletics administrators, diversity, equity and inclusion experts, health educators and representatives from leading organisations involved in athlete mental health. Through the consensus process, participants identified 42 concepts that member institutions might consider implementing on their campuses. Concepts were largely focused on organisational policies and practices such as staffing diversity and inclusion, expanded options for clinical support (ie, identity-relevant support groups) and within-organisation accountability. Concepts related to specific areas for stakeholder education were also identified. Institutions have the potential to play an important role in supporting the mental well being of student-athletes of colour, and the present concepts can help inform institutional action. While concepts proposed are believed to be broadly relevant across athletics settings, they would need to be further considered and tailored to reflect setting-specific organisational structures, resources and needs.

Barriers and facilitators to comprehensive, school-based physical activity promotion for adolescents prior to and during the COVID-19 pandemic: a qualitative study

This study aimed to identify barriers and facilitators to comprehensive, school-based physical activity (PA) promotion among adolescents prior to and during the coronavirus disease of 2019 (COVID-19) pandemic, considering the perspectives of students, parents, and school staff. Data were collected from 2020 to 2021 using semi-structured individual interviews with students (n = 15), parents (n = 20), and school staff (n = 8) at a Title I middle school (i.e. high percentage of students from low-income families). Two theoretical frameworks guided analysis: the Comprehensive School Physical Activity Program framework and Bronfenbrenner's ecological systems theory. Using an iteratively developed codebook, data were coded, thematically analyzed, and synthesized. PA barriers and facilitators were present throughout the school day, at home, and in the community. Key determinants included pandemic-induced challenges (e.g. COVID-19 exposure); neighborhood characteristics/weather (e.g. neighborhood safety); school-family communication/collaboration; implementation climate (i.e. school staff's support for programming); time, spatial, and monetary resources (e.g. funding); staffing capacity/continuity and school champions; staffing creativity and adaptability; PA opportunities before, during, and after school; and child's motivation/engagement. Efforts to improve school-based PA programs, irrespective of pandemic conditions, should include strategies that address factors at the community, school, family and individual levels. School-family communication/collaboration, school staff programming support, and PA opportunities throughout the day can help promote comprehensive, school-based PA.

Prevalence and Formal Reporting of Sexual Violence among Undergraduate Student-Athletes: A Multi-State Study

Sexual violence (SV) is a serious problem on college campuses, and student-athletes are one group of college students at risk for experiencing SV. The administrative context and close-knit bonds of college teams introduce opportunities and structures for responding to SV and delivering uniquely tailored prevention programming, but there is limited research about formal reporting of SV among student-athletes. The current study examines the prevalence of SV and SV reporting history and perceptions among a multi-state sample of undergraduate student-athletes. Student-athletes at 10 National Collegiate Athletic Association (NCAA) Division I institutions across the US participated in an online survey about their experiences of SV victimization, formal reporting of SV, knowledge of resources, and perceptions of responses to SV at their institutions. Among 1004 student-athletes who completed the survey, 29% experienced some type of SV since enrolling at their university, with higher prevalence of SV among student-athletes on women's teams (36%) compared to men's teams (13%). About one fifth of student-athletes felt very or extremely knowledgeable about where to make a report of SV, and only about 10% felt very or extremely knowledgeable about what happens when a student reports SV. Only 9% of participants who experienced SV filed a formal report at their institution. Perceptions about whether campus officials would take the report seriously or would conduct a fair investigation were most positive for students who experienced and formally reported SV. Further research with student-athletes about their decision to formally report and barriers to reporting is needed to build a more comprehensive understanding of the unique experiences of SV among student-athletes. Our results highlight the importance of including and targeting student-athletes in campus SV prevention efforts to build knowledge and trust in hopes of ultimately decreasing the prevalence and adverse consequences of SV.

Optimizing Concussion Care Seeking: A Longitudinal Analysis of Recovery

BACKGROUND

Approximately half of concussions go undisclosed and therefore undiagnosed. Among diagnosed concussions, 51% to 64% receive delayed medical care. Understanding the influence of undiagnosed concussions and delayed medical care would inform medical and education practices.

PURPOSE

To compare postconcussion longitudinal clinical outcomes among (1) individuals with no concussion history, all previous concussions diagnosed, and ≥1 previous concussion undiagnosed, as well as (2) those who have delayed versus immediate symptom onset, symptom reporting, and removal from activity after concussion.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Participants included 2758 military academy cadets and intercollegiate athletes diagnosed with concussion in the CARE Consortium. We determined (1) each participant's previous concussion diagnosis status self-reported at baseline (no history, all diagnosed, ≥1 undiagnosed) and (2) whether the participant had delayed or immediate symptom onset, symptom reporting, and removal from activity. We compared symptom severities, cognition, balance, and recovery duration at baseline, 24 to 48 hours, date of asymptomatic status, and date of unrestricted return to activity using tests of parallel profiles.

RESULTS

The ≥1 undiagnosed concussion group had higher baseline symptom burdens (P < .001) than the other 2 groups and poorer baseline verbal memory performance (P = .001) than the all diagnosed group; however, they became asymptomatic and returned to activity sooner than those with no history. Cadets/athletes who delayed symptom reporting had higher symptom burdens 24 to 48 hours after injury (mean ± SE; delayed, 28.8 ± 0.8; immediate, 20.6 ± 0.7), took a median difference of 2 days longer to become asymptomatic, and took 3 days longer to return to activity than those who had immediate symptom reporting. For every 30 minutes of continued participation after injury, days to asymptomatic status increased 8.1% (95% CI, 0.3%-16.4%).

CONCLUSION

Clinicians should expect that cadets/athletes who delay reporting concussion symptoms will have acutely higher symptom burdens and take 2 days longer to become asymptomatic. Educational messaging should emphasize the clinical benefits of seeking immediate care for concussion-like symptoms.

Optimizing Concussion Care Seeking: Identification of Factors Predicting Previous Concussion Diagnosis Status

PURPOSE

There is limited understanding of factors affecting concussion diagnosis status using large sample sizes. The study objective was to identify factors that can accurately classify previous concussion diagnosis status among collegiate student-athletes and service academy cadets with concussion history.

METHODS

This retrospective study used support vector machine, Gaussian Naïve Bayes, and decision tree machine learning techniques to identify individual (e.g., sex) and institutional (e.g., academic caliber) factors that accurately classify previous concussion diagnosis status (all diagnosed vs 1+ undiagnosed) among Concussion Assessment, Research, and Education Consortium participants with concussion histories ( n = 7714).

RESULTS

Across all classifiers, the factors examined enable >50% classification between previous diagnosed and undiagnosed concussion histories. However, across 20-fold cross validation, ROC-AUC accuracy averaged between 56% and 65% using all factors. Similar performance is achieved considering individual risk factors alone. By contrast, classifications with institutional risk factors typically did not distinguish between those with all concussions diagnosed versus 1+ undiagnosed; average performances using only institutional risk factors were almost always <58%, including confidence intervals for many groups <50%. Participants with more extensive concussion histories were more commonly classified as having one or more of those previous concussions undiagnosed.

CONCLUSIONS

Although the current study provides preliminary evidence about factors to help classify concussion diagnosis status, more work is needed given the tested models' accuracy. Future work should include a broader set of theoretically indicated factors, at levels ranging from individual behavioral determinants to features of the setting in which the individual was injured.

Optimizing Concussion Care Seeking: The Influence of Previous Concussion Diagnosis Status on Baseline Assessment Outcomes

BACKGROUND

The prevalence of unreported concussions is high, and undiagnosed concussions can lead to worse postconcussion outcomes. It is not clear how those with a history of undiagnosed concussion perform on subsequent standard concussion baseline assessments.

PURPOSE

To determine if previous concussion diagnosis status was associated with outcomes on the standard baseline concussion assessment battery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Concussion Assessment, Research, and Education (CARE) Consortium participants (N = 29,934) self-reported concussion history with diagnosis status and completed standard baseline concussion assessments, including assessments for symptoms, mental status, balance, and neurocognition. Multiple linear regression models were used to estimate mean differences and 95% CIs among concussion history groups (no concussion history [n = 23,037; 77.0%], all previous concussions diagnosed [n = 5315; 17.8%], ≥1 previous concussions undiagnosed [n = 1582; 5.3%]) at baseline for all outcomes except symptom severity and Brief Symptom Inventory-18 (BSI-18) score, in which negative binomial models were used to calculate incidence rate ratios (IRRs). All models were adjusted for sex, race, ethnicity, sport contact level, and concussion count. Mean differences with 95% CIs excluding 0.00 and at least a small effect size (≥0.20), and those IRRs with 95% CIs excluding 1.00 and at least a small association (IRR, ≥1.10) were considered significant.

RESULTS

The ≥1 previous concussions undiagnosed group reported significantly greater symptom severity scores (IRR, ≥1.38) and BSI-18 (IRR, ≥1.31) scores relative to the no concussion history and all previous concussions diagnosed groups. The ≥1 previous concussions undiagnosed group performed significantly worse on 6 neurocognitive assessments while performing better on only 2 compared with the no concussion history and all previous concussions diagnosed groups. There were no between-group differences on mental status or balance assessments.

CONCLUSION

An undiagnosed concussion history was associated with worse clinical indicators at future baseline assessments. Individuals reporting ≥1 previous undiagnosed concussions exhibited worse baseline clinical indicators. This may suggest that concussion-related harm may be exacerbated when injuries are not diagnosed.

Problematic Child Media Use During the COVID-19 Pandemic

OBJECTIVES

Assess how family stressors (including structural stressors, social determinants of health inequities, and parent psychological distress) relate to media rule implementation and problematic child media use during the coronavirus disease 2019 pandemic.

METHODS

Nationally representative survey of 1000 United States parents with at least one 6 to 17 year old child was conducted in October through November 2020.

RESULTS

Problematic use was greater in families where parents were employed full time, present in the home (eg, working from home), had low levels or formal educational attainment, and were experiencing more psychological distress. Although there was a small decline in the number of media-related rules implemented during the pandemic (fewer parents enforced screen limits on weekdays or weekends or limited screen use at mealtimes), there was no association between rule implementation and problematic media use.

CONCLUSIONS

Family stressors were associated with problematic child media use during the coronavirus disease 2019 pandemic. As we emerge from the pandemic, it will be important to help parents adjust their family's media practices cognizant of the fact that additional children may have developed problematic screen use behaviors. Such efforts should center the role of structural and social determinants of health inequities on the stressors that families experience and that impact media use.

Parent Communication and Decision Making About Firearm Storage

BACKGROUND

Many youths in the United States have access to an unlocked firearm in their home, and accidental discharge of unlocked firearms is a prevalent cause of pediatric injury and death. Discussions between adult family members have the potential to positively influence firearm storage practices.

PURPOSE

In families with two parenting adults, we tested the following hypotheses: (1) firearms will be more likely to be stored locked and unloaded when both parties are involved in the storage decision, and (2) both parties will be more likely to be involved in the storage decision when they have better relationship functioning and less avoidant communication.

METHODS

Cross-sectional survey using a stratified random sample of an area probability- and address-based panel. Participants were 749 adults aged 18-64 living in the United States with firearms and children in their households.

RESULTS

Overall, 62% of families stored guns locked and unloaded and in 55% both parenting adults were highly involved in storage-related decision making. Families where both parties were highly involved in these decisions had 1.65 times the odds of storing firearms safely (95% CI = 1.21-2.27). Odds of both being highly involved in these decisions were much lower in partnerships with more avoidant communication (OR = 0.16, 95% CI = 0.08-0.32) and higher in partnerships with more relationship satisfaction (OR = 1.08, 95% CI = 1.05-1.12).

CONCLUSIONS

Safe storage is most likely when both parenting adults are involved in the storage decision. Further research is needed to determine how to support productive within-family communication and decision making about this issue.

Parent-Child communication about concussion: what role can the Centers for Disease Control and Prevention's HEADS UP concussion in youth sports handouts play?

BACKGROUND

Concussion education for parents/guardians (hereafter referred to as parents) has the potential to play an important role in youth athlete concussion safety. The goal of this study was to evaluate the impact of the Centers for Disease Control and Prevention's (CDC) HEADS UP handout on parent-child communication about concussion.

METHODS

YMCA branches from 15 associations from across the United States were randomized to CDC HEADS UP intervention condition or education as usual control condition using a cluster randomization strategy. In the intervention condition, coaches shared parent- and athlete-specific handouts with parents and asked parents to share and discuss the athlete-specific handouts with their child. Generalized estimating equations, with repeated measures to account for the correlation among matched participants and YMCA associations, were employed.

RESULTS

Multivariable analyses exploring the relationship between time (pre- and post-intervention) and communication showed that the percent of parents who talked to their child about concussion increased in the intervention group (aRR=1.33, 95% CI=1.22, 1.44), but not in the control group.

CONCLUSION

CDC HEADS UP handouts help families talk about concussion safety. Sports organizations seeking to educate parents of athletes about concussion should consider using CDC HEADS UP handouts and following a similar dissemination strategy.

Parent influence on concussion reporting in first-year collegiate athletes

OBJECTIVE

To assess the relationship between sport-parenting practices and concussion reporting intentions of collegiate athletes across two levels of competition.

PARTICIPANTS

Entering first-year student-athletes (varsity and club) at a mid-sized university in the Southeast region of the United States (n = 327).

METHODS

Written surveys were completed prior to the start of the 2015 academic year. Structural equation modeling was used to test a model predicting concussion-reporting intentions.

RESULTS

College athletes were more likely to intend to report a suspected concussion when they believed their parents wanted them to report (B=-0.88, SD = 0.94), and when they experienced less sport achievement pressure from their parents (B=-0.12, SD = 8.07).

CONCLUSIONS

Parents influence the concussion safety of entering collegiate athletes at both the varsity and club level. Lower pressure sport parenting prior to college entry may help foster safer concussion reporting behaviors and may be an appropriate target for future intervention development work.

Concussion Education in the School Setting: A Scoping Review

BACKGROUND

Concussions are a prevalent injury among youth, and concussion education has the potential to promote positive concussion-related behaviors. Recent recommendations and legislation have increased concussion education provided in schools; however, little is known about the education context, delivery method, development, and evaluation. A scoping review was conducted to identify peer-reviewed literature on concussion education delivered in the school setting.

METHODS

Six databases were searched (MEDLINE, CINAHL, EMBASE, PsycINFO, SPORTDiscus, and ERIC) to identify published articles from 2002 to July 16, 2020 that delivered concussion education in the school setting. Included studies described the concussion education and were written in English.

RESULTS

A total of 11,373 articles were identified and screened, with 27 studies meeting eligibility criteria and therefore, included. The studies delivered education to various stakeholders including students (n = 12; 44.4%), coaches (n = 5; 18.5%), educators (n = 3; 11.1%), parents (n = 1; 3.7%), and a mixed audience (n = 6; 22.2%). The education format varied and six studies (22.2%) developed the education based on a theory, model, or framework.

CONCLUSIONS

This study found substantial variability in the context, delivery method, development, and evaluation of education delivered in schools and further evaluation of this education is needed to ensure it is best-suited for school-based stakeholders.

Park access and mental health among parents and children during the COVID-19 pandemic

BACKGROUND

Time spent outdoors and in nature has been associated with numerous benefits to health and well-being. We examined relationships between park access and mental health for children and parents during the COVID-19 pandemic. We also explored associations between park access and co-participation of parent and child in time outdoors, and child and parent physical activity.

METHODS

We used data from 1,000 respondents to a nationally representative U.S. survey of parent-child dyads during October-November 2020. Park access was defined as an affirmative response to: "do you have a park that you can safely walk to within 10 min of your home?" Child mental health was operationalized as the Strengths and Difficulties Questionnaire (SDQ) total difficulties score. The Patient Health Questionnaire-4 (PHQ-4) total score assessed parent mental health and the International Physical Activity Questionnaire (IPAQ) assessed parent physical activity. Child physical activity and co-participation in outdoor activity were reported as number of days in the prior week. Linear regression was used to examine relationships between park access and health outcomes in models adjusted for child and parent characteristics and COVID-19 impact.

RESULTS

Our sample included 500 parents of children ages 6-10 years, and 500 parent-child dyads of children ages 11-17 years. Park access was associated with a lower SDQ total score among children (β: -1.26, 95% CI: -2.25, -0.27) and a lower PHQ-4 total score among parents (β: -0.89, 95% CI: -1.39, -0.40). In models stratified by child age, these associations were observed for SDQ scores among adolescents ages 11-17 and for PHQ-4 scores among parents of children ages 6-10 years. Park access was also associated with 0.50 more days/week of co-participation in outdoor time (95% CI: 0.16, 0.84), and higher levels of parent physical activity (β: 1009 MET-min/week, 95% CI: 301, 1717), but not child physical activity (β: 0.31 days/week, 95% CI: -0.03, 0.66).

CONCLUSIONS

Park access was associated with better mental health among children and parents, and more parent physical activity and parent-child co-participation in outdooractivity during the COVID-19 pandemic. Access to nearby parks may be an important resource to promote health and well-being, for both individuals and families.

Differences in career longevity before and after implementation of the Women's Tennis Association Tour Age Eligibility Rule and Player Development Programmes: a 25-year study

OBJECTIVES

To assess differences in career longevity, as a potential marker of athlete well-being, before and after the 1995 implementation of the Women's Tennis Association (WTA) Age Eligibility Rule (AER) and Player Development Programmes (PDP), which focused on organisational, physical and psychosocial education, skill building and support for adolescent athletes (≤17 years).

METHODS

Career longevity data were collected through 2019 on adolescent players who began professional tournament play between 1970 and 2014 and reached a WTA singles ranking of 1-150 for a minimum of 1 week during their careers. Players were separated into pre-AER/PDP and post-AER/PDP groups, consisting of those who played their first professional events (FPE) before or after 1 January 1995. Measures of career longevity included career duration and premature retirement.

RESULTS

Eight-hundred and eleven players were included in this study (51% pre-AER/PDP). The median career duration was 14.2 years for the post-AER/PDP group compared with 12.1 years for the pre-AER/PDP group (p<0.001). Moreover, post-AER/PDP players had higher probabilities of 10-year and 15-year careers compared with pre-AER/PDP players. After adjusting for age at FPE, athletes in the pre-AER/PDP group had an increased risk of shorter career duration (HR 1.55; 95% CI 1.31 to 1.83) and increased odds of premature retirement (OR 5.39; 95% CI 2.28 to 12.75) than athletes in the post-AER/PDP group.

CONCLUSIONS

Adolescent athletes participating on the WTA after the combined AER/PDP initiative had longer career durations, higher probabilities of 10-year and 15-year careers, and decreased risk of premature retirement compared with those participating prior to AER/PDP. Organisational practices that encompass both education and competition regulation can positively affect career longevity related to improving athlete well-being.

Student awareness of campus medical amnesty policies

ObjectiveExamine students' awareness of medical amnesty policies and the influence of policy awareness on the expected consequences of bystander help seeking in alcohol-related emergencies among student-athletes and non-athletes. Participants: 1,012 college students. Methods: Spearman's correlation and chi-square tests were used to examine accuracy in awareness of amnesty policies. Nominal logistic regression was used to test the relationship between amnesty policy awareness and expected consequences of bystander help seeking. Results: About 25% of students were unsure if their school had an amnesty policy; of these students, 67% attended schools with such a policy. Students who were unsure about the presence of amnesty policies were more likely to expect serious negative consequences of calling for help for both non-athlete peers (B = 1.152 p < 0.001) and student-athlete peers (B = 0.887 p = 0.001). Conclusions: Greater attention is needed to how amnesty policies are implemented on college campuses, including how they are communicated to and interpreted by student-athletes.

A Framework for Pediatric Health Care Providers to Promote Active Play in Nature for Children

Aim:

Time outdoors and contact with nature are positively associated with a broad range of children’s health outcomes. Pediatricians are uniquely positioned to promote active play in nature (APN) but may face challenges to do so during well child visits. The objective of this study was to understand barriers to children’s APN, before and during the COVID-19 pandemic, and how health care providers could promote APN.

Methods:

Focus groups were conducted with 14 pediatric providers and interviews with 14 parents (7 in English, 7 in Spanish) of children ages 3 to 10 on public insurance. Dedoose was used for coding and content analysis. We contextualized this work within the WHO’s Commission on Social Determinants of Health conceptual framework.

Results:

Parents mentioned a range of material circumstances (time, finances, family circumstances, access to safe outdoor play spaces and age-appropriate activities) and behavioral/psychosocial factors (previous experiences in nature, safety, and weather concerns), many of which were exacerbated by the pandemic, that serve as barriers to children’s APN. Providers said they were motivated to talk to families about children’s APN but mentioned barriers to this conversation such as time, other pressing priorities for the visit, and lack of resources to give families.

Conclusions:

Many pre-pandemic barriers to APN were exacerbated by the COVID-19 pandemic. Well-child visits may be an effective setting to discuss the benefits of APN during and beyond the pandemic, and there is a need for contextually appropriate resources for pediatric providers and families.

Development of a scale to measure expected concussion reporting behavior

Background

Most concussion education aims to increase athlete self-report of concussive symptoms. Although the population burden of concussion is high, frequency with which this injury occurs on a given sports team in a given season is relatively low. This means that powering concussion education evaluation studies to measure change in post-injury symptom reporting behavior requires what is often a prohibitively large sample size. Thus, evaluation studies are typically powered to measure proximal cognitions. Expected reporting behavior, a cognition that reflects planned and reactive decision-making, is a theoretically indicated construct for inclusion in evaluation studies. However, previously no scales were available to measure this construct with demonstrated reliability and validity among youth athletes. The objective of this study was to develop and assess the validity of a brief single-factor scale to measure expected youth athlete concussion reporting behavior (CR-E) in a sample of youth athletes.

Methods

A mixed methods approach was used, including cognitive interviews with youth athletes, and quantitative item reduction and validation. Participants were youth athletes (aged 9–16) from the Seattle metropolitan and rural south-Georgia regions. After refining an initial pool of items using cognitive interviews with a diverse group of youth athletes (n = 20), a survey containing these items was administered to youth soccer and football players (n = 291). Item reduction statistics and sequential confirmatory factor analyses were used to reduce the initial scale using a randomly selected half of the sample. Then, a final confirmatory factor analysis and validation tests were applied to the other half of the sample of youth athletes. Predictive validation was conducted longitudinally in a separate sample of youth athletes (n = 155).

Results

Internal consistency was high (alpha = 0.89), model fit was excellent, validation tests were in the hypothesized directions, and the scale was feasible to use. Using the finalized 4-item scale, we observed that less than one-third of youth soccer and football athletes expect to “always” tell their coach about symptoms of a suspected concussion.

Conclusions

The CR-E measure should be included in future studies evaluating concussion education programming in youth athlete populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00364-4.

Effectiveness of an Education Platform (GoHuddle) for Increasing Likelihood of Coach Concussion Communication with Athletes

Research suggests coaches play a central role in establishing a context conducive to concussion reporting, particularly via direct verbal communication about concussion. Informed by qualitative interviews and stakeholder feedback, we developed a web-based concussion education platform for collegiate coaches (GoHuddle). The goal of GoHuddle is to encourage concussion safety-supportive coach communication using behavioral modeling and experiential learning. We then conducted a pre-post survey study to examine the impact of engaging with the platform on coach concussion communication, with outcomes of: (a) expected likelihood of communicating with athletes about concussive symptom reporting; (b) expected likelihood of pressuring medical staff to return athletes to play; and (c) belief in the usefulness of engaging in the communication described in a and b (i.e., response efficacy). We also assessed feasibility and acceptability of the platform in the collegiate sport context. The platform was sent to 435 coaches at five institutions, and 334 (77%) completed surveys (70% male, 37.8 years mean age). After completing GoHuddle, coaches had 2.5 greater odds of expecting to discuss concussion with their team (odds ratio [OR] 2.53, p < 0.001). Response efficacy for talking about concussion also increased significantly post-intervention (OR 3.78, p < 0.001). No significant change was seen in expectancies regarding pressure on medical staff to return athletes to play "as soon as possible." A high proportion (82%) of coaches would recommend this platform for coach concussion education. In conclusion, this study suggests GoHuddle is a feasible and acceptable approach to coach concussion education, and use of this platform holds promise for shifting coach communication about concussion.

Socioeconomic status and parent perceptions about the costs and benefits of youth sport

Objectives

Describe what costs and benefits parents across the socioeconomic spectrum weight most heavily when making decisions about sport participation for their children.

Method

Cross-sectional survey of a nationally representative online panel of parents of children between the ages of 5 and 18 (n = 1025, 52% response rate). Parents rated the importance of a series of potential costs and benefits of youth sport and these responses were compared across tertiles of per capita family income. We first examined the association between family income tertiles and cost and benefit variables. Model-based cluster analysis was then used to identity homogeneous groups of responses to costs and benefits.

Results

In all income tertiles, the top two benefits of sport were the same: having fun and being physically active. Sport as a means of keeping children out of trouble was very important for 64% of low-income parents as compared to 40% of high-income parents. Obtaining a college athletic scholarship was very important for 26% of low-income parents, as compared to 8% of high-income parents. Relative rankings of potential costs were similar by income tertile, with risk of concussion and other injury and the impact of sport on schoolwork prioritized across tertiles.

Conclusions

Parents prioritized fun and fitness in sport, and were concerned about injury and the impact of sport on academics. Lower income parents were the most likely to view keeping their child out of trouble, and the potential for a college athletics scholarship, as benefits of sport. Efforts to support parental decision making should be grounded in an understanding that family preferences are contextually constrained. While all parents should be appropriately informed about the potential costs and benefits they are weighting in their sports-related decision making, such family-focused efforts should be balanced with the recognition that structural change is needed to address income-related concerns about sport participation.

Needs assessment for physical activity information during COVID-19 among a nationally representative sample of parents and children ages 6-17 in the United States: a cross-sectional study

Background

The COVID-19 pandemic presented novel barriers to youth physical activity engagement. Identifying what resources parents and children are interested in receiving can support efforts to mitigate the negative impact of the pandemic on youth physical activity behavior. This study aimed to identify physical activity-related information needs during the COVID-19 pandemic among a nationally representative sample of American parents of children 6–10 years-old and parent-child dyads of children 11–17 years-old.

Methods

A cross-sectional survey was conducted by a market research company in October–November 2020. Parents and children were asked about their interest in specific types of information about helping their family and themselves, respectively, be active (Yes/No). Weighted percentages were calculated for reported information needs and compared using two-sample test of proportions.

Results

Final analytic sample was 1000 parents (55.4% female; 74.7% White; 74.0% non-Hispanic); 500 children 11–17 years-old (52.1% male; 77.6% White). Over 40% of participants were interested in information about being active during COVID-19. Parents were more likely to be interested in information if they always (versus never) worked from home [53.3% (95% CI: 43.3–63.0%) versus 22.0% (95% CI: 14.9–31.3%), p < 0.001]; had children attending school remotely versus in-person [47.3% (95% CI:40.2–54.5%) versus 27.5% (95% CI: 19.6–37.1%), p < 0.001]; and lived in a big city versus a rural area [66.5% (95% CI:54.5–76.7%) versus 34.1% (95% CI: 22.8–47.6%), p < 0.001]. Children most interested were those who did not have resources for online activity engagement and those worried about their safety or getting infected with COVID-19. Children were also more likely to be interested if their parents worked full-time versus not working [48.6% (95% CI:41.7–55.6%) versus 31.5% (95% CI: 24.1–39.9%), p < 0.001], and lived in a big city versus a rural area [57.2% (95% CI:45.3–68.3%) versus 27.8% (95% CI:17.8–40.7%), p < 0.001].

Conclusions

Families are interested in physical activity resources, particularly those whose daily routines and opportunities for physical activity may have been most significantly impacted by the pandemic. This includes parents who always worked from home or whose children attended school remotely. Identifying felt needs is an important step in developing tailored interventions that aim to effectively and sustainably support families in promoting physical activity.

Association of Children's Physical Activity and Screen Time With Mental Health During the COVID-19 Pandemic

IMPORTANCE

Children's physical activity and screen time are likely suboptimal during the COVID-19 pandemic, which may influence their current and future mental health.

OBJECTIVE

To describe the association of physical activity and screen time with mental health among US children during the pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey was conducted from October 22 to November 2, 2020, among 547 parents of children aged 6 to 10 years and 535 parent-child dyads with children and adolescents (hereinafter referred to as children) aged 11 to 17 years and matched down to 500 children per cohort using US Census-based sampling frames. Children aged 11 to 17 years self-reported physical activity, screen time, and mental health, and their parents reported other measures. Parents of children aged 6 to 10 years reported all measures. All 1000 cases were further weighted to a sampling frame corresponding to US parents with children aged 6 to 17 years using propensity scores.

EXPOSURES

Child physical activity, screen time, COVID-19 stressors, and demographics.

MAIN OUTCOMES AND MEASURES

Mental health using the Strengths and Difficulties Questionnaire for total difficulties and externalizing and internalizing symptoms.

RESULTS

Among the 1000 children included in the analysis (mean [SD] age, 10.8 [3.5] years; 517 [52.6%] boys; 293 [31.6%] American Indian/Alaska Native, Asian, or Black individuals or individuals of other race; and 233 [27.8%] Hispanic/Latino individuals), 195 (20.9%) reported at least 60 minutes of physical activity every day. Children reported a mean (SD) of 3.9 (2.2) d/wk with at least 60 minutes of physical activity and 4.4 (2.5) h/d of recreational screen time. COVID-19 stressors were significantly associated with higher total difficulties for both younger (β coefficient, 0.6; 95% CI, 0.3-0.9) and older (β coefficient, 0.4; 95% CI, 0.0-0.7) groups. After accounting for COVID-19 stressors, engaging in 7 d/wk (vs 0) of physical activity was associated with fewer externalizing symptoms in younger children (β coefficient, -2.0; 95% CI, -3.4 to -0.6). For older children, engaging in 1 to 6 and 7 d/wk (vs 0) of physical activity was associated with lower total difficulties (β coefficients, -3.5 [95% CI, -5.3 to -1.8] and -3.6 [95% CI, -5.8 to -1.4], respectively), fewer externalizing symptoms (β coefficients,  -1.5 [95% CI, -2.5 to -0.4] and -1.3 [95% CI, -2.6 to 0], respectively), and fewer internalizing symptoms (β coefficients, -2.1 [95% CI, -3.0 to -1.1] and -2.3 [95% CI, -3.5 to -1.1], respectively). More screen time was correlated with higher total difficulties among younger (β coefficient, 0.3; 95% CI, 0.1-0.5) and older (β coefficient, 0.4; 95% CI, 0.2-0.6) children. There were no significant differences by sex.

CONCLUSIONS AND RELEVANCE

In this cross-sectional survey study, more physical activity and less screen time were associated with better mental health for children, accounting for pandemic stressors. Children engaged in suboptimal amounts of physical activity and screen time, making this a potentially important target for intervention.

The Association Between School Closures and Child Mental Health During COVID-19

IMPORTANCE

In-person schooling has been disrupted for most school-aged youth during the COVID-19 pandemic, with low-income, Black, and Hispanic populations most likely to receive fully remote instruction. Disruptions to in-person schooling may have negatively and inequitably affected children's mental health.

OBJECTIVE

To estimate the association between school closures and child mental health outcomes and how it varies across sociodemographic factors.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional population-based survey study included a nationally representative sample of US adults aged 18 to 64 years with at least 1 child in the household. The survey was administered between December 2 and December 21, 2020, via web and telephone in English and Spanish. Participants were recruited from the NORC AmeriSpeak panel, an address-based panel with known probability sampling and coverage of 97% of US households.

EXPOSURES

Schooling modality (in person, fully remote, or hybrid), household income, age.

MAIN OUTCOMES AND MEASURES

Child mental health difficulties were measured with the parent-report version of the Strengths and Difficulties Questionnaire, with small, medium, and large effect sizes defined as 1.3-, 3.3-, and 5.2-point differences, respectively.

RESULTS

A total of 2324 adults completed the survey. Overall, 1671 respondents (71.9%) were women, 244 (10.5%) were Black, 372 (16.0%) were Hispanic, and 421 (18.1%) had a high school education or less. Children attending school in-person had higher household incomes (mean difference, $9719; 95% CI, $4327 to $15 111; P < .001) and were more likely to be White compared with those attending remotely (366 of 556 [65.8%] vs 597 of 1340 [44.5%]; P < .001). Older children in remote schooling had more mental health difficulties than those attending in-person schooling (standardized effect size, 0.23 [95% CI, 0.07 to 0.39] per year older; P = .006), corresponding to small effect sizes in favor of in-person schooling for older children and very small effect sizes favoring remote schooling for younger children. Children from families with higher income benefitted more from attending schools in-person compared with their peers from families with lower income (B = -0.20 [95% CI, -0.10 to -0.30] per $10 000-increase in annual income; P < .001), although this advantage was not apparent for children attending hybrid school (B = -0.05 [95% CI, -0.16 to 0.06] per $10 000-increase in annual income; P = .34), and directionally lower but not significantly different for children attending remote school (B = -0.12 [95% CI, -0.04 to -0.20] per $10 000-increase in annual income; P < .001). Learning pods fully buffered the associations of hybrid schooling (d = -0.25; 95% CI, -0.47 to -0.04) but not remote schooling (d = 0.04; 95% CI, -0.10 to 0.18) with negative mental health outcomes.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that older and Black and Hispanic children as well as those from families with lower income who attend school remotely may experience greater impairment to mental health than their younger, White, and higher-income counterparts. Ensuring that all students have access to additional educational and mental health resources must be an important public health priority, met with appropriate funding and workforce augmentation, during and beyond the COVID-19 pandemic.

Factors Influencing College Football Players' Beliefs About Incurring Football-Related Dementia

Background:

Football participation is associated with risks to acute and long-term health, including the possibility of incurring football-related dementia. Concerns have been raised regarding media coverage of these risks, which may have influenced athletes’ beliefs. However, little is known about football players’ views on football-related dementia. The risk-perception literature suggests that related risk perceptions and features of individual cognition, such as the ability to switch to reasoned, deliberative thinking, may influence individual perception of a long-term risk.

Purpose:

To evaluate factors influencing college football players’ belief that they are likely to incur football-related dementia in the future.

Study Design:

Cross-sectional study.

Methods:

Members of 4 National Collegiate Athletic Association Division I Power 5 Football teams participated in this survey-based study, providing responses to demographic, athletic, and risk-posture questions, and completed the cognitive reflection test. Logistic regressions were used to evaluate relationships between beliefs about football-related dementia and factors including athletic and demographic characteristics, football risk posture, health-risk posture, and cognitive reflection test score.

Results:

About 10% of the 296 participating athletes thought football-related dementia was likely to occur in their future. Skill players had lower odds than linemen of believing that football-related dementia was likely (odds ratio [OR], 0.35; 95% CI, 0.14-0.89). For each additional suspected concussion in an athlete’s career, his odds of believing football-related dementia was likely increased by 24% (OR, 1.24; 95% CI, 1.07-1.45). Acute and chronic football-related risk perceptions, as well as non–football-related health-risk perceptions, were positively associated with athletes’ belief that football-related dementia was likely. Higher cognitive reflection test scores, a measure of ability to switch to slow, deliberative thinking, was positively associated with odds of believing football-related dementia was likely (OR, 1.57; 95% CI, 1.12-2.21).

Conclusion:

Some athletes view football as generally riskier, while others view football as generally lessri sky. These risk postures are informed by athletes’ concussion history, primary playing position, and ability to switch from fast, reactive thinking to slow, deliberative thinking. Ensuring that athletes are appropriately informed of the risks of participation is an ethical obligation of universities; sports medicine clinicians are appropriate facilitators of conversations about athletes’ health risks.

Accuracy of US College Football Players' Estimates of Their Risk of Concussion or Injury

IMPORTANCE

Despite increased concern about the health consequences of contact sports, little is known about athletes' understanding of their own risk of sports-related injury.

OBJECTIVE

To assess whether college football players accurately estimate their risk of concussion and nonconcussion injury and to identify characteristics of athletes who misestimate their injury risk.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, questionnaires were given to 296 current college football players on 4 teams from the 3 of the 5 most competitive conferences of the US National Collegiate Athletic Association. Surveys were conducted between February and May 2017. Data were analyzed from June 2017 through July 2020.

MAIN OUTCOMES AND MEASURES

Multiple approaches were taken to compare athlete perceptions of their risks of concussion and nonconcussion injury with individual probabilities of these risks, which were modeled using logistic regression.

RESULTS

Of 296 male college-aged athletes from 4 football teams who participated in the survey, 265 (89%) answered all questions relevant for this study. Participating teams were similar to nonparticipating teams across nearly all measured characteristics. One hundred athletes (34%) had sustained 1 or more concussions, and 197 (68% of the 289 who responded to the question) had sustained 1 or more injuries in the previous football season. Logistic regression models of single-season injury and concussion had reasonably good fit (area under the curve, 0.75 and 0.73, respectively). Of the 265 participants for whom all relevant data were available, 111 (42%) underestimated their risk of concussion (χ2 = 98.6; P = .003). A similar proportion of athletes (113 [43%]) underestimated their risk of injury, although this was not statistically significant (χ2 = 34.0; P = .09). An alternative analytic strategy suggested that 241 athletes (91%) underestimated their risk of injury (Wilcoxon statistic, 7865; P < .001) and 167 (63%) underestimated their risk of concussion (Wilcoxon statistic, 26 768; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this survey study suggest that college football players may underestimate their risk of injury and concussion. The implications for informed participation in sport are unclear given that people generally underestimate health risks. It is necessary to consider whether athletes are sufficiently informed and how much risk is acceptable for an athlete to participate in a sport.

Sports Medicine Staffing Across National Collegiate Athletic Association Division I, II, and III Schools: Evidence for the Medical Model

CONTEXT

The ratio of clinicians to patients has been associated with health outcomes in many medical contexts but has not been explored in collegiate sports medicine. The relationship between administrative and financial oversight models and staffing is also unknown.

OBJECTIVE

To (1) evaluate staffing patterns in National Collegiate Athletic Association sports medicine programs and (2) investigate whether staffing was associated with the division of competition, Power 5 conference status, administrative reporting structure (medical or athletic department), or financial structure (medical or athletic department).

DESIGN

Cross-sectional study.

SETTING

Collegiate sports medicine programs.

PATIENTS OR OTHER PARTICIPANTS

Representatives of 325 universities.

MAIN OUTCOME MEASURE(S)

A telephone survey was conducted during June and July 2015. Participants were asked questions regarding the presence and full-time equivalence of the health care providers on their sports medicine staff. The number of athletes per athletic trainer was determined.

RESULTS

Responding sports medicine programs had 0.5 to 20 full-time equivalent staff athletic trainers (median = 4). Staff athletic trainers at participating schools cared for 21 to 525 athletes per clinician (median = 100). Both administrative and financial oversight from a medical department versus the athletics department was associated with improved staffing across multiple metrics. Staffing levels were associated with the division of competition; athletic trainers at Division I schools cared for fewer athletes than athletic trainers at Division II or III schools, on average. The support of graduate assistant and certified intern athletic trainers varied across the sample as did the contributions of nonphysician, nonathletic trainer health care providers.

CONCLUSIONS

In many health care settings, clinician : patient ratios are associated with patient health outcomes. We found systematic variations in clinician : patient ratios across National Collegiate Athletic Association divisions of competition and across medical versus athletics organizational models, raising the possibility that athletes' health outcomes vary across these contexts. Future researchers should evaluate the relationships between clinician : patient ratios and athletes' access to care, care provision, health care costs, health outcomes, and clinician job satisfaction.

Improving Concussion Education: Consensus From the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge

Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and MSA settings with a priori thresholds for retaining, discarding, and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and MSA cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes, and (5) organizational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioral health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.

Community-Engaged Approach to the Development and Implementation of a Student-Centered Return to Learn Care Plan After Concussion

BACKGROUND

Current return to learn (RTL) after concussion guidelines lack specificity for individualized student care, limiting potential for adoption and implementation. We used a community-engaged research framework to develop and evaluate the implementation of a student-centered care plan that assists school personnel in facilitating RTL.

METHODS

We used best-practice RTL guidelines and input from administrators and medical experts to iteratively develop a flexible student-centered care plan. Thirteen schools participated. Coding completion of care plans indicated feasibility and fidelity; interviews with RTL coordinators indicated acceptability.

RESULTS

The care plan includes educational materials, symptom checklists, and guidelines for classroom adjustments linked to student symptoms. Care plans were initiated for 24 (70.6%) of 34 students with concussions, indicating feasibility. Fidelity was high, with the following subsections completed: Action Checklist (90%), Symptom Evaluation (91%), Temporary Adjustment Recommendations (95%). Qualitative analysis of interviews suggested care plans were acceptable and facilitate consistent communication, prioritization of individual needs of students, and increased ability to delegate tasks to other school staff.

CONCLUSIONS

Implementation of a student-centered, individually tailored care plan for RTL is feasible and acceptable in public high schools. Future research should examine how to expediently initiate student-centered concussion care plans after diagnosis to optimize recovery.

International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes' mental health

Objectives

To develop an assessment and recognition tool to identify elite athletes at risk for mental health symptoms and disorders.

Methods

We conducted narrative and systematic reviews about mental health symptoms and disorders in active and former elite athletes. The views of active and former elite athletes (N=360) on mental health symptoms in elite sports were retrieved through an electronic questionnaire. Our group identified the objective(s), target group(s) and approach of the mental health tools. For the assessment tool, we undertook a modified Delphi consensus process and used existing validated screening instruments. Both tools were compiled during two 2-day meeting. We also explored the appropriateness and preliminary reliability and validity of the assessment tool.

Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1

The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) was developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for or already experiencing mental health symptoms and disorders. The SMHAT-1 consists of: (i) triage with an athlete-specific screening tool, (ii) six subsequent disorder-specific screening tools and (iii) a clinical assessment (and related management) by a sports medicine physician or licensed/registered mental health professional (eg, psychiatrist and psychologist). The International Olympic Committee Sport Mental Health Recognition Tool 1 (SMHRT-1) was developed for athletes and their entourage (eg, friends, fellow athletes, family and coaches).

Conclusion

The SMHAT-1 and SMHRT-1 enable that mental health symptoms and disorders in elite athletes are recognised earlier than they otherwise would. These tools should facilitate the timely referral of those athletes in need for appropriate support and treatment.

Improving concussion education: consensus from the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge

Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and military service academy settings with a priori thresholds for retaining, discarding and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and military service academy cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes and (5) organisational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioural health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.

Plans of US Parents Regarding School Attendance for Their Children in the Fall of 2020: A National Survey

IMPORTANCE

As schools consider reopening for in-person instruction prior to availability of a coronavirus disease 2019 (COVID-19) vaccine, families may be weighing their priorities regarding school attendance.

OBJECTIVE

To characterize the association of planned in-person school attendance during the COVID-19 pandemic with factors, including family socioeconomic characteristics, and parent attitudes and beliefs about their child's school attendance.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey study. Data were collected from June 2, 2020, to June 5, 2020, weighted to reflect population norms, and analyzed using ordered probit regression. A sample of US parents (of children ages 5-17 years) were recruited using a nonprobability survey panel with stratification by socioeconomic characteristics.

MAIN OUTCOMES AND MEASURES

The main outcome was parent-reported plan to send their child to school or keep their child home, conditional on their school opening for in-person instruction. Additional measures assessed family socioeconomic characteristics, medical vulnerability, worry about COVID-19 and multisystem inflammatory syndrome, confidence in their child's school, and homeschooling difficulties.

RESULTS

The sample of 730 parents was balanced by parent sex (53% women) with successful oversampling for Black (28%; n = 201) and Hispanic (27%; n = 200) participants. In estimates weighted to US population norms, 31% (95% CI, 27% to 34%) of participants indicated they would probably or definitely keep their child home this fall, and 49% indicated that they would probably or definitely send their child to school this fall. Factors associated with planning to keep children home included lower income (38% with incomes <$50 000 vs 21% with incomes $100 000-$150 000 per year; difference, 17%; 95% CI, 9% to 26%), being unemployed (40% unemployed vs 26% employed; difference, 14%; 95% CI, 5% to 25%), and having a flexible job (33% with flexible jobs vs 19% with inflexible jobs; difference, 14%; 95% CI, 5% to 30%). Planning to keep children home was also associated with fear of COVID-19 (B = 0.19; P < .001), fear of multisystem inflammatory syndrome (B = 0.12; P = .04), confidence in schools (B = -0.22; P < .001), and challenges of homeschooling (B = -0.12; P = .01). Race and ethnicity were not significantly associated with plans to keep children home.

CONCLUSIONS AND RELEVANCE

In this survey study, many parents planned to keep children home in fall 2020. Schools need to act soon to address parental concerns and provide options for what will be available for them should they opt to keep their child home. Structural barriers, such as lack of workplace flexibility and potential school-level inequities in implementation of preventive measures, must be acknowledged and addressed where possible.