Concussion-Related Anxiety Perceptions of Parents of Youth Athletes

Key Points

• A large proportion of parents of youth athletes reported being fearful, upset, worried, and anxious at the thought of their children sustaining a concussion.

• Greater concussion-related anxiety perceptions of parents were associated with being female and lacking a personal history of concussion.

• Athletic trainers should validate and address concussion-related anxiety perceptions as part of their preinjury awareness and postinjury management approaches specific to youth sport participation.

Concussion has been recognized as a public health concern, particularly within the youth sports community. Researchers have shown that early participation in contact sports, such as football and ice hockey, results in greater risk of traumatic brain injuries in young athletes.¹ Approximately 1 million to 2 million concussions occur annually in children, although this is likely an underestimate due to the absence of sports medicine coverage in youth sports and those not seeking care.² Given the insufficient resources available to this age group, the burden of injury identification and immediate management often falls on parents. Whereas parents have been shown to have moderate concussion knowledge, they may not be equipped to accurately understand all of the nuances of this invisible injury.^3–5 Although the physical and mental health benefits of playing a sport are well documented, parent concerns about the lack of medical involvement, knowledge and misconceptions of concussion, and the potential long-term effects of injury create hesitancy toward youth sport participation.^6,7

Anxiety can be characterized as negative thoughts or emotions related to potential upcoming events.⁸ A history of anxiety in both parents and children is linked to longer recovery times for children with concussion.⁹ However, few researchers have examined parents’ worry about the potential for future concussion or what we characterize as concussion-related anxiety. In a nationally representative sample of more than 1000 parents from the general population, Kroshus et al found that over half of parents are worried (28%) or very worried (23%) about concussion.¹⁰ Parents of youth athletes, however, may experience comparatively higher rates (>70%) of concussion-related anxiety.¹¹ In fact, parents have expressed more concern about concussion than smoking, drug use, depression, and unplanned pregnancy; thus, they experience considerable worry about the potential for their children to sustain a concussion in the future.¹⁰ Few researchers have explored factors that may influence this preemptive concussion-related anxiety, particularly among youth athletes and their parents.

Kroshus et al found that less education, lower socioeconomic status, and identifying as either Hispanic or Black were independently related to greater concern in parents about concussions.¹⁰ However, additional factors may need to be considered when understanding parents’ concerns and perceptions of concussion and concerns regarding the injury. The literature is split regarding sex differences in concussion perceptions for parent and collegiate athlete samples.^10,12 Further investigation is needed, as sex differences are commonly observed in relation to parent anxiety in general. Mothers typically experience higher levels of parent anxiety than fathers regardless of whether the child is experiencing illness or injury or is in good health.¹³ Another factor that may inform concussion-related anxiety in parents is history of concussion. Parent or child history of concussion is associated with improved parent concussion knowledge and care-seeking behaviors.^14,15 Researchers have suggested that concussion education may lessen concussion-related anxiety in parents.⁵ This assertion would be consistent with existing health literature, as educational programs have been shown to effectively diminish parent anxiety related to fever and surgery, although more research is needed in the context of pediatric concussion.^16,17

Collectively, in the literature, the understanding of concussion-related anxiety in parents of youth athletes is limited, and an appreciation of factors influencing these perceptions is needed to create intentional awareness procedures. This information may be useful for athletic trainers who are frequently on the front line of concussion education delivery, injury identification, and postinjury management for young athletes within the communities they serve. The primary purpose of this study was to describe the prevalence of concussion-related anxiety perceptions in parents of youth athletes. We hypothesized that most parents would exhibit concussion-related anxiety perceptions. The secondary purpose was to establish the associations among concussion-related anxiety and demographic variables including sex (male versus female), personal concussion history, child concussion history, and previous concussion education. We hypothesized that female sex, personal concussion history, and no previous concussion education or training would be associated with perceptions of anxiety regarding concussion. In this investigation, we will provide athlete trainers with essential knowledge regarding parents’ feelings about and perceptions of concussion that they can leverage to advance their delivery of psychologically informed care for this invisible injury.

METHODS

RESULTS

Participant Characteristics

A total of 490 parents started the survey, and 452 (92.2%) completed all items necessary to answer the research questions. The mean age of parent participants was 40.4 ± 13.0 years (median age = 43 years, 25th percentile = 38 years, 75th percentile = 47 years) with female parents comprising more than half (60.3%, n = 272/451) of participants (Table 1). Approximately 11.2% (n = 50/446) of parents reported a personal history of diagnosed sport-related concussion, and 17.5% (n = 78/446) reported that at least 1 of their children had a history of 1 or more diagnosed sport-related concussions. Additionally, 36.6% (n = 164/448) of parents indicated having received formal concussion education.

Table 1.Parent Characteristics

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PCI-A Anxiety Item Characteristics

Overall, 73.2% (n = 331) of parents agreed or strongly agreed that the possibility of their children sustaining a concussion is upsetting, 61.5% (n = 278) were fearful of their children sustaining a concussion, and 45.1% (n = 204) reported that the thought of their children having a concussion makes them feel anxious. Only 4.7% (n = 21) agreed or strongly agreed that concussions do not worry them. The median anxiety composite score was 15 (interquartile range [IQR], 13–17) overall, 16 (IQR, 13–28) for female parents, and 14 (IQR, 12–16) for male parents. Table 2 presents descriptive information for each anxiety perception item, and Figure 1 displays the level of agreement for each item. The internal consistency of the 4 anxiety items was Cronbach’s α = 0.8457, suggesting the items similarly measured the construct of anxiety.

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Table 2.Parent PCI-A Anxiety Factor Structure Items

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Factors Associated With PCI-A Anxiety Item Agreement

Univariate logistic regressions revealed female relative to male parents had greater odds of being upset (OR = 1.91; 95% CI = 1.25, 2.92), fearful (OR = 2.01; 95% CI = 1.36, 2.96), and anxious (OR = 2.20; 95% CI = 1.49, 3.25) of their child sustaining a concussion. Separately, female parents (OR = 0.31; 95% CI = 0.12, 0.79) had lower odds of expressing concussions “do not worry” them relative to male parents. Parents without a personal history of diagnosed concussion had greater odds of being upset (OR = 2.49; 95% CI = 1.36, 4.56), fearful (OR = 2.08; 95% CI = 1.15, 3.76), or anxious (OR = 2.92; 95% CI = 1.48, 5.76) relative to parents who had sustained a concussion previously. Figure 2 displays univariate ORs for anxiety items for each factor. Based on independent associations, we included these significant factors in the separate multivariable models. The multivariable logistic regression models included all individual anxiety factors that were significant from the univariate logistic regressions (Figure 3). In the final multivariable linear model for overall concussion anxiety perceptions, being female (OR = 1.26; 95% CI = 0.67, 1.84) and having no personal history of concussion (OR = 1.35; 95% CI = 0.44, 2.26) were associated with a higher anxiety perception composite score (F_2,422 = 15.32; P < .001, R² = 0.06).

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DISCUSSION

Our findings align with those of previous researchers who documented that parents of youth athletes have important concerns about concussion. Our hypothesis that more than 50% of our sample would have concussion-related anxiety perceptions was supported as most parents reported that they were upset, fearful, or worried by the thought of their children sustaining a concussion. Results regarding our second aim revealed that female parents and those who had not personally sustained a diagnosed concussion had greater odds of experiencing concussion-related anxiety. Overall, these findings show the potential emotional burden that parents experience related to concussion and their children even before an injury occurs. The notable concussion-related anxiety in parents demonstrated in this study should be considered by athletic trainers as part of their psychologically informed concussion management practices for youth athletics. This could include directly acknowledging and discussing common parent concussion concerns during an educational session or intentionally asking parents if they have concussion-related anxiety and what apprehensions they may have regarding their child’s concussions as part of postinjury communications. In both approaches, athletic trainers, neuropsychologists, researchers, and public health officials should work collaboratively to lessen concussion-related anxiety in parents by discussing the multifaceted benefits of sport participation as well as transparently educating parents on the current state of research regarding persisting and long-term issues related to concussions and head impacts.

At least 1 negative emotional perception regarding concussion was reported by approximately 75% of parents in our sample. The highest prevalence of agreement among the individual anxiety perception items was related to parents being upset or worried about their children sustaining a concussion. The lowest prevalence of agreement, although still substantial at 45.1%, was for the item related to feeling anxious. Our multisport findings align with and expand on previous soccer-specific studies in which researchers found parents believe a concussion is a serious injury that may lead to permanent damage and are concerned about their children sustaining a concussion.^6,11 In addition, the percentage of parents of youth athletes who reported concussion concerns in our study was approximately 25% greater than what was found in a previous investigation of parents from the general population.¹⁰ This difference could be due to several factors, such as the numerous mainstream media stories specifically about sport-related concussions, the inherent risk for sustaining an injury while participating in sports, and an increased exposure to vicarious concussion occurrences and experiences through individuals within athletic teams or youth sport environments. Overall, we expanded on the earlier work in soccer to include additional sports (ie, football, lacrosse, and ice hockey) and found similar results regarding the magnitude of negative emotional perceptions related to concussions. Together, these findings suggest that parents of youth athletes are likely to experience concussion-related anxiety, which warrants intervention.

This trend of concussion-related anxiety among parents of youth athletes may have major implications for youth sports. Tackle football participation has steadily decreased in recent years, which experts attribute, in part, to the rise in concussion knowledge and spread of information via mainstream media.^22,23 Furthermore, approximately 45% of parents of youth soccer athletes have considered not allowing their children to play soccer due to fears their children may experience a concussion.⁶ Parents who had sustained a concussion were less likely to allow their children to participate in football and ice hockey, which are sports that are notorious for collisions and higher concussion incidence rates.^24,25 Although parent concerns about concussion are understandable, the advantages of early and consistent engagement in physical activity and organized sport must also be considered. For children, sport participation provides both physical (eg, lower obesity risk, improved motor skills, and increased bone density) and psychological (eg, better self-esteem, less depression, and improved socialization skills) benefits. Youth sport participation even has long-term benefits, as adolescent sport involvement is related to a more active lifestyle that acts as a protective mechanism against chronic diseases later in life (eg, cardiovascular disease and type 2 diabetes).²⁶ During athlete and parent concussion education, athletic trainers should deliver a balanced message highlighting these benefits of sport participation while noting that the evidence is inconsistent regarding the relationship between contact sport participation and the development of neurological diseases (eg, chronic traumatic encephalopathy).^27,28 Furthermore, identifying sports with higher (ie, rugby, ice hockey, football, lacrosse, soccer, and wrestling) versus lower (ie, volleyball, field hockey, baseball, softball, and basketball) concussion incidence rates may be helpful as part of concussion education.¹⁸ Providing this information comprehensibly may aid families in choosing a sport for their child that aligns with their personal concussion risk tolerance and increase their overall awareness of the greater inherent risk of sustaining an injury in sports with more physical contact.

In addition to sport participation decisions, concussion-related anxiety of parents may be related to postinjury outcomes. Teel et al found that 4 in 10 parents reported moderate to severe stress after their child’s concussion, and this heightened stress response was related to increased recovery time.²⁹ Children whose parents experienced higher postinjury stress took approximately 2 weeks longer to recover than children whose parents had low stress, even after controlling for initial postinjury symptom scores.²⁹ In contrast, Zemek et al did not find that parent anxiety measured during acute concussion presentation at an emergency department was related to the persistence of symptoms after concussion in children.³⁰ However, parent anxiety was higher in those whose children were still experiencing symptoms at 1 month postinjury compared with those whose children had reached symptom resolution. Future research is needed to better understand the relationships among parent stress and anxiety and clinical outcomes for the injured child. Bidirectional pathways may exist between concussion-related anxiety and stress in parents and child outcomes postconcussion. During interviews, parents reported that their stress level was directly related to their child’s stress level, postinjury symptoms, and overall functioning.²⁹ The authors of these previous studies focused on indicators of parent stress and anxiety postconcussion, whereas we took a much broader approach to measuring the parent emotional burden of concussion (eg, upset, fearful, anxious, and worried) in the absence of injury.^29,30 More research is needed to learn how premorbid versus postinjury parent concussion-related anxiety is related to postconcussion assessment outcomes and recovery milestones in children, which may have important implications for concussion education and management strategies.

To gain an appreciation for factors that may influence parent concussion beliefs, we explored the relationship between parent sex and concussion-related anxiety. We found that female parents reported more concussion-related anxiety. This result is congruent with those reported in extant literature indicating that women have a greater lifetime prevalence of anxiety and mood disorders compared with men, which may be attributed to a combination of various factors including genetic, environmental, neurodevelopmental, and neurobiological differences.^31,32 Therefore, one might expect increased risk of anxiety to extend to a specific health-related construct, such as concussion. Evidence of this has been documented within the concussion literature. In 2 previous investigations, researchers reported higher general concussion anxiety in healthy female collegiate athletes than their male counterparts.^12,33 In addition, after concussion, adolescent female athletes have reported greater anxiety- and emotion-related symptoms than male athletes.³⁴ Finally, mothers of youth soccer players perceived concussion to be more harmful compared with fathers in 1 previous investigation, which could be related to the injury anxiety differences between male and female parents that we observed.³⁵ The sex-based findings regarding concussion-related anxiety perceptions from our study can be used by athletic trainers to tailor their injury education and communications based on the gender identity of the target audience. Although emotions are highly individualized, our findings suggest that female parents may need more concussion-related support. For example, when notifying mothers that their children have sustained a concussion, athletic trainers can proactively provide information that normalizes the presence of concussion-related anxiety perceptions in parents and afford them the opportunity to express their own concerns.

In addition to parent sex, we also considered whether child or personal concussion history was related to concussion-related anxiety perceptions of parents. Although we hypothesized that both child and parent concussion history, respectively, would be related to greater concussion-related anxiety in parents, we found that parent concussion history was related, but child concussion history was not. Specifically, parents who had not sustained a concussion had greater odds of reporting being upset, fearful, or anxious at the thought of their child sustaining a concussion. This finding regarding parent concussion history may be grounded in evolutionary psychology models regarding the fear of the unknown and the uncertainty and anticipation model of anxiety.³⁶ Individuals are inherently averse to unknowns, and researchers have theorized that fear of the unknown is important to the development of neuroticism, which is a personality trait characterized by anxiety, emotional instability, and depression.^37,38 The uncertainty and anticipation model of anxiety goes further to describe that negative reactions to uncertainty supports maladaptive responses to unknowns, which may include “inflated estimates of threat cost and probability, hypervigilance, deficient safety learning, behavioural and cognitive avoidance and heightened reactivity to threat uncertainty.”^36(p490) Compared with musculoskeletal injuries in sport that have external tissue damage that follows a predictable process of healing, concussions tend to be more mysterious and challenging to comprehend given their internal nature, uniqueness of clinical presentation, and variation in recovery patterns. For someone who has never sustained this injury and experienced the recovery process, it is understandable that fear of the unknown and anticipatory anxiety may be present. Thus, parent concussion history is yet another factor about which athletic trainers can inquire to inform their postinjury education and management approaches for youth athletes who sustained a concussion, knowing that those who have not personally experienced this injury may require or benefit from additional injury counseling and support.

CONCLUSIONS

The results of our study suggest that a substantial portion of parents of youth athletes exhibit feelings of being fearful, upset, worried, and anxious at the thought of their children sustaining a concussion. In addition, concussion-related anxiety perceptions of parents in our sample were associated with being female and lacking a personal history of concussion. These negative emotions about concussion should be considered and addressed when developing and implementing awareness approaches specific to youth sport participation. Given their important role in preinjury and postinjury concussion education for youth athletes and their families, we recommend that athletic trainers directly acknowledge that a concussion is a concerning injury that may invoke several negative emotions while also providing scientifically based information regarding proper immediate management, postinjury care and treatment options, and the potential protracted outcomes associated with concussion and sport participation. Further investigation into how concussion-related anxiety perceptions of parents relate to concussion recovery in youth athletes is warranted.