Perceived Coach Support and Concussion Symptom-Reporting: Differences between Freshmen and NonFreshmen College Football Players Christine M. Baugh, Emily Kroshus, Daniel H. Daneshvar, and Robert A. Stern
314
Introduction Concussion is a form of traumatic brain injury that has been defined as a “trauma-induced alteration in mental status that may or may not involve loss of consciousness.”1 Terms such as getting a “ding” or getting your “bell rung” are sometimes used as colloquialisms for concussion, but inappropriately downplay the seriousness of the injury.2 It is estimated that between 1.6 and 3.8 million concussions occur annually in the United States as a result of participation in sports or recreational activities.3 To date, there are no objective, biological markers for concussion; rather, the current diagnosis of concussion is dependent upon symptom reporting by the athlete. In the acute phase, concussions can result in a broad spectrum of symptoms that can be transient or last for days, weeks, or even months.4 Symptom prolongation is generally referred to as post-concussion syndrome.5 Variation in sympChristine M. Baugh, M.P.H., is the Clinical Research and Program Coordinator at the Boston University Chronic Traumatic Encephalopathy Center, a Research Instructor in Neurology at the Boston University School of Medicine, and a Lab Fellow at the Edmond J. Safra Center for Ethics at Harvard University. Christine received a master’s degree in public health (M.P.H.) concentrating in Health Law, Bioethics, and Human Rights from Boston University School of Public Health (Boston, MA) and a bachelor of arts (B.A.) in history and science from Harvard University (Cambridge, MA). She will be matriculating into Harvard’s Health Policy Ph.D. Program, concentrating in ethics, in fall 2014 (Cambridge, MA). Emily Kroshus, Sc.D., M.P.H., received her doctor of science (Sc.D.) from Harvard University’s School of Public Health in the Department of Social and Behavioral Sciences, with a concentration in Health Communication (Boston, MA). She has a master’s degree in public health (M.P.H.) from Johns Hopkins University’s Bloomberg School of Public Health (Baltimore, MD), and a bachelor of arts (B.A.) degree in economics from Princeton University (Princeton, NJ). Emily is currently a post-doctoral research fellow at the NCAA Sport Science Institute. Daniel H. Daneshvar, M.A., is an M.D./Ph.D. dual degree candidate at the Boston University School of Medicine (BUSM; Boston, MA). He has completed the degree requirements for a Ph.D. in Behavioral Neuroscience at BUSM, where he also completed his master’s degree. He received his bachelor of science (B.S.) in Brain and Cognitive Sciences from the Massachusetts Institute of Technology (MIT; Cambridge, MA). He is also the Co-Founder and Executive Director of the Sports Legacy Institute Community Educators (SLICE) program (Waltham, MA). Robert A. Stern, Ph.D., is a Professor of Neurology, Neurosurgery, and Anatomy and Neurobiology at Boston University School of Medicine (Boston, MA), where he is also Director of the Clinical Core of the Boston University (BU) Alzheimer’s Disease Center and the co-founder of the BU Center for the Study of Traumatic Encephalopathy. Dr. Stern received his Ph.D. from the University of Rhode Island in Clinical Psychology (Neuropsychology) and his bachelor of arts degree from Wesleyan University (Middletown, CT), and completed his post-doctoral fellowship training at the University of North Carolina School of Medicine (Chapel Hill, NC). journal of law, medicine & ethics
Baugh, Kroshus, Daneshvar, and Stern
tom duration is not well understood, but it is thought that cognitive and physical rest after the initial injury is critical.6 Repetitive concussive injuries are thought to lead to a later-life neurodegenerative disease called chronic traumatic encephalopathy, in some people.7 Given the incidence, prevalence, and possible shortterm and long-term health consequences, concussions have been increasingly seen as a public health priority.8 Due to the wide variety of signs and symptoms of concussion and the partial reliance on athlete selfreport of symptoms, the process of diagnosing concussion can be complex.9 Some studies have estimated that over 50% of concussions go undiagnosed,10 in large part due to athletes failing to report symptoms. This is especially problematic as athletes experiencing concussion symptoms and continuing to participate in their sport both prolong the recovery from their initial injury11 and put themselves at greater risk for magnified neurological consequences.12 Understanding factors that impact whether athletes report concussion symptoms will improve the overall concussion identification and management process, and ultimately improve athlete health outcomes. Previous studies have asked athletes why they did not report symptoms after a head impact. Zackery Kerr and colleagues provide a thorough review of rationales for athlete non-report of concussion symptoms.13 Some non-report is attributed to a lack of knowledge, such as not being aware that the injury was a concussion or that the symptoms should be reported.14 Other reasons reflect a decision that was, to at least some extent, volitional: for example, not wanting to be removed from a game or practice, not wanting to let down teammates or coaches, or fearing being cut from a team or receiving less playing time.15 Although the issue of athlete non-report of concussion exists at all levels of sport, it is of particular interest in collegiate sports where the incidence of diagnosed concussions is higher than at younger ages and lower levels of competition.16 The transition from high school to college is a time of heightened social and emotional disruption for many first-year students (often termed freshmen, in the U.S.).17 Freshmen athletes face an additional set of challenges: in addition to adapting to new academic and social environments, they must also adapt to a new athletic environment, including a change in coaches, teammates, competitiveness, and expectations.18 This transition is also often accompanied by a perceived loss of status as a standout athlete and decreased playing time.19 The time dedicated to sport, competitiveness of sport, and within team competition for playing time often also increase dramatically. concussions and sports • fall 2014
Importantly, athletes’ relationships with their coaches change as well; in high school, standout athletes often have very close personal relationships with their coaches.20 However, there can be an abrupt transition in college where head coaches have many other time constraints and may spend much less time with the athletes, particularly freshmen.21 Incentives for coaches also are different at the high school and college levels. Most high school coaches are teachers at the school and receive a modest income of $32,120, on average, for their dual responsibilities.22 In contrast, the most successful NCAA Division I college football coaches make over a million dollars per year with the potential for sizeable performancebased bonuses,23 not to mention performance-based job security.24 For this constellation of reason, college athletics, and in particular revenue producing sports such as Division I men’s football, is understandably a very different experience than high school athletics and may require time for adjustment for incoming students. The transition period from high school to college is an area currently unexplored in the concussion literature. When thinking about risk in the sport setting at the transition between high school and college, Bronfenbrenner’s Social Ecological Model25 is useful for framing the multiple levels of influence on concussion safety behaviors. These influences range from individual cognitions about safety, to interpersonal pressure or support for safety behaviors, to policy level variables to limit exposure to contact.26 Within the athletic environment, coaches and teammates are particularly influential on athlete’s decisions regarding safety behaviors.27 There may be variability between U.S. college coaches in the extent to which they communicate with athletes in support of concussion safety, and it is possible that those coaches who are more knowledgeable about concussions are more likely to communicate in support of concussion safety. In communicating directly with athletes in this capacity, coaches may be influencing athlete perceptions of injunctive norms: what they think others want them to do. The influence of coaches may also be a function of the individual athlete’s perceptions of the concussion-related attitudes and behaviors of these other actors — these perceptions are often termed descriptive norms. In a sample of male collegiate ice hockey players, their perception about what “most athletes” would do regarding concussion safety was a stronger predictor of athletes’ concussion symptom reporting than other variables such as their concussion knowledge or their concussion history.28 Norms are an important construct of the Theory of Planned Behavior (TPB).29 TPB has recently been pro315
S Y MPO SIUM
posed as relevant for explaining the motivational component of concussion reporting behavior.30 Within the formulation of TPB, behavior is, in part a product of how the athlete thinks others want him to behave in a given situation, and in part the importance the athlete places on the opinion of these others. Coaches play a central role in the lives of many college athletes, controlling playing time and in some cases serving as a parental figure for athletes who are away from home for the first time.31 Thus, seeking their approval and avoiding their disapproval may be considered important to some athletes. Learning what behaviors their coach values is a process that may take time. Freshmen may enter college with a good sense of whether or not their high school coach would want them to report symptoms of a suspected concussion, and they may speculate about whether or not their college coach would want them to report. However, it may take actually playing for the coach to internalize the correct injunctive norms through his verbal and nonverbal communication. The primary aim of this paper was to examine whether among U.S. college football players perceived support for concussion reporting from coaches and teammates would differ by the athlete’s year in school. We hypothesized that freshmen would perceive more support for concussion reporting from their coach than would their upperclassmen teammates. This hypothesis was based on the idea that increased competitive pressures in collegiate sport relative to high school may provide a disincentive for college coaches to encourage concussion reporting behaviors, and that for athletes, determining what the coach considers to be desirable safety behaviors is facilitated by exposure to the coach throughout a season of play. The secondary aim was to see whether perceived support for concussion reporting was associated with concussion reporting behaviors. Here we hypothesized that freshmen would be more likely to report symptoms of a concussion than older athletes, with perceived coach support attenuating this association. In addition, across all class years of athletes, those who perceive greater support from their coach to report a possible concussion would more frequently report concussion symptoms and less frequently continue to play while experiencing concussion symptoms.
Materials and Methods Sample and Procedure Coaches and/or athletic trainers at 110 NCAA Division 1 Football Championship Series schools were contacted prior to the start of the 2013 football season and asked whether their football team could partici316
pate in a survey-based study on concussions in collegiate sports. A convenience sample of 734 football players from 10 schools agreed to participate on a voluntary basis. The cohort included 230 freshmen, 164 sophomores, 189 juniors, 134 seniors, 17 second year seniors, and 4 athletes who did not provide their year in school. Due to the small class, second year seniors were restricted from this study’s sample, as were athletes who did not provide their year in school. Thus, 717 participants were included in the present analyses. Athletes were administered a survey in-person, in a group setting, at or near the athletic facility of the home institution, by a member of the research team. All surveys were completed during the 2013 football season. All research activities were approved by the Institutional Review Board at Boston University Medical Center and participants provided their informed consent prior to survey administration. All athletes were participating in a larger study of collegiate concussion management. Measures Demographic Characteristics: Athletes were asked to provide their year in school. Perceived Concussion Reporting Consequences: Athletes were asked, “If I report what I suspect might be a concussion, my [referent] would think I made the right decision.” Referents queried were: “my teammates,” and “my coach.” Responses were provided on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Concussion Frequency and Returning to Play with Concussion Symptoms: Athletes were asked to writein their numeric response to a series of questions related to concussion and suspected concussions sustained while playing football. Athletes were asked the following four questions, with regards to the two weeks prior to the survey: “How many times have you been diagnosed with a concussion by a medical professional (doctor, athletic trainer, nurse)?” “How many times have you sustained an impact that you suspect was a concussion but that was never diagnosed?” “How many times did you get a ding or get your bell rung?” “How many times have you returned to a game or practice while experiencing symptoms after a hit?” Athletes were also asked about the total number of diagnosed concussions during their football career.
journal of law, medicine & ethics
Baugh, Kroshus, Daneshvar, and Stern
Analysis All analyses were conducted in SPSS v.20. An alpha of 0.05 was adopted. Details of the statistical methodology can be found in Appendix 1.
Results There was a significant difference in perceived coach support for concussion reporting by year in school (F=3.90, p=0.009). Tukey post-hoc tests indicated that there were significant differences between freshmen and juniors (p=0.029) and freshmen and seniors (p=0.040). The difference between freshmen and sophomores did not reach statistical significance (p=0.055). In all cases, freshmen agreed more than their older teammates that their coaches supported concussion reporting. There were no significant differences between athletes from different years in school in perceived teammate support for reporting a possible concussion. Date of survey was not independently correlated with any perceived support outcome variable and thus was not included in the final regression models. See Table 1 for details. Generalized Linear Model (GLM) regression examining perceived coach support was significant overall (omnibus test value p
314
Introduction Concussion is a form of traumatic brain injury that has been defined as a “trauma-induced alteration in mental status that may or may not involve loss of consciousness.”1 Terms such as getting a “ding” or getting your “bell rung” are sometimes used as colloquialisms for concussion, but inappropriately downplay the seriousness of the injury.2 It is estimated that between 1.6 and 3.8 million concussions occur annually in the United States as a result of participation in sports or recreational activities.3 To date, there are no objective, biological markers for concussion; rather, the current diagnosis of concussion is dependent upon symptom reporting by the athlete. In the acute phase, concussions can result in a broad spectrum of symptoms that can be transient or last for days, weeks, or even months.4 Symptom prolongation is generally referred to as post-concussion syndrome.5 Variation in sympChristine M. Baugh, M.P.H., is the Clinical Research and Program Coordinator at the Boston University Chronic Traumatic Encephalopathy Center, a Research Instructor in Neurology at the Boston University School of Medicine, and a Lab Fellow at the Edmond J. Safra Center for Ethics at Harvard University. Christine received a master’s degree in public health (M.P.H.) concentrating in Health Law, Bioethics, and Human Rights from Boston University School of Public Health (Boston, MA) and a bachelor of arts (B.A.) in history and science from Harvard University (Cambridge, MA). She will be matriculating into Harvard’s Health Policy Ph.D. Program, concentrating in ethics, in fall 2014 (Cambridge, MA). Emily Kroshus, Sc.D., M.P.H., received her doctor of science (Sc.D.) from Harvard University’s School of Public Health in the Department of Social and Behavioral Sciences, with a concentration in Health Communication (Boston, MA). She has a master’s degree in public health (M.P.H.) from Johns Hopkins University’s Bloomberg School of Public Health (Baltimore, MD), and a bachelor of arts (B.A.) degree in economics from Princeton University (Princeton, NJ). Emily is currently a post-doctoral research fellow at the NCAA Sport Science Institute. Daniel H. Daneshvar, M.A., is an M.D./Ph.D. dual degree candidate at the Boston University School of Medicine (BUSM; Boston, MA). He has completed the degree requirements for a Ph.D. in Behavioral Neuroscience at BUSM, where he also completed his master’s degree. He received his bachelor of science (B.S.) in Brain and Cognitive Sciences from the Massachusetts Institute of Technology (MIT; Cambridge, MA). He is also the Co-Founder and Executive Director of the Sports Legacy Institute Community Educators (SLICE) program (Waltham, MA). Robert A. Stern, Ph.D., is a Professor of Neurology, Neurosurgery, and Anatomy and Neurobiology at Boston University School of Medicine (Boston, MA), where he is also Director of the Clinical Core of the Boston University (BU) Alzheimer’s Disease Center and the co-founder of the BU Center for the Study of Traumatic Encephalopathy. Dr. Stern received his Ph.D. from the University of Rhode Island in Clinical Psychology (Neuropsychology) and his bachelor of arts degree from Wesleyan University (Middletown, CT), and completed his post-doctoral fellowship training at the University of North Carolina School of Medicine (Chapel Hill, NC). journal of law, medicine & ethics
Baugh, Kroshus, Daneshvar, and Stern
tom duration is not well understood, but it is thought that cognitive and physical rest after the initial injury is critical.6 Repetitive concussive injuries are thought to lead to a later-life neurodegenerative disease called chronic traumatic encephalopathy, in some people.7 Given the incidence, prevalence, and possible shortterm and long-term health consequences, concussions have been increasingly seen as a public health priority.8 Due to the wide variety of signs and symptoms of concussion and the partial reliance on athlete selfreport of symptoms, the process of diagnosing concussion can be complex.9 Some studies have estimated that over 50% of concussions go undiagnosed,10 in large part due to athletes failing to report symptoms. This is especially problematic as athletes experiencing concussion symptoms and continuing to participate in their sport both prolong the recovery from their initial injury11 and put themselves at greater risk for magnified neurological consequences.12 Understanding factors that impact whether athletes report concussion symptoms will improve the overall concussion identification and management process, and ultimately improve athlete health outcomes. Previous studies have asked athletes why they did not report symptoms after a head impact. Zackery Kerr and colleagues provide a thorough review of rationales for athlete non-report of concussion symptoms.13 Some non-report is attributed to a lack of knowledge, such as not being aware that the injury was a concussion or that the symptoms should be reported.14 Other reasons reflect a decision that was, to at least some extent, volitional: for example, not wanting to be removed from a game or practice, not wanting to let down teammates or coaches, or fearing being cut from a team or receiving less playing time.15 Although the issue of athlete non-report of concussion exists at all levels of sport, it is of particular interest in collegiate sports where the incidence of diagnosed concussions is higher than at younger ages and lower levels of competition.16 The transition from high school to college is a time of heightened social and emotional disruption for many first-year students (often termed freshmen, in the U.S.).17 Freshmen athletes face an additional set of challenges: in addition to adapting to new academic and social environments, they must also adapt to a new athletic environment, including a change in coaches, teammates, competitiveness, and expectations.18 This transition is also often accompanied by a perceived loss of status as a standout athlete and decreased playing time.19 The time dedicated to sport, competitiveness of sport, and within team competition for playing time often also increase dramatically. concussions and sports • fall 2014
Importantly, athletes’ relationships with their coaches change as well; in high school, standout athletes often have very close personal relationships with their coaches.20 However, there can be an abrupt transition in college where head coaches have many other time constraints and may spend much less time with the athletes, particularly freshmen.21 Incentives for coaches also are different at the high school and college levels. Most high school coaches are teachers at the school and receive a modest income of $32,120, on average, for their dual responsibilities.22 In contrast, the most successful NCAA Division I college football coaches make over a million dollars per year with the potential for sizeable performancebased bonuses,23 not to mention performance-based job security.24 For this constellation of reason, college athletics, and in particular revenue producing sports such as Division I men’s football, is understandably a very different experience than high school athletics and may require time for adjustment for incoming students. The transition period from high school to college is an area currently unexplored in the concussion literature. When thinking about risk in the sport setting at the transition between high school and college, Bronfenbrenner’s Social Ecological Model25 is useful for framing the multiple levels of influence on concussion safety behaviors. These influences range from individual cognitions about safety, to interpersonal pressure or support for safety behaviors, to policy level variables to limit exposure to contact.26 Within the athletic environment, coaches and teammates are particularly influential on athlete’s decisions regarding safety behaviors.27 There may be variability between U.S. college coaches in the extent to which they communicate with athletes in support of concussion safety, and it is possible that those coaches who are more knowledgeable about concussions are more likely to communicate in support of concussion safety. In communicating directly with athletes in this capacity, coaches may be influencing athlete perceptions of injunctive norms: what they think others want them to do. The influence of coaches may also be a function of the individual athlete’s perceptions of the concussion-related attitudes and behaviors of these other actors — these perceptions are often termed descriptive norms. In a sample of male collegiate ice hockey players, their perception about what “most athletes” would do regarding concussion safety was a stronger predictor of athletes’ concussion symptom reporting than other variables such as their concussion knowledge or their concussion history.28 Norms are an important construct of the Theory of Planned Behavior (TPB).29 TPB has recently been pro315
S Y MPO SIUM
posed as relevant for explaining the motivational component of concussion reporting behavior.30 Within the formulation of TPB, behavior is, in part a product of how the athlete thinks others want him to behave in a given situation, and in part the importance the athlete places on the opinion of these others. Coaches play a central role in the lives of many college athletes, controlling playing time and in some cases serving as a parental figure for athletes who are away from home for the first time.31 Thus, seeking their approval and avoiding their disapproval may be considered important to some athletes. Learning what behaviors their coach values is a process that may take time. Freshmen may enter college with a good sense of whether or not their high school coach would want them to report symptoms of a suspected concussion, and they may speculate about whether or not their college coach would want them to report. However, it may take actually playing for the coach to internalize the correct injunctive norms through his verbal and nonverbal communication. The primary aim of this paper was to examine whether among U.S. college football players perceived support for concussion reporting from coaches and teammates would differ by the athlete’s year in school. We hypothesized that freshmen would perceive more support for concussion reporting from their coach than would their upperclassmen teammates. This hypothesis was based on the idea that increased competitive pressures in collegiate sport relative to high school may provide a disincentive for college coaches to encourage concussion reporting behaviors, and that for athletes, determining what the coach considers to be desirable safety behaviors is facilitated by exposure to the coach throughout a season of play. The secondary aim was to see whether perceived support for concussion reporting was associated with concussion reporting behaviors. Here we hypothesized that freshmen would be more likely to report symptoms of a concussion than older athletes, with perceived coach support attenuating this association. In addition, across all class years of athletes, those who perceive greater support from their coach to report a possible concussion would more frequently report concussion symptoms and less frequently continue to play while experiencing concussion symptoms.
Materials and Methods Sample and Procedure Coaches and/or athletic trainers at 110 NCAA Division 1 Football Championship Series schools were contacted prior to the start of the 2013 football season and asked whether their football team could partici316
pate in a survey-based study on concussions in collegiate sports. A convenience sample of 734 football players from 10 schools agreed to participate on a voluntary basis. The cohort included 230 freshmen, 164 sophomores, 189 juniors, 134 seniors, 17 second year seniors, and 4 athletes who did not provide their year in school. Due to the small class, second year seniors were restricted from this study’s sample, as were athletes who did not provide their year in school. Thus, 717 participants were included in the present analyses. Athletes were administered a survey in-person, in a group setting, at or near the athletic facility of the home institution, by a member of the research team. All surveys were completed during the 2013 football season. All research activities were approved by the Institutional Review Board at Boston University Medical Center and participants provided their informed consent prior to survey administration. All athletes were participating in a larger study of collegiate concussion management. Measures Demographic Characteristics: Athletes were asked to provide their year in school. Perceived Concussion Reporting Consequences: Athletes were asked, “If I report what I suspect might be a concussion, my [referent] would think I made the right decision.” Referents queried were: “my teammates,” and “my coach.” Responses were provided on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Concussion Frequency and Returning to Play with Concussion Symptoms: Athletes were asked to writein their numeric response to a series of questions related to concussion and suspected concussions sustained while playing football. Athletes were asked the following four questions, with regards to the two weeks prior to the survey: “How many times have you been diagnosed with a concussion by a medical professional (doctor, athletic trainer, nurse)?” “How many times have you sustained an impact that you suspect was a concussion but that was never diagnosed?” “How many times did you get a ding or get your bell rung?” “How many times have you returned to a game or practice while experiencing symptoms after a hit?” Athletes were also asked about the total number of diagnosed concussions during their football career.
journal of law, medicine & ethics
Baugh, Kroshus, Daneshvar, and Stern
Analysis All analyses were conducted in SPSS v.20. An alpha of 0.05 was adopted. Details of the statistical methodology can be found in Appendix 1.
Results There was a significant difference in perceived coach support for concussion reporting by year in school (F=3.90, p=0.009). Tukey post-hoc tests indicated that there were significant differences between freshmen and juniors (p=0.029) and freshmen and seniors (p=0.040). The difference between freshmen and sophomores did not reach statistical significance (p=0.055). In all cases, freshmen agreed more than their older teammates that their coaches supported concussion reporting. There were no significant differences between athletes from different years in school in perceived teammate support for reporting a possible concussion. Date of survey was not independently correlated with any perceived support outcome variable and thus was not included in the final regression models. See Table 1 for details. Generalized Linear Model (GLM) regression examining perceived coach support was significant overall (omnibus test value p
