Youth participation in tackle football is increasing each year. More than 2.8 million individuals over the age of 6 participate in tackle football.1 Two of the largest youth football organizations, Pop Warner Little Scholars and American Youth Football boast more 240,000 and 200,000 annual participants, respectively.1 Many other local, regional, and state organizations also sponsor youth tackle football leagues, which increases the total number of participants for this sport.1 As participation in youth football continues to increase, so do the numbers of injuries, particularly sport-related concussion.2 Recently, the Centers for Disease Control and Prevention declared sport-related concussion a serious public health concern.2 Given the complex nature of this injury, concussion can often go undiagnosed. The failure to recognize a concussion can possibly lead to long-term health deficits or death as a result of second-impact syndrome.3 Therefore, it is important that individuals involved in youth sports, including the players themselves, are able to recognize the signs and symptoms of a concussion, as well as understand the dangers a concussion can pose.
The recent attention on improving the detection and management methods for sport-related concussion in the professional, collegiate, and high school athletic levels has heightened the awareness and interest from both researchers and medical practitioners.4 The incidence rate of concussion at the youth sport level ranges from 2% to 6.5% of all injuries.5–8 In a more recent study, youth football players who reported to US emergency departments during 2001–2005 report 0.3 traumatic brain injuries (TBI) per 1000 participants per year for children ages 7 to 11.9 In addition, youth football players aged 12 to 17 years reported 0.8 TBIs per 1000 participants per year.9
Further research suggests that a lack of knowledge surrounding concussive symptoms has led to an underreporting of concussions.10–14 Research suggests that less than one quarter of collegiate athletes who sustained a concussion realized their symptoms were those of a concussion.10,11 Research exploring collegiate athletes’ knowledge of concussive symptoms and implications found that more than a quarter of athletes questioned continued to play while experiencing dizziness after a hit to the head.12 Furthermore, more than half of the athletes reported they did not understand the consequences that can result from a concussion.12 A study further exploring reporting behaviors of high school athletes found that not only did athletes under-report concussions, many of them continued to play in games and practices while experiencing concussive symptoms.14 That same study reported, in general, that those athletes with a higher knowledge of concussions including signs and symptoms, were more likely to report possible concussions.14 Specifically exploring youth athletes’ knowledge and attitudes toward concussion, one study suggested that although most athletes know what they should do after sustaining a possible concussion, many do not follow recommendations, perhaps returning to play too soon.15 Given the lack of research and the previously mentioned statistics, the current study aimed to assess youth football players’ knowledge and understanding of sport-related concussion.
Participants were 81 male youth football players between the ages of 8 and 14 years (M = 12.23, SD = 1.05) attending a youth tackle-football camp at a Big Ten university. Participants were from a variety of organizations and teams. Youth football players had an average of 3.62 (SD = 1.91) years of experience playing tackle football. No exclusionary criteria were used among participating athletes.
A 12-item survey was developed by researchers and certified athletic trainers to determine knowledge of sport-related concussion. Face and content validity were determined by researchers and certified athletic trainers prior to data collection. The survey went through numerous revisions prior to data collection; however, the survey was not pretested or posttested for reliability because researchers only had access to 1 group of youth football players at a single time point. Participants were asked to answer questions pertaining to the athlete’s knowledge of the dangers of concussion and whether the athlete believed he could recognize a concussion. Youth football players were presented with the following two scenarios: “If I am hit in the head and have a headache, it is OK to continue to play, as long as I didn’t lose consciousness (ie, black out)” and “If I think I may have a concussion, it is OK to continue to play football.” These questions were graded on a Likert scale ranging from 1 (disagree completely) to 5 (agree completely). Finally, the survey contained a list of 16 possible concussion signs and symptoms16; athletes attempted to identify the correct signs and symptoms, acknowledging that not all of those listed were correct.
The university’s institutional review board granted approval for the study and use of human subjects. The researchers obtained parental consent upon check in of their sons for a Big Ten university youth football camp, as well as child assents from all participants. Participants were then recruited to volunteer for the study. A total of 81 youth football players of 81 approached completed the survey on sport-related concussion knowledge during registration for the camp. Participants completed a short paper-and-pencil survey during the registration process and were given as much time as needed for completion of the survey. Participants were able to withdraw at any time and could choose to skip over questions. In addition, participants were informed they could ask questions at any time during the survey. Specifically, youth football players could ask their parents or researchers to explain any terms they did not understand. All responses were entered as anonymous data. Descriptive statistics were calculated for the demographic data, symptom score, and Likert scale questions using SPSS version 20.0 (IBM Corp, Armonk, New York). A linear regression was used to determine whether years of experience playing tackle football was predictive of symptom recognition. The statistical significance level was set at P < .05.
A total of 81 participants chose to complete the survey. Not all participants answered every question; therefore, the denominator for each question varies from 77 to 81. The mean number of correct responses for the signs and symptoms recognition portion was 11.9 ± 1.77 of 16 (74.4%) possibilities. Only 30 respondents (39%) recognized amnesia as being a correct sign of a concussion. Fewer than half (42.9%) of the participants recognized sleep disturbances as a sign of a concussion. Headache, which is the most common symptom seen with a concussion, was recognized by only 85.7% of respondents. Descriptive data on participants’ knowledge on the signs and symptoms of concussion are shown in Table 1.
Frequencies and Percentages of Players Correctly Identifying the Symptoms Presented in the Survey (N = 77)
The results of the questions answered on a Likert scale are shown in Table 2. Seventy-five percent of respondents completely agreed that they understand the dangers of concussion. Only 68.8% somewhat or completely agreed that they knew the signs and symptoms of a concussion.
Response of Youth Football Players on Concussion and Tackling Knowledge (N = 80)
Furthermore, 24.1% of respondents did not completely disagree with the statement “If I think I may have a concussion it is OK to continue to play football,” alluding to a misunderstanding of the dangers of playing with a possible concussion. Less than 40% of respondents (37.5%) completely disagreed that “If I am hit in the head and have a headache, it is OK to continue to play, as long as I didn’t lose consciousness (ie, black out),” leaving almost two-thirds of participants (62.6%) who were unsure of whether they should sit out. More specifically, almost one quarter (22.6%) of participants completely agreed or somewhat agreed with the statement, suggesting they believed that as long as they do not lose consciousness, it is OK to continue to play after being hit in the head.
Further analysis through a linear regression, exploring the years of experience playing tackle football as a predictor of symptom recognition, was not significant (t = −0.036, P = .971, R2 = 0.000). This suggests the experience gained in youth football does not predict a better recognition of concussion symptoms. Similarly, age was not predictive of symptom recognition (t = 0.848, P = .399, R2 = 0.010).
The danger of returning to play too soon after a concussion or continuing to play when a concussion is suspected necessitates a need for better understanding of concussion signs and symptoms by not only the coaches and parents but also the players themselves.3 Too often, a concussion can go unnoticed by those around the player, which makes it important for a young player to recognize the signs and symptoms of a concussion.10 Early recognition of a concussion allows the player to begin the recovery process, possibly preventing further complications or a protracted recovery. For an athlete to recognize a concussion, further education surrounding concussions is imperative, particularly given our results, which suggest that many youth football players are unaware of the signs and symptoms of a concussion.
Given that some concussions may result in many symptoms, whereas others show only one, it is important to know all of the possible signs and symptoms of a concussion, not just those most often reported. The current study showed a continued misunderstanding of the signs and symptoms of concussions. Previous research suggests that headaches are the most commonly reported symptom of a concussion.17 Although the majority of our respondents recognized headache as a concussive symptom, 14.3% still failed to recognize headache as a symptom. Research also suggests dizziness and confusion are frequently reported with concussions.17 In the current research, 11.7% of respondents failed to recognize dizziness as a symptom, whereas almost one quarter of respondents (23.4%) did not select confusion as a symptom. Given these findings, the current study suggests that even the most frequently reported symptoms may be unknown to some youth football players.
The presence of on-field amnesia has been found to be predictive of neurocognitive deficits.18 Given these findings, it is important to recognize amnesia as a concussive symptom. However, the current study found that the majority of participants did not recognize amnesia as a symptom. In fact, amnesia was recognized as a symptom by only 39% of athletes. Future research should continue to explore this lack of recognition, as the current participants may not have understood the term amnesia.
Although loss of consciousness has been shown not to be predictive of recovery from a concussion,18 almost one quarter (22.6%) of the athletes somewhat agreed that it was okay to return to play with a headache, as long as there had been no loss of consciousness. In fact, only 37.5% of participants disagreed completely with the statement. This sort of misconception can lead to an athlete returning to play while still experiencing concussive symptoms (ie, a headache). If an athlete returns to play too soon, the effects can be catastrophic.3 Specifically, younger athletes returning to play too soon can incur second impact syndrome or possibly death.19
The current results indicate that many athletes are unaware of the common signs and symptoms of concussions and could, after incurring a concussion, continue to play while experiencing concussive symptoms. This supports previous research suggesting that athletes may continue to play in practice and games even while continuing to experience concussive symptoms.16 Thus, further education about concussion among youth football players is needed to alleviate many of the misconceptions that still exist.
Our study was limited by many factors, including those inherent to survey research. We assumed that the players themselves were answering the questions and that the parents and other participants nearby were not influencing them. The survey also assumes that respondents are answering truthfully and carefully, fully reading all questions. Certain vernacular used in the survey, such as the word amnesia, may have been difficult for the participants to understand. However, youth football players could ask their parents to explain any terms they did not understand, and researchers were nearby and were available to answer any questions the participants may have. Given the time frame and the ability to reach this particular sample, the survey did not undergo any pretesting for reliability, although face and content validity were determined by certified athletic trainers and researchers before testing. More specific demographic data regarding race and ethnicity were not obtained, presumably limiting the ability to generalize the findings. Also, information regarding previous concussion education was not gathered, making it difficult to ascertain whether more education is needed or the education given is not appropriate and therefore different education is needed. Furthermore, information regarding any history of concussions was not gathered, which may have influenced the results. Finally, the survey was administered at a Big Ten university football camp and may not represent those players who do not attend similar camps. Despite these limitations, our findings suggest that the knowledge and understanding youth football players have about concussions may be inadequate. Further education is needed to ensure proper management of concussive injuries. Specific attention should be paid to the understanding of the most common signs and symptoms of a concussion and what action should be taken if a concussion is suspected. In addition, research should continue to explore ways to enhance concussion knowledge and understanding among youth athletes, potentially introducing an educational intervention designed to increase this knowledge.
Implications for Clinical Practice
Given the study findings, school football programs should implement an educational intervention with the coaches and players to ensure proper recognition of potential concussive injuries and continue to explore the effectiveness of these interventions with pre- and posttests. Because previous research suggests youth football coaches are not fully aware of the signs and symptoms of a concussion or the implications of such injuries,15 the players themselves must be knowledgeable and able to recognize a suspected concussion. However, the current study demonstrates the athletes themselves are not informed of the potential signs and symptoms of a concussion. Many athletes failed to recognize common signs and symptoms of a concussion; furthermore, the majority suggested it would be okay to continue to play after sustaining a possible concussion, as long as no loss of consciousness occurred. Given the previously mentioned dangers of returning to play too soon, specifically the risk of second impact syndrome,3 education should be implemented with the intent to increase awareness of the signs and symptoms of a concussion, the dangers of returning to play too soon, and what to do if a suspected concussion has occurred. Specifically, information should be distributed to the coaches, players, and parents, describing the signs and symptoms of a concussion and noting what to do if a suspected concussion has occurred.
- Sporting Goods Manufacturers Association. (2009). Single Sport Report. Vol. 2010. Silver Spring, MD: Sporting Goods Manufacturers Association.
- Wong RH, Wong AK, Bailes JE. Frequency, magnitude, and distribution of head impacts in Pop Warner football: the cumulative burden. Clin Neurol Neurosurg. 2014;118:1–4. doi:10.1016/j.clineuro.2013.11.036 [CrossRef]
- Cantu RC. Second impact syndrome. Clin Sports Med. 1998;17(1):37–44. doi:10.1016/S0278-5919(05)70059-4 [CrossRef]
- McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus statement on Concussion in Sport 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Athl Train. 2009;4(4):434–448. doi:10.4085/1062-6050-44.4.434 [CrossRef]
- Adickes MS, Stuart MJ. Youth football injuries. Sports Medicine. 2004;34(3):201–207. doi:10.2165/00007256-200434030-00005 [CrossRef]
- Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503.
- Stuart MJ, Morrey MA, Smith AM, Meis JK, Ortiguera CJ. Injuries in youth football: a prospective observational cohort analysis among players aged 9 to 13 years. Mayo Clin Proc. 2002;77(4):317–322. doi:10.4065/77.4.317 [CrossRef]
- Dompier T, Powell J, Barron M, Moore M. Time-loss and non–time-loss injuries in youth football players. J Athl Train. 2007;42(3):395–402.
- Mello MJ, Myers R, Christian JB, Palmisciano L, Linakis JG. Injuries in youth football: national emergency department visits during 2001–2004 for young and adolescent players. Acad Emerg Med. 2009;16(3), 243–248. doi:10.1111/j.1553-2712.2009.00357.x [CrossRef]
- Delaney JS, Lacroix VJ, Gagne C, Antoniou J. Concussions among university football and soccer players: a pilot study. Clin J Sport Med. 2001;11(4):234–240. doi:10.1097/00042752-200110000-00005 [CrossRef]
- Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concussions among university football and soccer players. Clin J Sport Med. 2002;12(6):331–338. doi:10.1097/00042752-200211000-00003 [CrossRef]
- Kaut KP, DePompei R, Kerr J, Congeni J. Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention. Clin J Sport Med. 2003;13(4):213–221. doi:10.1097/00042752-200307000-00004 [CrossRef]
- McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004;14(1):13–17. doi:10.1097/00042752-200401000-00003 [CrossRef]
- Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Mueller FO, Marshall SW. Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study. J Athl Train. 2013;48(5):645–653. doi:10.4085/1062-6050-48.3.20 [CrossRef]
- Mrazik M, Perra A, Brooks BL, Naidu D. Exploring minor hockey players’ knowledge and attitudes toward concussion: implications for prevention [published online ahead of print February 28, 2014]. J Head Trauma Rehabil. doi:10.1097/HTR.0000000000000018 [CrossRef]
- Valovich McLeod TC, Schwartz C, Bay RC. Sport-related concussion misunderstandings among youth coaches. Clin J Sport Med. 2007;17(2):140–142. doi:10.1097/JSM.0b013e31803212ae [CrossRef]
- Guskiewicz KM, Weaver NL, Padua DA, Garrett WE. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med. 2000;28(5):643–650.
- Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med. 2003;13(4):222–229. doi:10.1097/00042752-200307000-00005 [CrossRef]
- Cantu R, Voy R. Second impact syndrome. Phys Sportsmed. 1995;23(6):27–34.
Frequencies and Percentages of Players Correctly Identifying the Symptoms Presented in the Surveya (N = 77)
|Abnormal sense of smell||70 (90.9)|
|Abnormal sense of taste||72 (93.5)|
|Blurred vision||63 (81.8)|
|Black eye||73 (94.8)|
|Chest pain||73 (94.8)|
|Loss of consciousness||60 (77.9)|
|Numbness/tingling in upper extremity||56 (72.7)|
|Sharp burning pain in the neck||51 (66.2)|
|Sleep disturbances||33 (42.9)|
|Weakness of neck range of motion||44 (57.1)|
Response of Youth Football Players on Concussion and Tackling Knowledge (N = 80)
|QUESTION||NO. (%) OF RESPONDENTS|
|DISAGREE COMPLETELY (1)||DISAGREE SOMEWHAT (2)||NEITHER AGREE NOR DISAGREE (3)||AGREE SOMEWHAT (4)||AGREE COMPLETELY (5)|
|I understand the dangers of concussions||0 (0)||0 (0)||4 (5)||16 (20)||60 (75)|
|I know the signs and symptoms of a concussion||7 (8.8)||4 (5)||14 (17.5)||32 (40)||23 (28.8)|
|If I am hit in the head and have a headache, it is okay to continue to play as long as I didn’t lose consciousness (ie, black out)||30 (37.5)||8 (10)||24 (30)||7 (8.8)||11 (13.8)|
|If I think I may have a concussion, it is okay to continue to play football||60 (75)||6 (7.5)||7 (8.8)||3 (3.8)||3 (3.8)|