Objective To determine collegiate student-athletes' experiences with concussions, whom they were talking with, and patterns of concussion recognition. Design Randomized trial. Setting National Collegiate Athletic Association (NCAA) teams. Participants 815 collegiate student-athlete controls in collision and contact sports from an intervention study. Interventions (or Assessment of Risk Factors) Sex (male/female). Outcome Measures With whom student-athletes discussed concussions (coaches, athletic trainers, teammates), whether student-athletes sustained concussions themselves or suspected a teammate sustained a concussion, and whether they reported their concussion or their teammates' suspected concussion. Main Results There was a significant gender difference in discussing concussions with a coach [χ2(1, n=808) =7.9, p=.005]. Males were 1.62 (Odds Ratio) times more likely to discuss concussion with their coach. No gender differences were found in discussions with athletic trainers or teammates. There were no significant gender differences in sustaining or reporting one's own concussion. However, there was a significant gender difference in suspecting a concussion in a teammate, (χ2(1, n=804) =7.0, p=.008). Males were 1.83 (OR) times more likely to suspect a concussion in a teammate than females. There were no significant gender differences in reporting a suspected concussion in a teammate, (χ2(1, n=545) =1.15, p=.29). Overall 91 of 138 student-athletes who suspected they had a concussion indicated reporting and 70 of 128 reported teammates' suspected concussion. Conclusions Findings suggest that discussions and reporting about concussions among student-athletes are influenced by gender and play an important role in how concussions are discussed.

Objective: To determine if a peer-led concussion reporting worksheet activity could elucidate barriers to reporting in collegiate athletes. Participants: Five hundred and three athletes from 7 universities across all three NCAA divisions. Methods: A supplementary qualitative analysis of responses to a concussion reporting worksheet completed during an RCT of a novel peer concussion education program. The first column of the worksheet required participants to list thoughts that prevent reporting and the second column required replacement thoughts that facilitate reporting. Results: A qualitative phenomenological thematic analysis of responses to the first column of the worksheets identified themes that coalesced into three areas: 1) missing out on athletic and social events, 2) losing one's competitive edge, and 3) negative interpersonal interaction/self-perception. Conclusions: Barriers to concussion reporting from several areas central to the collegiate athlete experience were identified. These barriers should be considered during clinical assessment and when developing concussion education programs.

Abstract Objective To quantify the influence of barriers that prevent intention to report concussions in female athletes. Hypothesis: NCAA Division 1 (D1) athletes will have higher overall reporting barrier scores than Division 3 (D3). Method Participants/Setting: 70 participants started the study and 13 were removed due to incomplete questionnaires, resulting in 57 participants (38 from D1). Athletes participating in contact sports (e.g., soccer) were recruited via email or flyers posted in training rooms. Measurement: A 21-item online questionnaire consisting of eight demographic questions and 13 questions related to barriers that prevent reporting. The barrier items were modified from themes derived from a published qualitative study of 503 collegiate athletes who completed a reporting worksheet. Participants rated agreeability [0 (strongly disagree) to 100 (strongly agree)] for the items that prevent reporting. Results Descriptive statistics indicated barriers likely to prevent reporting (e.g., Losing Playing Time; M = 78.02, SD = 22.61) and those less likely (e.g., Negative Reaction from Teammates; M = 44.75, SD = 31.63). The overall barrier to reporting score was not significantly different between D1 (M = 817.34, SD = 247.90) and D3 (M = 740.11, SD = 225.74), t (55) = 1.141, p = 0.259, d = 0.32. The internal consistency of the 13 barrier items was good, α = 0.852. Conclusions Barriers to reporting with greater saliency were identified, which may need to be prioritized during concussion education. The overall questionnaire score did not significantly differ between D1 and D3 suggesting that barriers operate similarly at different levels of competition. The questionnaire’s good internal consistency suggests it has potential as a research tool.

Objective To understand concussion knowledge and attitudes toward safety among NCAA coaches. Design Cross-sectional. Setting Online survey. Participants 227 coaches at NCAA Division I, II, III colleges and universities. Outcome Measures A mixed-methods survey of Concussion Knowledge (CK), Concussion Attitude Index (CAI), coaches' perceptions of concussion management, the culture of concussion, and student-athlete reporting. Main Results Females had higher levels of CK (M=18.3,se=.58) compared to males (M=15.9,se=.46), F(1,212)=10.7,p=.001,ɳ2=.048 , but no gender difference in CAI. There were no significant differences in CAI or CK based on number of years collegiate coaching. Number of years collegiate coaching significantly predicted both CK F(1,198)=3.98, p=.048,R2=.015 and CAI, F(1,182)=8.85,p=.003,R2=.046 with more years coaching positively correlated with CAI (r(n=259)=.19,p=.01) and negatively correlated with CK, r(n=259)=-.18,p=.01. Coaches believed their role was to support Athletic Trainers and instruct and enforce safety. They believed concussions are serious though perhaps overly-hyped. Coaches indicated athletes 'report', 'overreport', and 'underreport'. Coaches called for better diagnostic assessments and shorter return to play protocols. Conclusions Overall, coaches had relatively strong knowledge of concussion symptoms with female coaches having slightly higher scores. Understanding of coaches' knowledge and attitudes towards concussion provides awareness of what coaches know in the larger socio-ecological framework of concussion care.

Objective To describe thoughts that impede concussion reporting and those that might facilitate reporting in student-athletes that completed a concussion reporting worksheet as part of a peer concussion education program (PCEP). Design Document review with qualitative data analysis. Setting During a randomized controlled trial, 30 teams with relatively high concussion rates from 10 colleges/universities across all 3 NCAA divisions received the PCEP. Participants Worksheets were returned from 503/773 (65%) male and female athletes. Interventions (or Assessment of Risk Factors) Two peer concussion educators provided an education module to their teammates designed to enhance concussion reporting based on cognitive-behavioral therapy (CBT). Outcome Measures Worksheets where student-athletes identify thoughts that impede concussion reporting and replace them with thoughts that might facilitate reporting. Main Results Qualitative data analysis of thoughts that impede reporting yielded 11 themes including concerns about losing playing time, letting down teammates, losing one's spot on the team, ending a career, having a negative impact on fitness and skill level, game and situational factors, negative reactions from teammates and coaches, uncertainty about symptoms, adverse impact on academic functioning, and missing out on social activities. Analysis of thoughts that might facilitate reporting led to 10 themes including reporting aids athletic performance, helps the team, will result in quicker return to play, protects against long-term health implications, will be supported by my coach and teammates, and has academic advantages. Conclusions A worksheet activity based on CBT indicated that student-athletes are capable of changing their thinking in a manner that has the potential to support concussion reporting.

Objective To describe the experiences of peer concussion educators (PCE's) who implemented a peer concussion education program (PCEP) with collegiate athletes. Design Online debriefing questionnaire. Setting During a randomized controlled trial, 30 teams with relatively high concussion rates from 10 colleges across all 3 NCAA divisions received the PCEP. Participants Twenty/60 collegiate student-athletes serving as PCE's. Interventions (or Assessment of Risk Factors) Two student-athletes per team are trained as PCE's to deliver presentations to enhance concussion knowledge and reporting, which features a worksheet where teammates list thoughts that impede reporting and replace them with thoughts that facilitate reporting. Outcome Measures The debriefing questions were: 1) What did you like about being a peer educator? 2) What challenges did you face? 3) What suggestions do you have for improving the program? 4) What worked well? Main Results Qualitative data analysis revealed the following themes: Question 1: a) Educating my teammates about concussion, b) The opportunity to learn more about concussions. Question 2: a) Difficulty engaging teammates and being taken seriously, b) Difficulty with the material describing the scientific aspects of concussion. Question 3: a) Make the science easier to understand, b) Make the material more engaging, c) Change nothing. Question 4: a) Having the support of the athletic trainer, b) The concussion reporting exercise, c) The PowerPoints were helpful, especially the videos and diagrams. Conclusions The PCE's reported positive experiences including the opportunity to educate their teammates along with challenges including being taken seriously by their teammates and presenting on the more 'scientific' aspects of concussion.

OBJECTIVE To determine Southern African parents' concussion knowledge and intention to report in youth athletes. METHOD A diverse sample of 48 Southern African parents of youth athletes ages 5-18 completed an online survey. Recruitment included: 1) contacting school administrations to forward the survey to parents and 2) a social media post. The Concussion Knowledge Checklist (CKC) consists of 27 items, 19 true and eight false symptoms, with a score range of 0-54. The Intention to Report Scale consists of seven questions on a Likert scale, with a score range of 7-49. Higher scores indicate greater knowledge and intention to report, respectively. RESULTS CKC score (M = 37.24; SD = 7.1) indicates a moderate degree of concussion knowledge. Certain symptoms (i.e., blurred vision) were accurately endorsed at a high rate (83%). Conversely, affective symptoms, such as more emotional, were accurately endorsed at a low rate (25%). The Intention to Report Scale score (M = 40.98; SD = 5.97) suggests a moderate to strong degree of participants' intention to report. CONCLUSIONS Participants indicated a moderate degree of concussion knowledge. However, variability was evidenced by some symptoms (e.g., blurred vision) endorsed at a high rate and others, for example, more emotional, at a low rate. These findings have possible implications for concussion education. The Intention to Report Scale indicated a moderate to strong degree of parents' intention to report their children with a suspected concussion.

Primary Objective To examine the convergent validity of the Test of Effort (TOE), a performance validity test (PVT) currently under development that employs a two-subtest (one verbal, one visual), forced-choice recognition memory format. Research Design A descriptive, correlational design was employed to describe performance on the TOE and examine the convergent validity between the TOE and comparison measures. Methods and Procedures A sample of 53 individuals with chronic acquired brain injury (ABI) were administered the TOE and three well-validated PVTs (Reliable Digit Span [RDS], Test of Memory Malingering [TOMM] and Dot Counting Test [DCT]). Main Outcomes and Results The TOE appeared more difficult than it actually was, suggesting adequate face validity. Medium-to-large correlations were observed between the TOE and established PVTs, suggesting good convergent validity. Provisional cutoff scores are offered based on performance of a subgroup of participants with "sufficient effort." Conclusions Overall, the TOE shows promise as a PVT measure for clinical use. Future studies with larger and more diverse samples are needed to more fully determine the psychometric characteristics of the TOE.

Context: Concussion education and prevention programs require reliable and valid instruments to evaluate the theory, mechanisms, and outcome of these interventions Objective: To assess the psychometric properties of measures evaluating concussion education and prevention programsDesign: Descriptive epidemiological Setting: 10 NCAA-member universities Patients or Other Participants: 841 student-athletes in an RCT control group testing an ecological, peer-led concussion education program Main Outcome Measures: Instruments adapted for assessing concussion knowledge and Theory of Planned Behavior/Theory of Reasoned Action (TPB/TRA) cognitive mediators of reporting behavior (attitudes, subjective norms, perceived control, and intentions to report concussion). Participants completed measures at baseline, after one hour, and after one month Results: Internal consistency and test-retest reliability were moderate for both the concussion knowledge and cognitive mediator measures. TPB/TRA was supported subscale intercorrelation and item factor analysis in the cognitive mediator scale. Factor analysis of the concussion knowledge measure revealed subscales for physical/cognitive, psychological/affective, and non-symptoms. The intermediate TPB/TRA mediators of attitudes, norms, and perceived control predicted greater intention-to-report, which predicted increased likelihood of reporting concussion one month later.Conclusions: Measures of concussion knowledge and cognitive mediators of reporting adapted from the literature show adequate psychometric properties and support TPB/TRA application for concussion reporting behaviors.

Background More than 460,000 female and male student-athletes compete in college sports each year, with 5.5 concussions reported per 1,000 athlete exposures. The majority of these concussions occurred during competition and are somewhat more likely to be reported by female athletes. Aims To evaluate moderating effects of gender differences in response to a Peer Concussion Education Program (PCEP). Method A total of 1,100 male and 511 female student-athletes from 60 teams (30 experimental, 30 control) representing all National Collegiate Athletic Association divisions from high-concussive sports participated before, postintervention, and 1-month following the intervention. Participants completed assessments of symptom and return-to-play knowledge, reporting behavior, and reporting attitudes. Results The PCEP was more effective than control on all measures, females in the PCEP showed significantly greater changes than males in return to play knowledge, intention to report self and teammate, and indirect attitudes for self and teammate. PCEP females were more likely to discuss concussions with athletic trainers, peers, and teammates. In addition, females had a higher likelihood of reporting their own suspected concussion. Discussion Females had greater rates of change in understanding of some key components of the PCEP. Conclusion These findings suggest that females may learn differently in a peer environment and have different attitudes toward reporting and safety when consideration is given to the well-being of others.

Background Sports related concussions continue to be a public health concern and improving reporting behavior a focus of educational programs. While educational programs have addressed changes in knowledge of concussion symptoms, it has been challenging to design educational programs which have lasting effects on reporting behavior. Aims The current analysis describes an intervention in which thoughts about reporting behavior are actively written down in a worksheet exercise to “pre-arm” athletes with cognitions designed to enhance reporting behavior prior to the injury event. Method A total of 503 male and female college athletes participating in collision (football, field hockey, ice hockey, lacrosse, and soccer) and contact sports (baseball, basketball, and softball) from 7 colleges/universities competing across all three NCAA divisions provided data collected during a randomized trial of a peer concussion education program. Results Qualitative analysis revealed 10 themes that would improve reporting including short-term benefits, faster recover, safe and healthy return to play, reporting helps the team, reporting protects the brain, risk aversion, long-term benefits, coach will be supportive, teammates will be supportive and understanding, and academic performance will be affected. Discussion Athletes had awareness of key risks involved in concussions and understood both short- and long-term consequences. Conclusion These findings have important implications for understanding how to change athletes’ thoughts about reporting concussions.

CONTEXT:The National Collegiate Athletic Association and US Department of Defense have called for educational programs to change the culture of concussion reporting, increase reporting behavior, and enhance the safety of players and service members.OBJECTIVE:To evaluate the effects of a novel peer concussion-education program (PCEP) in changing knowledge, attitudes, and norms about concussion reporting among collegiate student-athletes and assess program implementation.DESIGN:Randomized controlled trial and qualitative analysis of interviews.SETTING:National Collegiate Athletic Association athletic teams from randomly selected colleges or universities.PATIENTS OR OTHER PARTICIPANTS:A total of 1614 male and female student-athletes from 60 teams at 10 colleges and universities and 8 athletic trainers.INTERVENTION(S):The PCEP intervention trains 2 peer concussion educators to provide 2 education modules to their teammates. Knowledge, attitudes (oneself and teammates), and concussion occurrence or reporting were assessed at baseline, postintervention, and 1 month later. Eight athletic trainers were interviewed about program implementation.RESULTS:Compared with the control group, the intervention group showed greater increases occurred postintervention and at 1 month in concussion knowledge (F1,2648 = 51.3, P < .0001), intention to report (oneself, F2,2633 = 82.3, P < .0001; teammates, F2,2624 = 53.9, P < .0001), return-to-play protocol knowledge, (F2,2632 = 28.4, P < .0001), direct subjective norms (oneself, F2,2625 = 51.7, P < .0001; teammates, F2,2644 = 40.6, P < .0001), direct perceived behavioral control (oneself, F2,2628 = 53.7, P < .0001; teammates, F2,2615 = 68.2, P < .0001), and indirect attitudes (oneself, F2,2626 = 47.1, P < .001; teammates, F2,2623 = 40.9, P < .0001). Peer concussion-education program participants discussed concussion more often with a teammate (F1,1396 = 13.96, P < .0001) or athletic staff (F1,1396 = 6.62, P < .001). Qualitative program analysis revealed both positive aspects of the PCEP and areas for improvement.CONCLUSIONS:The PCEP showed promise in increasing concussion knowledge, intention to report concussion, reporting a teammate's concussion, and facilitating attitudinal changes that support reporting among student-athletes.

Context A novel peer concussion-education program (PCEP) was developed to enhance concussion knowledge and reporting among collegiate student-athletes. Objective To describe the PCEP and its development and implementation. Design Program development consisting of a literature review, focus group, and pilot implementation. Setting Athletics department at a college participating at the National Collegiate Athletic Association Division II-sanctioned competition level. Patients or Other Participants Fifteen student-athletes from the women's soccer and men's lacrosse teams participated in the focus group. Four peer concussion educators (PCEs) were debriefed after the pilot implementation of the PCEP with the women's soccer and men's lacrosse teams. Data Collection and Analysis Focus-group data were analyzed qualitatively. The PCEs were debriefed, and responses were organized into recommendation types. Results The literature review contributed information that supported the development of the PCEP's conceptual model. Focus-group results provided information used to train the PCEs and refine the PCEP's education modules. The pilot implementation and PCE debriefing supplied information used to further revise the education modules, PCE training, and PCEP implementation procedure. Conclusions The PCEP was developed based on the Theory of Reasoned Action and Planned Behavior and uses a peer-mediated, cognitive-behavioral, and interdisciplinary model to enhance concussion knowledge of and reporting by collegiate student-athletes. After a focus-group discussion and pilot implementation, we revised the PCEP and its education modules and developed an online manual to facilitate broad dissemination.

OBJECTIVE:The current study was designed to understand the culture of concussion among college student-athletes. Participants: Eight men's lacrosse and seven women's soccer players. Methods: A focus group was conducted to understand thoughts, barriers, team culture, and what was needed to feel safe reporting symptoms. Thematic analysis was conducted to identify key themes. Results: Themes included concerns about being taken out, pushing through, wanting to play, severity influencing reporting, changes about concussion reporting, uncertainty about symptoms, concussion have changed the game, reporting a teammate, wanting someone else to make the call, desire to raise awareness, deception, wanting professors to have more understanding, circumstances influencing reporting, helmets specific for concussion, malingering, and the return to play protocol being too long. Conclusion: Factors ranging from intrinsic to more distal cultural and environmental factors appear to influence reporting concussions. Student-athletes identified factors unique to the college athlete environment.

Objective To evaluate the effectiveness of a novel peer concussion education program designed to increase knowledge of concussions, reporting of concussive events, and attitudes for both teammates and individuals in high concussive sports. Background Over 460,000 student-athletes compete in 24 NCAA sports every year. Concussions are estimated to occur between 0.43—0.57 per 1000 athletic events for student-athletes (Covassin, et al., 2016; Daneshvar et al., 2011) but these rates rely in part on self-report, which is likely affected by factors including the culture surrounding athletics (IOM, 2013). The Institute of Medicine, NCAA, Department of Defense, and the CDC have all called for educational interventions to change the culture of competitive athletics pertaining to concussion so that reporting of concussion becomes the norm. Design/Methods A multi-site randomized controlled trial was conducted to evaluate the effectiveness of the program. Measures of concussion knowledge, knowledge of the return to play protocol, intention to report concussions, direct subjective norms, direct perceived behavioral control, and indirect perceived behavioral control were assessed at baseline, post-intervention, and at a one-month follow-up with the last four measuring perspectives for both self and teammate. Results 1614 male and female student-athletes from 60 teams (30 experimental, 30 control) belonging to 10 colleges/universities across all 3 NCAA Divisions completed the study. Results indicated that student-athletes who participated in the program demonstrated greater increases in concussion knowledge, intention to report concussion, understanding of the return to play protocol, direct subjective norms, direct perceived behavioral control, and indirect perceived behavioral control for both self and teammate compared to controls post-intervention and at the one-month follow-up. Conclusions The novel peer-mediated approach to concussion education shows promise in increasing concussion knowledge, intention to report concussion, and for facilitating attitudinal changes that support reporting among student-athletes and in changing the norms of concussion reporting on a team.

The purpose of this study is to determine knowledge of traumatic brain injury among educators. Few studies have examined knowledge of traumatic brain injury in this population and fewer still have included a substantial proportion of general education teachers. Examining knowledge of traumatic brain injury in educators is important as the vast majority of children with traumatic brain injury will return to school and many are likely to require support in the short term and some will require special education services in the long term. The Common Misconceptions of Traumatic Brain Injury questionnaire was completed by 94 educators. Participants demonstrated accurate knowledge on a number of questionnaire items associated with the identification of individuals with traumatic brain injury, common socio-emotional effects, and recovery from traumatic brain injury; however, a considerable degree of uncertainly was indicated on several items relevant to the school setting. In addition, substantial misconception rates were noted on only four items including one pertaining to recovery and another concerning the likelihood of additional brain injuries. Knowing someone with traumatic brain injury, participating in training and having taught a student with traumatic brain injury resulted in greater knowledge. Implications of these findings for educators are discussed.

OBJECTIVE:To identify potential misconceptions that nursing students have regarding traumatic brain injury (TBI) and recovery.DESIGN:Descriptive questionnaire.SETTING:University.MAIN MEASURE:Thirty-item questionnaire addressing knowledge about TBI and recovery.PARTICIPANTS:One hundred eight undergraduate students, 65 in the prenursing program and 43 nursing majors.RESULTS:In general, nursing students had a lower frequency of misconceptions than did university students in a prior study, and the more advanced nursing majors had a lower frequency of misconceptions than did the prenursing students. Substantial misconceptions did exist, though, especially concerning unconsciousness, amnesia, and recovery.CONCLUSIONS:Nursing students possess several misconceptions pertaining to TBI and recovery that have the potential to adversely affect assessment, treatment, and education of patients and family members. Education focusing on TBI and recovery should be included in the nursing curriculum and be a part of continuing education at the professional level.

Schools request consultation from neuropsychologists employed outside the school setting to enhance assessment and intervention for children with neurological, medical, and psychological conditions. The legislative and administrative parameters governing special education services for exceptional children most pertinent to the consulting neuropsychologist are examined. The role of the school-based multidisciplinary team in determining eligibility for special education is discussed. Potential roles for the clinical neuropsychologist on the school-based team and approaches to interprofessional collaboration between clinical neuropsychologists and school psychologists are presented. Reimbursement for services and ethical considerations are also discussed.