CONCUSSION KNOWLEDGE AMONG PARENTS AND COACHES OF YOUTH
ATHLETES (AGES 8-12)

A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science

by
Stephanie Hjortedal, LAT, ATC, PES

Research Advisor, Jamie Weary, DPT, LAT, ATC
California, Pennsylvania
2013

ii

iii
ACKNOWLEDGEMENTS

I want to take this opportunity to thank the people in my life that
help me complete one of the most crazy and adventurous year of my life. I
would never have been able to do this on my own and I appreciate the help
and support from all those involved in my life. First and foremost, I
would like to thank my thesis committee – Dr. Jamie Weary, Dr. Linda
Meyer, and Mike Lesako – for their hard work and support throughout this
process. Your guidance and wisdom has helped make this thesis into
something I am extremely proud of. In addition, a big thank you to all the
parents and coaches who participated in my study.
Secondly, I would like to personally thank Mike and Mark Lesako, the
coaches and the athletes at Washington & Jefferson College for welcoming
me with open arms. I appreciate the opportunities they provided me to grow
as a certified athletic trainer and for making me feel like family. To my
classmates, who in only a year have become my family, I know we will all
do great things. Every one of you supported me at a time when I was far
away from home and I can never thank you enough for everything you did for me.
Last and most important, I want to thank my family & friends back
home for all their support from across the country, especially my mother
and father. You have made me into the person I am today. You truly are the
people I look up to most in the world and I love you both very much. Also,
to the WSU Athletic Training staff and classmates who made me into the
professional I am today I thank you from the bottom of my heart. I will
always be proud to call myself a WSU Cougar, GO COUGS!!!

iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS
LIST OF TABLES
INTRODUCTION
METHODS

. . . . . . . . . . . . . . iv

. . . . . . . . . . . . . . . vii

. . . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . . 8

Research Design
Subjects

. . . . . . . . . . . . . . 8

. . . . . . . . . . . . . . . . . 9

Preliminary Research. . . . . . . . . . . . . 9
Instruments . . . . . . . . . . . . . . . . 10
Procedures

. . . . . . . . . . . . . . . . 11

Hypotheses

. . . . . . . . . . . . . . . . 12

Data Analysis
RESULTS

. . . . . . . . . . . . . . . 13

. . . . . . . . . . . . . . . . . . 14

Demographic Data . . . . . . . . . . . . . . 14
Hypothesis Testing

. . . . . . . . . . . . . 17

Additional Findings . . . . . . . . . . . . . 21
DISCUSSION . . . . . . . . . . . . . . . . . 25
Discussion of Results . . . . . . . . . . . . 26
Conclusions . . . . . . . . . . . . . . . . 30
Recommendations. . . . . . . . . . . . . . . 33

v
REFERENCES . . . . . . . . . . . . . . . . . 35
APPENDICES . . . . . . . . . . . . . . . . . 40
APPENDIX A: Review of Literature

. . . . . . . . 41

Introduction . . . . . . . . . . . . . . . . 42
Prevalence. . . . . . . . . . . . . . . . 44
Mechanism of Injury . . . . . . . . . . . . 45
Signs & Symptoms . . . . . . .
Short/Long Term Effects .
Concussion Knowledge

. . . . . . 46

. . . . . . . . 47

. . . . . . . . . . . . 49

Coaches . . . . . . . . . . . . . . . . . 50
Parents . . . . . . . . . . . . . . . . . 52
Media Influence. . . . . . . . . . . . . . 54
Concussion Prevention . . . . . . . . . . . . 56
Concussion Recognition . . . . . . . . . . . . 58
Neurocognitive Testing . . . . . . . . . . . 59
Concussion Management . . . . . . . . . . . . 61
Return to Play Guidelines

. . . . . . . . . 63

Resources for Coaches & Parents . . . . . . . . 65
Summary . . . . . . . . . . . . . . . . . . 67
APPENDIX B: The Problem . . . . . . . . . . . . 68
Statement of the Problem . . . . . . . . . . . 69
Definition of Terms . . . . . . . . . . . . . 69
Basic Assumptions . . . . . . . . . . . . . . 70

vi
Limitations of the Study . . . . . . . . . . . 71
Significance of the Study. . . . . . . . . . . 71
APPENDIX C: Additional Methods .

. . . . . . . . 72

IRB: California University of Pennsylvania (C1) . . 73
Primary Survey (C2) . . . . . . . . . . . . . 75
Parents Version . . . . . . . . . . . . . 76
Coaches Version . . . . . . . . . . . . . 87
Survey Cover Letter (C3) . . . . . . . . . . . 98
REFERENCES . . . . . . . . . . . . . . . . . 101
ABSTRACT . . . . . . . . . . . . . . . . . . 105

vii
LIST OF TABLES
Table

Title

Page

1

Concussion Signs and Symptoms

. . . . . . . . 3

2

Gradual Return to Play Protocol. . . . . . . . 6

3

State of Residency . . . . . . . . . . . . . 15

4

Personal Concussion History . . . . . . . . . 15

5

Frequency Table of Sports for Participants . . . 16

6

One-way ANOVA statistics: Hypothesis 1 . . . . . 17

7

Independent t-test: Hypothesis 2 . . . . . . . 18

8

Independent t-test: Hypothesis 3 . . . . . . . 19

9

Independent t-test: Hypothesis 4 . . . . . . . 20

10

Independent t-test: Personal Concussion History . 21

11

One-way ANOVA statistics: State of Residency

12

Correct Symptom Recognition Section of Subjects . 23

13

Comparison of Symptom Recognition Section. . . . 24

. . 22

1
INTRODUCTION

Concussions are an inevitable aspect of athletic
competition. A concussion is considered a mild traumatic
brain injury that can affect how the brain normally
functions.1-9 Although initial symptoms of a concussion can
seem mild, these symptoms can lead to severe problems in
the future.10-13 Mild traumatic brain injuries can affect a
person’s physical, cognitive, and psychological aspects of
life.14-18 This is an injury that must be taken seriously at
all levels of competition.
There are many detrimental effects that can occur
after sustaining a concussion. In retired athletes, serious
cognitive issues can begin to surface such as memory loss,
dementia, and depression.19-21 Longer recovery times of
verbal memory and reaction time are being seen in college
athletes with a previous history of concussions.22 Any
athlete can be at risk for Second Impact Syndrome, which
causes rapid swelling of the brain resulting in brain
damage or death.23-24 Second Impact Syndrome occurs when an
individual sustains a second concussion before the first
concussion has fully resolved. Youth athletes must be
protected from these dangerous risks by improving
prevention, recognition and management of concussions.

2
With medical professionals, such as physicians or
athletic trainers, who are rarely present at youth sporting
events, the responsibility falls on the parents and coaches
to keep the youth athletes safe. To do this, parents and
coaches of youth athletes must be properly educated on
concussion prevention, recognition and management.
There are many mechanisms that can cause a concussion.
Concussions can be caused by a direct hit to the head or an
indirect hit to another area of the body that causes a
shearing or a rotational force to the brain.1,8,10,25 One of
the reasons concussions are so difficult to recognize is
each individual may present with different signs and
symptoms. In addition, some symptoms present right away,
while others can take days or weeks to develop.26 Physical,
cognitive, and behavioral symptoms can all result from
sustaining a concussion.27-28 Table 1 shows concussion signs
and symptoms that can present in each of the three
categories stated above. Educating parents and coaches of
youth athletes of signs and symptoms can increase proper
recognition and management of concussions.

3
Table 1. Concussion Signs & Symptoms
Physical











Balance
problems
Vision problems
Dizziness
Fatigue
Headache
Lightheaded
Nausea/Vomiting
Slurred Speech
Ringing in ears
Sensitivity to
light

Cognitive








Amnesia
Confusion
Easily
distracted
Feeling in a
fog
Poor
concentration
Slow to answer
questions
Disorientation

Behavioral






Irritability
Personality
change
Anxiety
Depressed
mood
Easily
frustrated

There are many short and long term effects that can
occur following a concussion. Short term effects can last
anywhere from a few days to a couple weeks.27 These can
include headache, photophobia, difficulty concentrating,
short term memory issues, poor balance and insomnia.
Research has shown that once an athlete has sustained a
concussion, the athlete is at a higher risk of sustaining a
second concussion.29 Long term effects can include memory
loss, early onset dementia/Alzheimer, emotional distress,
depression, chronic traumatic encephalopathy and increased
risk of suicide.19-21 These long term effects are usually
seen in athletes that have sustained multiple concussions
or repetitive subconcussive hits to the head such as
boxing, football, hockey or soccer players.

4
Awareness of concussions continues to increase among
the athletic population. However, there is still room for
improvement regarding concussion recognition and management
knowledge among parents and coaches of youth athletes. In a
study by O’Donoghue et al12, youth sport coaches were found
to have a moderate knowledge of sport-related concussions
with a mean score of 84% on concussion knowledge. In a
study by Coghlin, Myles and Howitt4, 76.32% of parents
incorrectly assumed that an athlete must lose consciousness
to be considered a concussion. To help protect youth
athletes, educational efforts must continue in order to
increase concussion knowledge among parents and coaches.
Another area that must be looked into is the influence
the media has on youth athletes. How the media portrays
concussions among professional athletes influences the
perception of risk by youth athletes, parents, and coaches.
In a study by McLellan and McKinley11, media portrayal of
suspected concussions sustained by European professional
rugby players were assessed. Sixty percent of the athletes
suspected of sustaining a concussion were shown to continue
or return to play during the game. If the media is showing
concussions to be an injury that you can recover from so
quickly, how are youth athletes, parents, coaches going to
understand the damage concussions can cause?

5
Concussions can be difficult to prevent. There is no
specific equipment that can prevent every concussion, but
there are factors that can reduce the risk of sustaining a
concussion. The first way to reduce the risk of concussions
is for coaches to teach proper technique in dangerous
maneuvers such as tackling in football. Mouth guards help
disperse the force of a hit to the jaw or face, while a
helmet helps disperse the force of a hit to the head.18,30 By
dispersing the force of a hit, it can reduce the disruptive
forces placed on the brain. Another prevention strategy
that is gaining attention is strengthening an individual’s
neck muscles to reduce jarring motions of the head after a
hit.
Concussions are evaluated utilizing several different
methods. These methods include subjective information from
the athlete, balance testing, cognitive questions and
neurocognitive testing.31-32
Although there has been a great amount of research
with college and professional athletes, there is little
research on specific management guidelines for youth
athletes, specifically under the age of fourteen. The
trouble with youth athletes is baseline cognition may be
difficult to assess due to rapid cognitive development seen
during childhood.33-34 As with all post-concussion protocols,

6
youth athletes, should not return to play until all
symptoms have resolved35. A seven day progressive return to
play protocol is used by most medical professionals for
youth athletes. This protocol starts with no physical or
cognitive exertion and ends with full return to play.18,31,36
Without proper rest, symptoms can be exacerbated after
cognitive or physical activity.34,37
There is no single return to play guideline used for
the entire athletic population. One component shared by all
return to play guidelines is an athlete should not begin a
progression until fully asymptomatic.38 Most return to play
guidelines follow that of the Zurich Concussion Consensus
Statement. There are six steps that guide athletes back
into full contact play.30 Refer to Table 2 for each step of
the return to play progression.30
Table 2. Gradual Return to Play Protocol
Return to Play Stages
1. No activity
2. Light aerobic exercise
3. Sport-specific exercise
4. Non-contact drills
5. Full contact practice
6. Full return to play

7

The research shows that concussions are a prevalent
issue among athletes of all ages.14,25,38-40 However, little
research has been conducted on concussions specifically
among youth athletes and the educational tools that are
available to this population. Proper prevention,
recognition and management of concussions must be
implemented to protect youth athletes from short and long
term effects. For youth athletes this can best be achieved
by educating parents and coaches. Therefore, the purpose of
this study is to assess concussion knowledge among parents
and coaches of youth athletes between the ages of 8-12.

8
METHODS

The primary purpose of this study is to examine
concussion knowledge among parents and coaches of youth
athletes. This section will include the following
subsections: research design, subjects, instruments,
procedures, hypotheses, and data analysis.

Research Design

A descriptive design was used for this study. The
dependent variable is concussion knowledge score obtained
from the Concussion Knowledge Survey. The independent
variables are youth sport parents, youth sport coaches, CPR
certification, first aid certification, and attendance of a
concussion awareness class. The survey went through
validity and reliability testing. The survey was reviewed
by a panel of experts consisting of ten certified athletic
trainers. In addition, the survey was taken by ten parents/
coaches of youth athletes to assess reliability of the
survey. Reliability testing was performed on the survey and
received a Cronbach’s α of 0.732.

9
Subjects

The survey was distributed to an unknown number of
male and female parents and coaches of youth athletes. All
subjects included in this study either coached a youth
athletic team, or have a child that participated in youth
sports or both a parent and coach of a youth athlete.
Individuals coaching or parenting an adolescent under the
age of 8 or over the age of 12 were excluded in order to
target concussion knowledge of youth athletes.
Participation in the study was on a voluntary basis upon
completion of the Concussion Knowledge Survey. The study
was approved by the Institutional Review Board at
California University of Pennsylvania (Appendix C1). All
participants’ identities remained anonymous and did not
appear in the study.

Preliminary Research

The Concussion Knowledge Survey (Appendix C2) was a
previously used survey in a study by Gourley et al5. The
purpose of the survey was to assess general knowledge of
sport-related concussions and recognition of concussion-

10
related symptoms. Gourley et al5 performed preliminary
research to assess the clarity of the survey.

Instruments

The survey was created electronically using
www.surveymonkey.com. Subjects were asked to complete a
demographic information section. The first question
determined if the participant was above 18 years of age. If
the participant was under the age of 18, the participant
was thanked and dismissed from the survey. An additional
question was added to determine if the participant was a
coach or a parent of a youth athlete. If the participant
was neither a coach nor a parent of a youth athlete, the
participant was thanked and dismissed from the survey.
Demographic information questions were different based on
population choice (parent vs. coach). The parents’
demographic questions included: age, gender, state of
residency, number of children, age of children
participating in a sport, sports the children participate
in, previous medical training, level of education, and
personal concussion history. The coach demographic
questions included: age, gender, state of residency, sports
coached, years of coaching, levels coached, level of

11
education, previous medical training, personal concussion
history, and coaching clinics attended. If the participant
was both a parent and a coach of a youth athlete the
subject answered the parent demographic questions.
Additional questions assessed the participant’s
knowledge of concussions, signs and symptoms, recognition,
management, and return to play decisions. The entire survey
took approximately ten minutes to complete. There was
minimal risk for the participant to complete the survey.

Procedures

The researcher applied and obtained approval from the
IRB at California University of Pennsylvania (Appendix C1)
before any research was conducted. Participants for the
study were contacted in two different ways. Some
individuals were personal contacts of the researcher and
were asked to participate in the survey on a voluntary
basis. This was considered a convenience sample. Other
participants were obtained through youth sports
associations. Contacts for youth coaching organizations
were found by searching youth sport leagues’ web sites and
emailing current coaches of youth athletes. The researcher
contacted youth sports organization leaders, through

12
contact info found on the organizations’ website, to
explain the purpose of the study. Once permission was
obtained from each youth sports organization leader, the
researcher sent the survey via email to the youth sports
organization leader. Then the youth sports organization
leader distributed the survey to the organization’s parents
and coaches. The study was distributed by the youth
coaching association through their mailing lists.
The survey was sent to youth sport coaches and parents
with a cover letter explaining the purpose of the study and
a link to the survey. Informed consent was stated and
implied when the participant clicked on the link to take
the survey.
A reminder e-mail was sent one week after the original
e-mail to encourage survey completion. There was no
obligation of the subject to participate in the study. All
subjects remained anonymous with no way to trace answers
back to one subject. There was minimal risk for the subject
to participate in the survey.

Hypotheses

The following hypotheses are based on previous
research and the researcher’s review of the literature.

13
1.

There will be no difference in concussion
knowledge score between parents and coaches of
youth athletes.

2.

There will be no difference in concussion
knowledge score between youth sport parents with
CPR and first aid certification, and youth sport
parents without CPR and first aid certification.

3.

There will be no difference in concussion
knowledge score between youth sport coaches with
CPR and first aid certification, and youth sport
coaches without CPR and first aid certification.

4.

There will be no difference in concussion
knowledge score between youth sport coaches who
have attended a concussion awareness class or
clinic, and youth sport coaches who have not
attended a concussion awareness class or clinic.

Data Analysis

All data was analyzed by SPSS version 18.0 for windows
at an α of 0.05.

The first research hypothesis was

analyzed using a one way ANOVA. The other three hypotheses
were analyzed using an independent t-test.

14
RESULTS

The purpose of this study was to assess concussion
knowledge among parents and coaches of youth athletes. The
data was obtained using an electronic survey. This section
contains the following subsections: Demographic
Information, Hypothesis Testing and Additional Findings.

Demographic Information

The participants consisted of parents and coaches of
youth athletes who obtained the survey through the
researcher’s personal contact or from a youth sports
organization leader. A total of 85 surveys were returned
with 70 fully completed (82.4%). The sample consisted of
parents of youth athletes (n=38), coaches of youth athletes
(n=14), and subjects who were both a parent and a coach of
youth athletes (n=18). Table 3 represents the state of
residency of the participants. The highest number of
responses were received from Pennsylvania with 22 parents
and coaches. There was only one respondent from California.

15
Table 3. State of Residency
Classification
Parents
N (%)
California
0 (0)
Pennsylvania
7 (10)
Texas
13 (18.6)
Utah
2 (2.9)
Virginia
1 (1.4)
Washington
8 (11.4)
West Virginia
7 (10)

Coaches
N (%)
1 (1.4)
7 (10)
0 (0)
0 (0)
1 (1.4)
4 (5.7)
1 (1.4)

Both
N (%)
0 (0)
8 (11.4)
4 (5.7)
0 (0)
0 (0)
5 (7.1)
1 (1.4)

Table 4 represents personal concussion history of the
participants. Only 22.8% (n=16) of parents and coaches of
youth athletes had a personal history of being diagnosed
with a concussion.

Table 4. Personal Concussion History
Classification
Previous History
N (%)
Parents
8 (11.4)
Coaches
6 (8.5)
Both
2 (2.9)

No History
N (%)
30 (42.9)
8 (11.4)
16 (22.9)

Table 5 represents the sports the parents’ children
participated in and the sports coached by the coaches. The
subjects were allowed to choose more than one sport.
Basketball had the highest number of responses from parents
of youth athletes with a total of 41 (58.6%). While boxing,
strength/conditioning and water polo had the lowest number
of responses with 0 parents of youth athletes for each
sport. Soccer had the highest number of responses with

16
seven coaches and basketball had the second highest
response with five coaches.

Table 5. Frequency Table of Sports for Participants
Sport
Parents
Coaches
N (%)
N (%)
Baseball
38 (15.6)
2 (6.7)
Basketball
41 (16.8)
5 (16.7)
Boxing
0 (0.0)
0 (0.0)
Cheerleading
6 (2.5)
1 (3.3)
Field Hockey
4 (1.6)
1 (3.3)
Football
31 (12.7)
3 (10.0)
Golf
6 (2.5)
0 (0.0)
Gymnastic
5 (2.0)
0 (0.0)
Hockey
2 (0.8)
0 (0.0)
Lacrosse
4 (1.6)
2 (6.7)
Martial Arts
10 (4.1)
0 (0.0)
Rugby
2 (0.8)
0 (0.0)
Skiing
4 (1.6)
0 (0.0)
Soccer
33 (13.5)
7 (23.3)
Softball
12 (4.9)
2 (6.7)
Strength/Conditioning
0 (0.0)
2 (6.7)
Swimming
17 (7.0)
0 (0.0)
Tennis
5 (2.0)
0 (0.0)
Track & Field
11 (4.5)
2 (6.7)
Water Polo
0 (0.0)
0 (0.0)
Wrestling
4 (1.6)
0 (0.0)
Volleyball
9 (3.7)
3 (10.0)

17
Hypothesis Testing

All hypotheses were tested with a level of
significance set at α ≤ 0.05.
Hypothesis 1: There will be no difference in
concussion knowledge score between parents and coaches of
youth athletes.
A one-way ANOVA was used to determine if there was a
difference in the total scores on the Concussion Knowledge
Survey between parents and coaches of youth athletes. The
results of the analysis are presented below in Table 6.
Table 6. One-way ANOVA statistics: Hypothesis 1
Classification
N
Mean
Parents
38
20.45
Coaches
14
21.29
Both
18
20.39

Conclusion:

SD
2.658
2.525
2.173

The pretest means of concussion knowledge

scores between parents, coaches, and both (a parent and a
coach) were compared using a one-way ANOVA. No significant
difference was found (F(2, 67)= 0.653, p > .05). The
concussion knowledge score from the three groups did not
differ significantly from one another. Participants who
were parents had a mean score of 20.45 (SD = 2.658) out of
a possible 26 (78.7%). Participants who were coaches had a
mean score of 21.29 (SD = 2.525) out of 26 (81.9%).

18
Participants who were both a parent and a coach had a mean
score of 20.39 (SD = 2.173) out of 26 (78.4%).
Hypothesis 2: There will be no difference in
concussion knowledge score between youth sport parents,
with CPR and first aid certification, and youth sport
parents without CPR and first aid certification.
An independent t-test was used to determine if there
was a difference in concussion knowledge score of parents
with CPR/first aid certification and parents without
CPR/first aid certification. The results of the analysis
are presented below in Table 7.
Table 7. Independent t-test: Hypothesis 2
Parents
N
Mean
With CPR/First Aid
28
20.64
Without CPR/First Aid
27
20.26

SD
2.281
2.754

Conclusion: An independent-samples t-test was
calculated comparing the mean score of participants who
identified themselves as a parent with CPR/first aid
certification to the mean score of participants who
identified themselves as a parent without CPR/first aid
certification. No significant difference was found
(t(53) = .563, p > .05). The concussion knowledge score was
out of a possible 26. The mean of the parents with
CPR/first aid certification (M = 20.64, SD = 2.281) was not

19
significantly different from the mean of parents without
CPR/first aid certification (M = 20.26, SD = 2.754).
Hypothesis 3: There will be no difference in
concussion knowledge score between youth sport coaches,
with CPR and first aid certification, and youth sport
coaches without CPR and first aid certification.
An independent t-test was used to determine if there
was a difference in concussion knowledge score of coaches
with CPR/first aid certification and coaches without
CPR/first aid certification. The results of the analysis
are presented below in Table 8.
Table 8. Independent t-test: Hypothesis 3
Coaches
N
Mean
With CPR/First Aid
20
21.00
Without CPR/First Aid
12
20.42

SD
2.128
2.712

Conclusion: An independent-samples t-test was
calculated comparing the mean score of participants who
identified themselves as a coach with CPR/first aid
certification to the mean score of participants who
identified themselves as a coach without CPR/first aid
certification. No significant difference was found (t(30) =
.677, p > .05). The mean of the coaches with CPR/first aid
certification (M = 21.00, SD = 2.128) was not significantly
different from the mean of coaches without CPR/first aid
certification (M = 20.42, SD = 2.712).

20
Hypothesis 4: There will be no difference in
concussion knowledge score between youth sport coaches, who
have attended a concussion awareness class or clinic, and
youth sport coaches who have not attended a concussion
awareness class or clinic.
An independent t-test was used to determine if there
was a difference in concussion knowledge score of coaches
who have attended a concussion class/clinic and coaches who
have not attended a concussion class/clinic. The results of
the analysis are presented below in Table 9.
Table 9. Independent
Coaches
Attended Class
Not Attended Class

t-test: Hypothesis 4
N
Mean
7
21.14
7
21.43

SD
2.673
2.573

Conclusion: An independent t-test compared the mean
scores of coaches who had attended a concussion
class/clinic and coaches who had not attended a concussion
class/clinic. The data showed no significant difference
between the means of the two groups (t(12) = -.204, p >
.05). The mean of coaches who had attended a concussion
class/clinic was lower (M = 21.14, SD = 2.673) than coaches
who had not attended a concussion class/clinic (M = 21.43,
SD = 2.573).

21
Additional Findings

Using the demographic section and the total score of
the Concussion Knowledge Survey, several tests were
conducted in an attempt to determine additional findings.
An independent t-test was used to determine if there
was a difference in total scores between participants who
had a personal history of sustaining a concussion and those
who have never sustained a concussion. The results of the
test are represented in Table 10.
Table 10. Independent t-test: Personal Concussion History
Classification
N
Mean
SD
History of Concussion
16
21.53
1.821
No History of Concussion
54
20.30
2.611

Conclusion: An independent t-test compared the mean
scores of participants who had a personal history of
sustaining a concussion and those who had no history of
sustaining a concussion. The data showed no significant
difference between the means of the two groups (t(68) = 1.899, p > .05). The mean of the participants with a
personal history of sustaining of a concussion (M = 21.63,
SD = 1.821) was not significantly different from the mean
of participants without a personal history of sustaining a
concussion (M = 20.30, SD = 2.611).

22
A one-way ANOVA was used to determine if there was a
difference in total scores between participants based on
the subject’s state of residency. The results of the test
are represented in Table 11.
Table 11. One-way ANOVA statistics: State of Residency
Classification
N
Mean
SD
Pennsylvania
22
20.91
2.635
Washington
17
20.65
2.370
Texas
17
20.12
2.619

Conclusion:

The pretest means of concussion knowledge

scores based on the participant’s state of residency
(Washington, Pennsylvania, and Texas) were compared using a
one-way ANOVA. No significant difference was found (F(2,
53)= .467, p > .05). The concussion knowledge score from
the three groups did not differ significantly from one
another. Participants who resided in the state of
Pennsylvania had a mean score 20.91 (SD = 2.635).
Participants who resided in the state of Washington had a
mean score of 20.65 (SD = 2.370). Participants who resided
in the state of Texas had a mean score of 20.12 (SD =
2.619).
Table 12 represents the symptom recognition section of
the Concussion Knowledge Survey. The section is broken up
by the participants status of either being a parent, coach,
or both a parent and coach of a youth athlete.

23
Table 12.Correct Symptom Recognition Section of Subjects*
Symptom
Abnormal sense of smell
Abnormal sense of taste
Loss of memory
Blurred vision
Chest pain
Dizziness
Confusion
Headache
Nosebleed
Loss of consciousness
Sharp burning pain in neck
Nausea
Upper extremity numbness
Weakness in neck ROM
Sleep disturbances
Problem studying/focusing
Loss of appetite
Sensitivity to light
Change in mood/behavior

Parents

Coaches

21(55.3%)
22(57.9%)
36(94.7%)
37(97.4%)
30(78.9%)
37(97.4%)
37(97.4%)
37(97.4%)
14(36.8%)
37(97.4%)
22(57.9%)
37(97.4%)
16(42.1%)
19(50.0%)
35(92.1%)
35(92.1%)
7(18.4%)
34(89.5%)
35(92.1%)

7(50.0%)
6(42.9%)
14(100%)
14(100%)
12(85.7%)
14(100%)
14(100%)
14(100%)
8(57.1%)
14(100%)
6(42.9%)
14(100%)
7(50.0%)
7(50.0%)
14(100%)
14(100%)
3(21.4%)
14(100%)
14(100%)

Both
7(38.9%)
9(50.0%)
18(100%)
18(100%)
17(94.4%)
18(100%)
18(100%)
18(100%)
7(38.9%)
17(94.4%)
9(50%)
18(100%)
5(27.8%)
6(33.3%)
16(88.9%)
18(100%)
3(16.7%)
17(94.4%)
17(94.4%)

*Correct responses bolded

There were several concussion symptoms that more than
95% of the subjects answered correctly. These included:
blurred vision, dizziness, confusion, headache, loss of
consciousness, and nausea. In addition, there were several
detractor symptoms that less than 60% of subjects answered
correctly. These included: abnormal sense of smell,
abnormal sense of taste, nosebleed, sharp burning pain in
the neck, upper extremity numbness, weakness in neck ROM
and loss of appetite. Only 41.4% of subjects correctly
answered that a nosebleed is not a symptom of a concussion.
In addition, only 40% of subjects correctly answered that
upper extremity numbness/weakness is not a symptom of a

24
concussion. Although, the high success rate of correctly
identifying concussion symptoms is impressive, the low
level of correctly identifying the detractor symptoms is
disheartening.
The survey used in this study was adapted from Gourley
et al1. The three additional symptoms (loss of appetite,
sensitivity to light, and change in mood/behavior) that
were added to the current survey’s sign/symptom section
were removed to compare the results between Gourley et al1
and the present study. Table 13 compares the correct
symptom recognition section between the study by Gourley et
al1 and the current study.
Table 13.Comparison of Symptom Recognition Section*
Symptom
Abnormal sense of smell
Abnormal sense of taste
Loss of memory
Blurred vision
Chest pain
Dizziness
Confusion
Headache
Nosebleed
Loss of consciousness
Sharp burning pain in neck
Nausea
Upper extremity numbness
Weakness in neck ROM
Sleep disturbances
Problem studying/focusing
*Correct responses bolded

Gourley
32%
34%
82%
86%
56%
88%
88%
87%
26%
81%
21%
82%
27%
20%
56%
57%

Current Study
50.0%
52.9%
97.1%
98.6%
84.3%
98.6%
98.6%
98.6%
41.4%
97.1%
52.9%
98.6%
40.0%
45.7%
92.9%
95.7%

25
The mean symptom score for subjects who were parents
in the current study was 12.33 of 16 (77.1%). The study by
Gourley et al1 showed the mean recognition of symptom score
for parents was 9.23 of 16 (57.7%). In this study 92.9% of
parents and coaches of youth athletes correctly identified
sleep disturbances as a sign of a concussion. Studies
conducted by Valovich et al6 and Gourley et al found that
12.8% and 56%, respectively, identified sleep disturbances
as a sign of a concussion. In addition, Gourley et al found
that only 57% correctly identified problems with
homework/studying as a sign of a concussion. The present
study found that 95.7% of subjects correctly recognized
problems with homework/studying as a concussion symptom.
Over the three years between the current study and Gourley
et al1, concussion knowledge appears to have increased among
parents and coaches of youth athletes.

DISCUSSION

This study has produced several findings related to
the concussion knowledge among parents and coaches of youth
athletes. The following section will discuss these findings
and is divided into the following subsections: Discussion
of Results, Conclusions, and Recommendations.

26
Discussion of Results

Everyone has heard the word concussion thrown around
either on television or at the local sporting event, but
some people still do not understand the detrimental effects
a concussion can have on an athlete. A concussion is
considered a mild traumatic brain injury that can affect a
person’s physical, cognitive, and psychological aspects of
life3. While there is extensive research about concussions
at the professional, collegiate and even the high school
levels, there is a lack of literature at the youth level.
In addition, licensed medical professionals who are trained
in the prevention, recognition and management of
concussions are not required to attend youth athletic
events. For this reason the responsibility of safety among
youth athletes falls onto the parents and coaches. The
purpose of this study was to assess concussion knowledge
among parents and coaches of youth athletes.
The researcher’s first hypothesis was that there would
be no significant difference between the concussion
knowledge score of parents and coaches of youth athletes.
Studies conducted by Stevens et al26 and Gourley et al1,
examined concussion knowledge among parents of youth
athletes through the use of surveys. Both surveys found a

27
moderate knowledge of concussions by parents and coaches.
Gourley et al1 stated that youth athletes and parents are
moderately aware of the signs and symptoms of concussion
and have little knowledge in proper concussion management.
Table 6 in the results section shows the mean score of
parents at 20.45 (78.7%), the mean score of coaches at
21.29 (81.9%) and the mean score of both a parent & a coach
at 20.39 (78.4%) out of a possible 26. While the difference
in scores between parents and coaches of youth athletes is
not statistically significant, the overall score is still
moderately low.
The second hypothesis inspected in this study stated
that there would be no difference in concussion knowledge
scores between youth sport parents with CPR and first aid
certification, and youth sport parents without CPR and
first aid certification. Gourley et al1 found a significant
difference in the number of symptoms correctly identified
by parents with first aid certification or general medical
training than those without. Table 7 in the results section
shows the mean score of parents with CPR and first aid
certification at 20.64 (79.4%) and the mean score of
parents without CPR and first aid certification at 20.26
(77.9%) out of a possible 26. The results did support this
hypothesis, as there were no significant differences

28
between concussion knowledge score of parents with CPR and
first aid certification and those without CPR and first aid
certification.
The third hypothesis examined in this study stated
that there would be no difference in concussion knowledge
score between youth sport coaches with CPR and first aid
certification, and youth sport coaches without CPR and
first aid certification. Valovich et al6 found a significant
difference between coaches with CPR or first aid
certification than those without these credentials6. Table 8
in the results section shows the mean score of coaches with
CPR and first aid certification at 21.00 (79.4%) and the
mean score of coaches without CPR and first aid
certification at 20.42 (77.9%) out of a possible 26.

The

results did support this hypothesis, as there were no
significant differences between concussion knowledge score
of coaches with CPR and first aid certification and those
without CPR and first aid certification.
The fourth hypothesis inspected in this study stated
that there would be no difference in concussion knowledge
score between youth sport coaches who have attended a
concussion awareness class or clinic, and youth sport
coaches who have not attended a concussion awareness class
or clinic. O’Donoghue et al12 and Bramley et al2 found a

29
statistical significance in the management of concussions
among high school coaches who had attended a concussion
workshop versus coaches who had never attended a concussion
workshop. Table 9 in the results section shows the mean
score of coaches who have attended a concussion
class/clinic at 21.14 (81.3%) and the mean score of coaches
who have not attended a concussion class/clinic at 21.43
(82.4%) out of a possible 26. The results did support this
hypothesis, as there were no significant differences
between the two groups.
In addition to examining the stated hypotheses, the
researcher discovered additional findings by using
supplementary demographic information and Concussion
Knowledge Survey scores. The first additional finding used
the concussion knowledge score to compare subject who had a
history of sustaining a concussion and those without a
history of sustaining a concussion. Although there was no
statistical significance, the mean score for participants
with a history of sustaining a concussion (M = 21.53) was
slightly higher than those of participants who had never
sustained a concussion (M = 20.30).
The second additional finding used the concussion
knowledge score to compare subjects based on their state of
residency. Only the three states with the highest number of

30
participants were utilized. Although there was no
statistical significance, the mean score for subjects
residing in Pennsylvania (20.91) was higher than the mean
score of participants residing in Washington and Texas
(20.65 and 20.12, respectively).
The third additional finding compared the current
study’s symptom recognition score to Gourley et al1 symptom
recognition score. Only subjects who were parents of youth
athletes were used in the comparison, as Gourley et al1 did
not include coaches of youth athletes. In the three years
between the previous study and the current study, symptom
recognition score had increased from 9.23 (57.7%) to 12.33
(77.1%) out of a possible 16. Parents are improving their
ability to recognize concussion symptoms among youth
athletes. The ability to recognize concussion symptoms is
important in protecting the youth athlete.

Conclusions

Similar to other studies1,5,6,10,16, the researcher found
no statistically significant differences of concussion
knowledge score between parents and coaches of youth
athletes. The moderate score on the Concussion Knowledge
Survey shows that parents (M = 20.45, 78.7%) and coaches (M

31
= 21.29, 81.9%) of youth athletes could benefit from a
continued increase in concussion education. The safety of
youth athletes falls on the shoulders of parents and
coaches; therefore this population needs to be well
informed on concussion prevention, recognition, and
management.
Many other studies have found a statistical
significance between participants with CPR certification,
first aid certification or attendance of a concussion
education course and concussion knowledge1,2,4,5. This is
contrary to the results found in this study. This study
found no statistical significance of concussion knowledge
between participants with or without CPR/first aid
certification, or those who had or had not attended a
concussion course. Although, the results of this study
support the researcher’s second, third and fourth
hypotheses; this lack of statistical significance could be
due to the low response rate of the study.
In the additional findings, the researcher examined
the effect state residency had on the concussion knowledge
score. Interestingly, participants from Pennsylvania,
Washington and Texas had very similar mean scores despite
various concussion laws. The mean concussion scores for
Pennsylvania were 20.91 (80.4%), Washington 20.65 (79.4%),

32
and Texas 20.12 (77.4%). The Pennsylvania concussion law,
entitled the Safety In Youth Sports Act, was enacted on
July 1, 2012. The bill stated that once each school year, a
coach shall complete a concussion management certification
training course offered online41. The coach is not allowed
to coach an athletic activity until the completion of the
concussion training course. The Washington concussion law,
entitled the Zackery Lystedt Law, was enacted in September
2009. The bill stated that each school district’s board of
directors will develop the guidelines for concussion
management42. In addition, the board must create forms to
educate coaches, athletes, and parents about the
signs/symptoms of a concussion and return to play
decisions. The Texas concussion law, entitled Natasha’s
Law, was enacted on September 1, 2012. The bill stated that
each school district must appoint a concussion oversight
team (COT) that will establish a return to play protocol43.
The COT must include at least one physician. In addition,
every two years coaches and licensed health care
professionals either employed or volunteering for the
school, must participate in at least two hours of
concussion training. Even with such diverse laws, the
states’ mean concussion knowledge scores were very similar.
Both Pennsylvania and Texas concussion laws are relatively

33
new, it would be interesting to see if concussion knowledge
continues to increase in these states.
Based on the results of this study, it can be
concluded that concussion education training should
continue to be implemented at the youth level. If parents
and coaches of youth athletes participate in concussion
education it will provide a safer environment for all youth
athletes.

Recommendations

This study has the potential to be improved with a few
recommendations. The first recommendation is the sample
size should be much larger. The researcher used a
convenience sample of personal contacts and local youth
sports associations to gain participants. A larger sample
size would create a more accurate view of the current
concussion knowledge among parents and coaches of youth
athletes in the United States.
Another recommendation would be to try and maintain a
similar number of participants in each group (parents vs.
coaches vs. both). Since, there were many more parents (n =
38) compared to coaches (n = 18) and both a parent and a
coaches (n =14) the results might not accurately represent

34
the difference in concussion knowledge between the three
groups. This could be accomplished by distributing surveys
to more youth sports associations.
A third recommendation would be to include subjects
who are parents of children that do not participate in
youth athletics. Children are still at risk of sustaining a
concussion from a fall or blow to the head, even if they do
not participate in athletics. This could determine if
parents of youth athletes have a significantly higher
knowledge of concussions compared to parents whose children
do not participate in youth athletics.
The final recommendation would be to perform this same
study in another three years. The original study by Gourley
et al1 was performed in 2010. By comparing the original
study and the current study many improvements in concussion
knowledge can be seen among parents and coaches of youth
athletes. With the recent implementation of concussion laws
across the country there could be an increases in
concussion knowledge over the next few years. Performing
this study every two to three years can show learning over
time of the prevention, recognition and management of
concussions.

35
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40

APPENDICES

41

APPENDIX A
Review of Literature

42
REVIEW OF LITERATURE
Concussions have become a hot button topic lately, not
only at the professional level, but all levels of
athletics. A concussion is considered a mild traumatic
brain injury that can affect how the brain normally
functions. Although initial symptoms of a concussion can
seem mild these symptoms can lead to severe problems in the
future. Mild traumatic brain injuries can affect a person’s
physical, cognitive, and psychological aspects of life.
This is an injury that must be taken seriously at all
levels of competition.
Many concussion studies are conducted at the
professional, collegiate and high school level; however
little research is available on concussions in youth
sports. As the knowledge of concussions continues to grow
more detrimental effects are being discovered in older
athletes who have sustained multiple concussions over their
athletic career. Researchers are starting to see an
increasing number of older athletes who have cognitive
issues such as memory loss, dementia, Alzheimer’s, Chronic
Traumatic Encephalopathy and depression1. Even at the
college level, athletes with a previous history of a
concussion take longer to recover verbal memory and

43
reaction time than athletes without a history of a
concussion2. High school athletes can suffer terrifying
affects as this population is at an increased risk of
Second Impact Syndrome which can result in permanent brain
damage or death3. For these reasons it is important to
reduce the amount of concussions sustained by youth
athletes by improving prevention, recognition and
management of concussions.
Parents and coaches of youth athletes can play a key
role in decreasing the prevalence of concussions by
understanding proper prevention, recognition, and
management strategies. Without the presence of medical
professionals, such as physicians and licensed athletic
trainers, parents and coaches of youth athletes must become
advocates for the safety and health of all youth athletes.
To begin protecting youth athletes from the dangers of
concussions, with the help of parents and coaches,
concussion knowledge must be assessed to create a baseline
of understanding. Once knowledge is assessed, educational
concussion efforts can be implemented to continue to
improve knowledge and management of these conditions.
Therefore, the purpose of this study is to examine the
extent of concussion knowledge coaches and parents of youth

44
athletes possess, with focuses on concussion recognition
and management.
Prevalence
Concussions are a common occurrence among youth
athletes. In a five year study by Yang et al4, 3,712 youth
athletes from ages five to eighteen were hospitalized due
to a suspected concussion. Mechanisms of injury ranged from
sports-related, falls, and car accidents. The hospital
charges from these incidents resulted in over 29 million
dollars4.
A study conducted by Yard and Comstock5 determined
whether high school athletes who had sustained a concussion
complied with recommended return to play guidelines during
the years 2005-2008. Concussions were reported by certified
athletic trainers from 100 high schools across the country.
Compliance was based on the American Academy of Neurology
(AAN) or the Prague return to play guidelines. Over the
course of the study 1,308 concussions were reported. Under
the AAN guidelines, 40.5% of athletes were found to return
to play prematurely. Under the Prague guidelines, 15% of
athletes were found to return to play prematurely. Under
the Prague guidelines, 21.9% of male athletes were noncompliant (not following the guidelines either by returning

45
too early or with symptoms still present) compared to 11.8%
of females being non-compliant. Since there is not a golden
standard return to play guideline, concussions are being
managed in many different ways.

Mechanism of Injury
Many people assume that to sustain a concussion, the
athlete must be hit in the head. In actuality, a concussion
can be caused by either a direct hit to the head, an
indirect shearing, or a rotational force6. Browne and Lam
conducted a study that compared the characteristics of
concussions in children as the result of sports or other
physical activity7. Approximately 592 cases were recorded
with children ranging in age from six to sixteen. The data
showed 25.7% of concussions brought into the hospital were
sports-related. Of the sports-related concussions, 54%
resulted from a fall and 45% resulted from a collision.
In a study by Pickett et al8, specifically on soccer
players presenting to the emergency department, over 235
head injuries were observed over five years. Mechanisms of
injury included: 65.1% contact with another player, 26.4%
heading and 9.8% attempted heading. Due to the fact that
concussions have many mechanism of injury it makes this
injury even more difficult to diagnose.

46
Signs & Symptoms
There are many signs and symptoms that can occur from
a concussion. Some can occur within seconds of injury or
develop over several weeks later9. Signs and symptoms also
vary from person to person. These variations are what make
concussions so hard to recognize for non-health care
professionals. Behavioral changes can include irritability,
personality changes and depressed mood. Physical changes
can include dizziness, blurred vision, poor coordination,
and tinnitus. Cognitive changes can include amnesia,
feeling in a fog, and poor concentration.
Headache, dizziness and confusion are the most wellknown concussion symptoms10; however, there are many other
symptoms that go unrecognized. In a survey conducted by
Coghlin, Myles and Howitt11, parents failed to recognize
sleep problems, disorientation, and emotional irritability
as signs of a concussion. Educating parents and coaches on
the lesser known symptoms can increase concussion
recognition among youth athletes.
In a study by Frommer et al12, concussion symptoms were
compared between male and female high school athletes. Data
was collected from 100 high schools using the High School
Reporting Information Online system. Over two years 812
sports-related concussions were recorded. No significant

47
gender difference was found in the number of symptoms
reported. The difference was found in the types of symptoms
reported. Male athletes reported more amnesia and
confusion/disorientation than did female athletes. Female
athletes reported more drowsiness and sensitivity to noise
than did male athletes. Also, no significant gender
differences were found between symptom resolution time and
return to play timeline. Although concussion symptoms and
resolution time can vary from individual to individual
certain similarities can be found between males and
females.

Short/Long Term Effects
Concussions can cause many short and long term
effects. Not long ago having your “bell rung” was
considered to be a harmless injury that an athlete could
just shake off and return back to the game or practice.
Research now has shown that severe consequences can occur
from improper management of single or repeated concussions.
Short term effects can include a few days of headache,
avoidance of bright light and feeling in a fog. These
symptoms can be very mild and resolve quickly. More severe
effects include difficulty concentrating, poor balance, and
insomnia that can last for a week or more.

48
Once an athlete has sustained a concussion, there is a
greater risk of sustaining a second one with more severe
symptoms13. Second Impact Syndrome is also a possibility
which results in rapid swelling of the brain causing brain
damage or death. Another effect that can proceed a
concussion is Post-Concussion Syndrome (PCS). With PostConcussion Syndrome, symptoms of a concussion can continue
for weeks, months or even years without resolving. PostConcussion Syndrome can occur whether it’s the first
concussion or a subsequent one.
Long term effects are starting to show in older
athletes who have participated in sports for many years.
Football players are showing the most detrimental negative
effects from concussions. Multiple low intensity and/or
subconcussive hits to the head can cause long term effects.
These include: long term memory loss, early onset dementia,
Alzheimer, emotional distress, depression, and suicide. For
this reason concussions need to be handled with care and
conservative treatment, especially with the youth athlete.
Chronic traumatic encephalopathy (CTE) is a
neurodegeneration of the brain that is believed to be the
result of repeated head injuries. These can include mild
traumatic brain injuries as well as asymptomatic
subconcussive hits to the head. This sort of trauma

49
triggers degeneration of the brain tissue and causes a
build-up of an abnormal protein called tau14. The onset of
CTE usually occurs in mid-life once the individual has
retired from his/her sport. Signs and symptoms of CTE are
usually recognized by family and friends. Cognitive
difficulties include poor memory and information
processing. Behavioral differences begin to emerge, such as
irritability, anger, and apathy. This phenomenon was first
seen in retired boxers, but more cases are being found in
football, professional wrestlers, hockey, and soccer
players. Although there is no concrete evidence that proves
repeated concussions will result in CTE there is an
increasing correlation between the two variables.

CONCUSSION KNOWLEDGE

Awareness of concussions has increased significantly
over the past decade. However there is still a need for
concussion education among parents, coaches and athletes
that participate in youth and high school sports. Many
youth sport coaches still believe that loss of
consciousness is required to be considered a concussion15.
Guilmette, Malia and McQuiggan found that high school
coaches were significantly more knowledgeable about

50
concussions than a general public sample10. Due to the fact
that medical professionals are rarely at youth sporting
events it is extremely important that coaches and parents
have accurate and current knowledge on concussions.

Coaches
Coaches of youth athletes need to become more aware of
preventing, recognizing, and managing injuries that can be
sustained by the young athlete. Information on concussions
has been increasing over the years. However concussion
recognition and management strategies have not trickled
down to the youth arena as well as in the professional and
collegiate leagues.
In a study by O’Donoghue et al16, 126 high school
coaches completed a survey measuring concussion knowledge.
The participants displayed a moderate knowledge of sportrelated concussions with a mean score of 84%. The greatest
area of knowledge was seen in recognition with a mean score
of 92%. The area with the least amount of knowledge was
management with a mean score of 79%. Gender revealed a
significant difference in recognition score. Male
participants (7.59 ± 0.63) scored significantly higher than
did female participants (7.02 ± 0.97) on the recognition
section. Similarly, coaches with a personal history of a

51
concussion (7.61 ± 0.67) scored significant higher than
those without a personal history of a concussion (7.30 ±
0.85) on the recognition section. Improvements in
concussion education and management are still needed among
coaches and must be addressed to help protect adolescent
and youth athletes.
Valovich et al15 conducted a study to assess youth
sports coaches’ basic knowledge of concussions. Over 250
coaches were recruited to participate in a survey
containing a symptom checklist, a concussion scenario, and
four true/false questions pertaining to concussion
management. The mean number of correct responses for the
symptom recognition was 9.78 ± 2.07 out of a possible 16.
Participants were less likely to recognize vision problems,
sleep disturbances, and nausea as symptoms of a concussion.
In addition, 42% of subjects incorrectly thought that loss
of consciousness was required for a concussion to occur.
Surprisingly, 26% of participants would let an athlete
return to play while still symptomatic. It is very
important that coaches understand under no circumstance
should an athlete be placed back in practice or competition
if the athlete is suspected of having a concussion.
Broglio et al17 conducted a study to evaluate the
concussion knowledge and medical practice among athletes,

52
coaches and medical staff involved with club level soccer.
The survey distributed exclusively to coaches aimed to
determine how coaches perceive concussions, including
recognition and management of concussions. The results
indicated that 98.7% of coaches were able to correctly
identify symptoms not associated with a concussion
(hyperactivity, talking more than usual, elation). However,
only 38.9% coaches accurately identified symptoms that are
commonly associated with concussion (drowsiness, fatigue,
sleeping more than usual, difficulty concentrating). In
addition, 25.9% of coaches incorrectly guessed that
prescription medication was the best way to recover from a
concussion. Also, only 70.4% of participants agreed that an
athlete should only return to play when they are symptom
free. Awareness should be increased on cognitive and
behavioral symptoms observed with concussions as many
coaches are only looking for physical symptoms such as
headache and dizziness.

Parents
Parents of youth athletes can be the greatest advocate
in concussion recognition and management as they would be
most likely to recognize unusual symptoms and behaviors in
their children. It is the parents’ responsibility to help

53
keep the youth athlete safe from undue injury. If medical
personnel are not present to evaluate and care for the
youth athletes the parents must learn to recognize and
manage serious injuries, such as concussions.
In a study by Gourley, Valovich-McLeod, and Bay18,
youth athletes and parents were surveyed to measure
awareness and recognition of concussions. Over 73 youth
athletes and 100 parents responded to the survey. No
difference was seen in recognition scores between youth
athlete and parents. Parents with a previous history of
first aid certification or general medical training scored
significantly higher on symptom recognition than those
without a medical background. About half of parents
correctly identified sleep disturbances and difficulty
concentrating (56% and 57% respectively) as concussion
symptoms. Youth athletes and parents should receive
specific education on concussion recognition as many still
fail to recognize cognitive and behavioral symptoms.
Coghlin, Myles, and Howitt11 conducted a study
assessing the ability of hockey parents/guardians to
recognize concussion symptoms in adolescent children. The
survey consisted of true/false questions and a symptom
checklist. The symptom checklist included eight false
detractors symptoms. The data showed that 76.32% of parents

54
believe that an athlete must lose consciousness to be
considered a concussion. It was determined that mothers
scored significantly higher on recognizing the signs and
symptoms associated with a concussion. Surprisingly, 47.4%
of participants incorrectly guessed hearing voices and
lowered pulse rate as signs/symptoms of a concussion.
Although efforts from concussion awareness organizations
have helped increase concussion knowledge among athletes,
parents, and coaches, this population could still benefit
from continuing concussion education.
It is clear that educating parents of youth athletes
on concussion recognition and management is pivotal to
youth safety in organized sports. By increasing awareness
of concussion symptoms among parents of youth athletes the
chance of chronic long term brain effects can be
significantly reduced.

Media Influence
Recently the media, specifically in sports, has come
under fire as how concussions are portrayed to the public.
Many children idealize professional athletes and become
determined to play like their heroes. Professional athletes
are constantly shown playing through injuries that should
require them to be taken out of the game or practice. A

55
study was conducted by McLellan and McKinley to establish
the incidence rate of probable concussions among
professional European rugby players in games that were
broadcasted and how the injury was managed19. Twenty
incidents were determined as an observable injury/impact to
the head which were classified as probable concussions. Of
the televised rugby games 30.8% showed a player visibly
experiencing a probable concussion. Of the twenty
incidents, 60% of the athletes were shown to continue or
return to play during the game after being inspected by the
medical staff. Based on the commentary provided by the
media during the game, 66% of the athletes who continued or
returned to play had experienced a probable concussion. It
was observed that most injured players were shown to
continue playing or return to play despite being visibly
concussed.
In general, the media tends to celebrate players who play
injured and question those who take the required time off20.
Under reporting of concussions is a big concern among high
school athletics. Perhaps the portrayal of professional
athletes returning to play so quickly after being concussed
is a contributing factor.

56
CONCUSSION PREVENTION

Preventing a concussion is a difficult charge to
undertake. One of the first ways to help prevent an athlete
from sustaining a concussion is proper technique in high
risk sport specific skills. For example, in football,
proper demonstration of tackling form is very important.
Brain and neck injuries can occur from improper form, such
as spearing and helmet to helmet contact. Excessive
violence between athletes during athletic activities can
increase the risk of concussion21. Coaches, parents and
officials should foster a competitive, yet respectfully
safe environment for athletes.
Protective equipment, such as mouth guards and
helmets, have been suggested to reduce the risk of
concussions. Mouth guards have been shown to prevent dental
and orofacial injuries. In addition, mouth guards can help
disperse the force of a hit to the jaw or face, thereby
reducing the disruptive forces placed on the brain22.
Although the main purpose of athletic helmets is to prevent
skull fractures, it can be helpful in reducing the risk of
sustaining a concussion. Biomechanical studies have shown a
reduction in impact forces to the brain with the use of
helmets21. Again, like the mouth guard, by dispersing the

57
force across the helmet it will decrease the negative
impact on the brain.
A prevention strategy that has recently been
researched is neck muscle strength in comparison to risk of
concussion. The thought is by strengthening the neck
muscles, the athlete can maintain the head in a fixed
position during an impact, thus dispersing the force of the
impact9. The problem with this theory is most impacts occur
suddenly and without warning so the athlete may not have
time to tense the neck muscles before impact.
It is quite difficult to fully prevent athletes from
obtaining a concussion. However, there are several
techniques that can be employed to help reduce the risk of
concussions among athletes at any level.

CONCUSSION RECOGNITION

Parents and coaches are the first line of defense in
recognizing concussion symptoms in youth athletes.
Therefore, it is the coaches and parents that must protect
the young athletes from long term effects of a concussion.
Parents and coaches must be educated on the signs and
symptoms that may present with a concussion and management
strategies if a child had sustained a concussion.

58
Currently there are no neurocognitive assessment tools
specifically designed for young children23. Since cognition
is developing so quickly in children symptoms are much more
difficult to assess versus symptoms that may be seen in an
adolescent24. One symptom that often goes unrecognized in
children is a change in mood or behavior8. Parents are more
adept at noticing these kinds of changes in behavior and
cognition. By increasing the awareness of lesser known
concussion symptoms parents and coaches of youth athletes
can better recognize concussions that may have gone
unnoticed.
Neuroimaging techniques are occasionally used when an
individual is suspected of sustaining a concussion. Due to
the fact that concussions do not always cause structural
damage to the brain, neuroimaging devices are used to rule
out more critical injuries such as hemorrhages. Although,
brain computed tomography (CT) cannot fully diagnosis a
concussion it should be used whenever there is a suspicion
of an intracerebral structural lesion21. Functional magnetic
resonance imaging is becoming more popular is terms of
concussion evaluation as it demonstrates activation
patterns within the brain.

59
Neurocognitive Testing
Over the years the reliance on neurocognitive testing
has increased as a tool for concussion assessment and
management. The most widely used neurocognitive testing
database is the Immediate Postconcussion Assessment and
Cognitive Testing (ImPACTTM) developed by the University of
Pittsburgh Medical Center25. These types of test assess an
individual’s cognition ranging from verbal and visual
memory to reaction time. In the past, concussion
recognition and management were purely based on athletes
self-reporting symptoms; however, this can be an unreliable
technique as most often athletes would not want to be
pulled out of competition. The purpose of neurocognitive
testing is to add another tool to help assess concussion
among individuals, not as a purely diagnostic tool.
Van Kampen et al26 created a study to evaluate player
symptom reporting sensitivity as judged by postconcussion
symptoms and ImPACTTM testing among high school and
collegiate athletes. Participants were examined two days
after sustaining a concussion and post-injury ImPACT
results and symptom scores were compared with baseline
scores and with age and education matched non-injured
athletes as a control group. The authors found that 64% of
concussed athletes had a significant increase in symptoms

60
compared to baseline scores based on the postconcussion
symptom score. In addition, 83% of concussed athletes had
significantly decreased neurocognitive scores when compared
to the individual’s own baseline scores. By including the
ImPACTTM scores, there was an increased sensitivity of 19%.
Relying purely on athletes’ self-reporting is not an
effective way to assess and manage concussions.
Neurocognitive testing can increase diagnostic accuracy
when used along with self-reported symptoms.
Neurocognitive testing is also being used to help find
patterns in concussion severity and recovery time when
compared with age, gender, history of concussions, etc. In
a study by Covassin et al27, age and sex differences were
observed among concussed individuals based on symptoms,
ImPACTTM scores and postural stability, such as, the Balance
Error Scoring System (BESS). A total of 296 high school and
collegiate athletes were used for the study. Participants
were examined at two, seven and fourteen days postconcussion. Results revealed that female athletes performed
significantly worse than male athletes on visual memory
(65.1% and 70.1%, respectively) and number of reported
symptoms (14.4 and 10.1, respectively). It was also found
that high school athletes performed worse than college
athletes on verbal (78.8% and 82.7%) and visual memory

61
(65.8% and 69.4%). In addition, high school males scored
worse on the BESS test than college males (18.8 and 13.0).
Simiarily, high school females scored worse on the BESS
test than college females (21.1 and 16.9). Neurocognitive
testing helps provide an objective measurement for
concussion management.

CONCUSSION MANAGEMENT

There is little research on definite management
guidelines for youth athletes, specifically under the age
of fourteen. The trouble with youth athletes is baseline
cognition may be different due to rapid cognitive
development seen during childhood9. In addition, children
take longer to recover from neurocognitive symptoms.
Children are more at risk for sustaining concussions due to
lower mylienation, greater head to body ratio and thinner
cranial bones28. Youth athletes should not return to play
until all symptoms have resolved. A seven day progressive
return to play protocol is used by most medical
professionals for youth athletes. This protocol starts with
no physical or cognitive exertion and ends with full return
to play.

62
An athlete must be symptom free for 24 hours before
proceeding to the next protocol level. After the initial
injury the athlete should not be left alone and should be
monitored for several hours incase signs of deterioration
appear21. During the acute recovery period (1-7 days postconcussion) there is increased vulnerability of additional
injury to the brain23. If an athlete receives a second
concussion before the first concussion fully resolves there
is a high risk of Second Impact Syndrome.
Cognitive rest is an often neglected aspect of
concussion management. Cognitive activity causes an
increase in neurometabolic demand on the brain. Research
has shown that concussed subjects have exacerbated symptoms
following cognitive activity, known as the cognitive
exertion effect29. The goal is to avoid excessive mental
challenges during the initial stage post-concussion. This
is a difficult treatment to follow as most athletes are
students. The best way to manage this aspect of the
concussion is for parents, coaches, teachers and school
administrators to work together.
Accommodations may be needed to help the athlete
continue to succeed in class while waiting for concussive
symptoms to resolve. Accommodations can include: excused
absences from class, rest periods during the school day,

63
extension of assignment deadlines, postponement of test,
extended testing time, use of a reader for school work, use
of a scribe or a temporary tutor30. It may be difficult to
convince academic faculty that a concussion warrants the
need for cognitive rest and/or academic assistance. This
challenge can be reduced by educating the staff on
concussions so the athlete can receive the proper care
needed to heal as quickly and safely as possible.

Return to Play Guidelines
At the moment there is no single return to play
guideline that is used throughout the athletic population.
Although there are several return to play guidelines used
throughout the country and each have very similar
components. The most important factor in a return to play
decisions is the athlete should be completely asymptomatic
before beginning any progression. If the athlete is
experiencing any concussive symptom(s), they should refrain
from participating in any physical or cognitive activity.
During the 2009, 3rd International Conference on
Concussion in Sport, held in Zurich, a consensus statement
was drafted on concussions in sport which included a
graduated return to play protocol21. It compromised six
steps that should be followed by the concussed athlete. The

64
first step is no activity; complete physical and cognitive
rest. The second step is light aerobic activity. This could
include walking, swimming or stationary cycling; however
the athlete’s heart rate should not exceed 70% of maximum
heart rate. The athlete should not participate in any
resistance training as well. The third step is sportspecific exercise. This could include shooting baskets,
dribbling a soccer ball, participating in walk-through,
skating drills, etc.
The second half of the return to play protocol begins
with the fourth step which is non-contact training drills.
This is a progression to more complex drills such as
passing routes in football, running through plays, etc. The
athlete may also begin participating in resistance
training. The fifth step is full contact practice. The
athlete is free to participate fully in all drills during
practice. This may only occur after obtaining medical
clearance. The final step is full return to game play. It
must be stressed that for an athlete to proceed to the next
step in the progression they must be symptom free for 24
hours. For example, if an athlete is in step two and is
instructed to walk for 20 minutes. Later that night the
athlete develops a headache and sensitivity to light. Now,
the athlete must return to step one until all symptoms have

65
resolved for 24 hours. A progressive return to play
guideline is needed to ensure proper safety for all
athletes.

RESOURCES FOR COACHES & PARENTS

There are many resources available to coaches and
parents to increase awareness of concussions. One example
is the Centers for Disease Control and Prevention’s “Heads
Up” website. The website provides an online training course
specifically designed for youth sports31. It also includes
fact sheets and posters for parents and athletes.
Concussion information is being relayed through all types
of media. In a study by Goodman et al32 a video game was
developed that present information on concussions while the
game was played. After playing the game the subjects had an
increase awareness of concussion symptoms and proper
management. Physicians and athletic trainers are always an
excellent resource for parents and coaches to utilize.
Recently in Pennsylvania House Bill No. 2728 was
passed that required all coaches of school entities to take
an online or face-to-face concussion education course. The
purpose of this bill was to establish a standard of care
for managing concussions and head injuries among student

66
athletes.

The bill applies to all school entities within

Pennsylvania. Every year, as stated by the bill, parents
must review a concussion fact sheet and sign an
acknowledgment before the student may participate in any
athletic activity. In addition, every two years coaches
must complete a concussion training course offered by the
Center for Disease Control and Prevention. It is then the
coach’s responsibility to remove an athlete from play if a
concussion is suspected. Failure to follow this duty will
result in suspension from coaching for the remainder of the
season. The bill also gives authority to licensed/certified
health care practioners and game officials to remove an
athlete from play if a concussion is suspected. There are
several resources available on the Pennsylvania Department
of Health’s website.
By educating parents and coaches of youth athletes
they will be more likely to take action if they understand
the severity of concussions and the long term effects this
injury can cause33. In the end, the best way to protect
youth athletes from concussions is to educate parents and
coaches to recognize concussion symptoms, proper management
and safe return to play guidelines.

67
SUMMARY

The research shows that concussions are a prevalent
issue among athletes of many ages. However, little research
has been conducted on concussion specifically among youth
athletes and the educational tools that are available to
this population. Proper prevention, recognition and
management of concussions must be implemented to protect
youth athletes from both short and long term effects. For
youth athletes, this can best be achieved by educating
parents and coaches. Due to the debilitating long term
effects that are being seen in retired athletes, it is
important to decrease the amount of concussions sustained
by athletes at all levels. To do this the best place to
start is at the beginning. By explaining the detrimental
effects concussions can cause when children first start
athletics, it can be stressed how proper prevention,
recognition, and management can help protect youth
athletes. Educational efforts have increased at the
professional, collegiate and high school levels. Now it is
time to increase awareness at the youth level.

68

APPENDIX B
The Problem

69

STATEMENT OF THE PROBLEM

The purpose of the study is to assess concussion
knowledge among parents and coaches of youth athletes. It
is important to assess this relationship because without
medical professionals at youth sporting events parents and
coaches must assume responsibility of medical care for
youth athletes. By examining the amount of concussion
knowledge it can be determined how competent parents and
coaches can prevent, recognize and manage a concussion
sustained by a youth athlete.

Additionally it would be

beneficial to see how concussion education can best be
implemented for parents and coaches of youth athletes.

Definition of Terms
The following definitions of terms will be defined for
this study:
1)

Concussion – a complex pathophysiological process
affecting the brain induced by traumatic biomechanical
forces.

2)

Mild Traumatic Brain Injury – an individual who has
suffered a traumatically induced physiological
disruption of brain function.

70
3)

Return to Play – the term used when an athlete has
been cleared by a medical professional to engage in
physical activity without any limitations.

4)

Medical Professional – a licensed physician or
certified athletic trainer.

5)

Youth Athlete – an individual who participates in a
coach sponsored athletic activity and is between the
ages of 8-12.

6)

Neurocognitive Testing – a computerized or written
test evaluating an individual’s cognition including
both short and long term verbal and visual memory,
attention, reaction time, and processing speed.

Basic Assumptions
The following are basic assumptions of this study:
1)

The subjects will be honest when they complete the
demographic sheets.

2)

The subjects will answer to the best of their ability
on the survey.

3)

The subjects will have access to a computer and
internet in order to complete the online survey.

4)

The sample obtained will be representative of the
population.

71
Limitations of the Study
The following are possible limitations of the study:
1)

The survey is a convenience survey and is not
completely random.

2)

The survey was completed online and without any
supervision by investigators.

3)

There may be trouble distributing the surveys to
parents and coaches of youth athletes.

4)

The survey was sent to youth sport associations and
school districts to be forwarded to the appropriate
target audience.

Significance of the Study
The significance of the study will be to reveal the
concussion knowledge of parents and coaches of youth
athletes. Concussions are a prevalent problem among
athletes, it is important to properly recognize and manage
concussions sustained by youth athletes. The responsibility
of youth athletes is largely placed on parents and coaches.
Therefore, this population must be educated on proper
concussion prevention, recognition and management
strategies. This study will help assess the level of
knowledge parents and coaches of youth athletes already
possess and if educational programs are still needed.

72

APPENDIX C
Additional Methods

73

APPENDIX C1
Institutional Review Board ApprovalCalifornia University of Pennsylvania

74
Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP, Chair
Dear Ms. Hjortedal:
Please consider this email as official notification that
your proposal titled “Concussion Knowledge Among Parents
and Coaches of Youth Athletes” (Proposal #12-035) has been
approved by the California University of Pennsylvania
Institutional Review Board as submitted.
The effective date of the approval is 2/18/2013 and the
expiration date is 2/17/2014. These dates must appear on
the consent form.
Please note that Federal Policy requires that you notify
the IRB promptly regarding any of the following:
(1) Any additions or changes in procedures you might
wish for your study (additions or changes must be
approved by the IRB before they are implemented)
(2) Any events that affect the safety or well-being of
subjects.
(3) Any modifications of your study or other responses
that are necessitated by any events reported in
(2).
(4) To continue your research beyond the approval
expiration date of 2/17/2014 you must file
additional information to be considered for
continuing review. Please contact
instreviewboard@calu.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

75

APPENDIX C2
Concussion Knowledge Survey

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Concussion Knowledge Survey:
Parents Version

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Concussion Knowledge Survey:
Coaches Version

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Appendix C3
Survey Cover Letter

99

Dear Youth Parent or Youth Coach:
My name is Stephanie Hjortedal, and I am currently a
graduate student pursing a Master of Science degree in
Athletic Training at California University of Pennsylvania.
This study is part of a research thesis required in the
graduate study curriculum. I am conducting a survey to
assess concussion knowledge among parents and coaches of
youth sports. While the media has shown the long-term
detrimental effects of sports-related concussions, the
purpose of this survey is to identify the level of
concussion recognition and management among parents and
coaches of youth athletes. My goal is to continue building
concussion awareness at the ground level, and to optimize
the care and safety of youth athletes.
Coaches and parents of youth athletes are being asked to
participate in this research; however, your participation
is voluntary and you do have the right to choose not to
participate. If you are neither a parent nor coach of a
youth athlete you will be directed to the end of the survey
and thanked for your time. You also have the right to
discontinue participation at any time during the survey, at
which time your data will be discarded. If you have
received this survey via a sports organization and choose
not to participate in the survey, it will have no bearing
on your, or the athlete’s, activity level with that
organization. This survey is not under the auspices of the
organization itself. You must be 18 or older to participate
in the survey. The California University of Pennsylvania
Institutional Review Board has reviewed and approved this
project. The approval is effective nn/nn/nn and expires
mm/mm/mm.
All survey responses are anonymous and will be kept
confidential. Informed consent to use the data collected
will be assumed upon completion of the survey. Data
collected electronically will be stored on California
University of Pennsylvania servers with the individual
files password protected. Any hard copy data collected,
such as informed consent forms, etc., will be stored in the
Health Sciences Department in the graduate athletic
training education program director's office, Room 115.

100
Minimal risk is posed by participating as a subject in this
study. I ask that you please take this survey at your
earliest convenience as it will only take approximately 10
minutes to complete. If you have any questions regarding
this project, please feel free to contact the primary
researcher, Stephanie Hjortedal at HJO0057@calu.edu. You
can also contact the faculty advisor for this research (Dr.
Jamie Weary, ATC, weary@calu.edu or 724-938-5708).
Please click the following link to access the survey
https://www.surveymonkey.com/s/MNR378L
Thank you for taking your time to take part in my thesis
research. I greatly appreciate your time and effort put
into this task.
Sincerely,
Stephanie Hjortedal, LAT, ATC, PES
Primary Researcher
California University of Pennsylvania
250 University Ave
California, PA 15419
HJO0057@calu.edu

101
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Valovich-McLeod TC, Gioia GA. Cognitive rest: The
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McGrath N. Supporting the student-athlete’s return to
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Chrisman SP, Schiff MA, Rivara FP. Physician
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105
ABSTRACT
TITLE:

CONCUSSION KNOWLEDGE AMONG PARENTS AND
COACHES OF YOUTH ATHLETES (AGES 8-12)

RESEARCHER:

Stephanie Hjortedal, LAT, ATC, PES

ADVISOR:

Dr. Jamie Weary, LAT, ATC

DATE:

May 2012

PURPOSE:

The purpose of this study was to assess
concussion knowledge among parents and
coaches of youth athletes between the ages
of 8-12.

Design:

Descriptive Survey

Settings:

Population-Based Survey

Participants:

38 parents, 14 coaches, and 18 subjects who
were both a parent and a coach voluntarily
participated in the Concussion Knowledge
Survey.

INTERVENTIONS: The independent variables were being a
parent or coach of a youth athlete, CPR
certification, first aid certification, and
attendance of a concussion class or clinic.
The dependent variable was the score on the
Concussion Knowledge Survey.
RESULTS:

There was no significant difference in
concussion knowledge score between parents
and coaches of youth athletes. In addition,
there was no significant difference in
concussion knowledge score between parents
or coaches with CPR/first aid certification
and parents or coaches without CPR/first aid
certification. Also, no significant
difference was found in concussion knowledge
score between coaches who had attended a
concussion class and coaches who have never
attended a concussion class.

CONCLUSIONS:

Without the presence of health care
professional at youth athletic events the

106
responsibility of the youth athlete falls
upon the shoulders of the parents and
coaches. Although no significance difference
of concussion knowledge was seen between
parents and coaches of youth athletes,
subjects demonstrated a moderate knowledge
of concussion prevention, recognition and
management. Based on the results of this
study, it can be concluded that concussion
education training should continue to be
implemented at the youth level.