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.

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.

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.

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.

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.

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.

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.

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.

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.

Many youths in the United States have access to an unlocked firearm in their home. Accidental discharge of unlocked firearms is a common cause of youth injury and death. Discussions between adult family members have the potential to move families towards safer firearm storage practices. We surveyed 749 firearm-owning parents in the United States who live with a romantic partner and have at least one child under the age of 18. Nearly two-thirds of families stored all firearms locked and unloaded. In slightly more than half of families, the person responding to the survey and their romantic partner were both highly involved in storage-related decision making. Families where both parties were highly involved in these decisions were more than one and a half times more likely to store firearms locked and unloaded compared to families where both parties were not involved in these decisions. This shared involvement in decision making was more likely in higher quality relationships and in relationships where there was less avoidance of the topic of firearm storage. Learning how to support positive and useful discussions within families about firearm storage is an important direction for future work.

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 (ß: -1.26, 95% CI: -2.25, -0.27) and a lower PHQ-4 total score among parents (ß: -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 (ß: 1009 MET-min/week, 95% CI: 301, 1717), but not child physical activity (ß: 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.

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.

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.

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.

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.

What Do Parents Need to Know About Concussion? Developing Consensus Using the Delphi Method.

OBJECTIVE: Many schools and sports leagues provide preseason concussion education to parents/guardians, and in some jurisdictions, it is required for interscholastic sports participation. However, directives about content are absent or vague. The purpose of this study was to obtain expert consensus about what parents/guardians need to know to about concussion. DESIGN: A modified Delphi process with nationally recognized expert panel members was used to obtain consensus about parent/guardian behaviors relevant to concussion prevention, identification, and management and knowledge domains relevant to performance of those behaviors. RESULTS: Sixteen parent/guardian behaviors and 24 knowledge domains were identified. However, consensus was not achieved regarding whether it is realistic to expect parents/guardians to perform approximately one-third of the behaviors that experts agreed mattered. This variability may reflect underlying uncertainty about the capacities of some parents/guardians to put knowledge into action or the belief that there are other barriers to action. Furthermore, for most knowledge domains, there was a lack of agreement about whether or not there could be a "correct" answer on the basis of current scientific knowledge. CONCLUSIONS: These findings raise practical and ethical questions: how can we expect parents/guardians to help prevent, identify, or manage concussion if they cannot have all the information required to engage in these behaviors due to lack of scientific consensus? This issue is not unique to concussion. Best practices for risk communication and shared decision-making can inform how we think about educating parents/guardians about concussion inside and outside of the health care setting.

Understanding Decision Making by Families About Youth Football Participation Postconcussion.

Many families are concerned about their child's risk of concussion, and some seek counsel from clinicians about whether or not to return to contact sports participation postinjury. The present study sought to identify factors that parents weight most heavily in forming their preferences regarding whether their child should return to contact sport after recovering from a concussion. Survey data were collected from 568 parents of youth football players (aged 7-14 years) in the Pacific Northwest region of the United States (73% response rate). Approximately two thirds (63%) of parents preferred that their child retire from football after one or two concussions. Multivariable linear regression indicated parents above the sample mean in terms of how strongly they valued football participation preferred their child stop after more concussions than parents below the sample mean (ß = .44, standard error [SE] = 0.06, p < .001). Factors endorsed by the most parents as making them "much more likely" to want their child to stop playing football included the belief that their child will experience cognitive issues later in life as a result of concussions (65.0%) and that their child will get another concussion while playing football (43.5%). Within the context of a clinical visit postconcussion, physicians may need to help families clarify their values related to football participation and provide information about the potential outcomes of returning to contact sport. A formalized shared decision aid could help support consistent implementation of this potentially challenging conversation.

Content analysis of concussion education for coaches of youth and high school sport.

OBJECTIVE: Describe the extent to which concussion education provided to coaches of US high school and youth sport is inclusive of information necessary for them to engage in target behaviors related to the prevention, identification and management of concussion. METHODS: Sport organizations included in the sample were US state high school governing bodies and national governing bodies (NGBs) for youth sports with the highest concussion incidence rates. The concussion education resources made available online for coaches by these organizations were coded for content relevant to concussion prevention, identification and management. RESULTS: All but one state high school governing body required coach concussion education, two NGBs required coach education, seven recommended it and only one did not require or recommend it. All educational materials covered at least 84% (n = 16/19) of the relevant knowledge domains. DISCUSSION: Existing concussion education for coaches is addressing most, but not all, topics that may help coaches engage in concussion prevention, identification and management. Additional program development work is warranted to augment educational content related to coach communication about concussion safety with athletes and parents. Content appropriateness notwithstanding, further research is needed to understand the acceptability, efficacy, and implementation of concussion education for coaches.

Social support during youth concussion recovery.

PURPOSE: We explored the lived experience of high-school aged girls receiving social support during concussion recovery to better understand (1) how they define meaningful social support and barriers/facilitators to receiving it; (2) who provides that support; and (3) the role of peers. METHODS: In person, semi-structured interviews were conducted with 10 girls (aged 14-19 years) with a personal history of concussion. RESULTS: Close friends, youth with personal history of concussion, and parents were identified as key providers of meaningful social support during concussion recovery. Participants identified specific examples of support provided by each group. Close friends built a sense of social inclusion that mitigated feelings of social isolation. Youth with a personal history of concussion used their lived experiences to communicate empathy and validate the participant's challenges. Parents assisted with practical challenges (e.g. accessing accommodations) by leveraging their "adult power". Participants identified that lack of understanding of their lived experiences was a key barrier to receiving support. They proposed solutions focused on education initiatives highlighting personal accounts from youth with concussion, and specific examples of how peers can help. CONCLUSIONS: Fostering social support may require strategies tailored to each group of key providers as they mitigate different challenges in recovery.

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.

Concussion Incidence, Duration, and Return to School and Sport in 5- to 14-Year-Old American Football Athletes.

OBJECTIVE: To collect prospective data on concussion incidence, risk factors, duration of symptoms, and return to school and sport in 5- to 14-year-old American football participants. STUDY DESIGN: We conducted a prospective cohort study over 2 years collecting data during two 10-week fall seasons. Youth with concussion were followed to determine time to return to school, sport, and baseline level of symptoms. Logistic regression was used to estimate the risk of sustaining a concussion associated with baseline demographic factors. Time to return to school, sport, and baseline symptoms were analyzed using Kaplan-Meier survival curves. RESULTS: Of 863 youth followed (996 player-seasons), 51 sustained a football-related concussion, for an athlete-level incidence of 5.1% per season. Youth with history of concussion had a 2-fold increased risk for sustaining an incident concussion (OR, 2.2; 95% CI, 1.1-4.8). Youth with depression had a 5-fold increased risk of concussion (OR, 5.6; 95% CI, 1.7-18.8). After a concussion, 50% of athletes returned to school by 3 days, 50% returned to sport by 13 days, and 50% returned to a baseline level of symptoms by 3 weeks. CONCLUSIONS: Concussion rates in this study were slightly higher than previously reported, with 5 of every 100 youth sustaining a football-related concussion each season. One-half of youth were still symptomatic 3 weeks after injury. Further research is needed to address the risk of concussion in youth football.