- Email: [email protected]
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks
ARTICLE IN PRESS THE JOURNAL OF PEDIATRICS • www.jpeds.com
ORIGINAL ARTICLES
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks Michael Fishman, BA1, Eleanor Taranto, AB1, Meryl Perlman, MD2, Kyran Quinlan, MD, MPH3, Holly J. Benjamin, MD4,5, and Lainie Friedman Ross, MD, PhD2,4 Objective To examine attitudes and practices of pediatricians toward sports-related head trauma and youth participation in tackle football and ice hockey. Study design A respondent-anonymous electronic survey was distributed 3 times to members of the American Academy of Pediatrics Section of Bioethics, Council on Injury, Violence, and Poison Prevention, and Council on Sports Medicine and Fitness. Results Of 791 eligible pediatricians, 227 (29%) responded. Most respondents (189/223; 85%) treat sportsrelated concussions, among whom 83% (137/165) reported access to an established return-to-play protocol within their practice. Virtually all (160/166; 96%) reported increased parental awareness/concern regarding concussions and 85% (139/163) reported increased visits for head trauma. Overall, 77% (140/183) would not allow their son to play tackle football and 35% (64/181) and 34% (63/184) would not allow their son or daughter, respectively, to participate in ice hockey. Most respondents endorsed limiting or eliminating tackling (143/176; 81%) and checking (144/ 179; 80%) from practice. Respondents were evenly divided in their support for counseling against youth participation in full-contact sports, with 48% in favor (87/180). Conclusions Most respondents would not allow their own child to play tackle football and endorsed limiting or eliminating tackling in practice. The American Academy of Pediatrics should consider recommending restrictions on tackling in football to support the current concussion concerns of its members. (J Pediatr 2017;■■:■■-■■). See related article, p •••
A
pproximately 44 million children (aged 5-18 years) participate in organized sports in the US, and this number is growing.1,2 Because of the number of youth sports participants, a large proportion of all sports-related concussions occur in children. Concussions, which account for almost 9% of all high school athletic injuries,3,4 occur mainly in tackle football (hereafter referred to as football) and ice hockey.5 There is a lack of reliable research, however, regarding the long-term effects of concussions in youth athletes and the appropriate duration of rest needed before safe return to play/ return to learn.6,7 Primary care pediatricians care for a significant proportion of children with concussions. In one pediatric network, 82% of concussed children and adolescents had their first visit with a pediatric primary care provider.8 Nevertheless, pediatricians believe that the current level of training and lack of formal guidelines are insufficient to treat adequately this “silent epidemic.”9,10 Given pediatricians’ front-line role in the treatment of children’s concussions, our primary goal was to determine their attitudes and clinical recommendations about participation in contact sports, with a focus on football and ice hockey. We examined further how these attitudes and recommendations may differ depending on the physician’s membership in the American Academy of Pediatrics (AAP) Section on Bioethics (SOB), Council on Injury, Violence, and Poison Prevention (COIVPP), or Council of Sports Medicine and Fitness (COSMF), as well as other demographic characteristics. These 3 sections were selected with the expectation that they would express a diverse range of concerns and attitudes regarding full-contact sports participation. From the 1Pritzker School of Medicine; 2MacLean Center
Methods A respondent-anonymous survey was distributed 3 times to members of the 3 AAP sections (SOB, COIVPP, and COSMF) who are subscribed to electronic mailing
AAP COIVPP COSMF SOB
American Academy of Pediatrics Council on Injury, Violence, and Poison Prevention Council on Sports Medicine and Fitness Section on Bioethics
for Clinical Medical Ethics, University of Chicago, Chicago, IL; 3Department of Pediatrics, Rush University Medical Center, Chicago, IL; 4Department of Pediatrics; and 5Department of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL Supported by the University of Chicago Pritzker School of Medicine Summer Research Project (to M.F. and E.T.). Also supported by National Institute of Diabetes and Digestive and Kidney Diseases (T35DK062719-29 [to E.T].). The authors declare no conflicts of interest. Portions of this study were presented at the University of Chicago Pritzker School of Medicine Summer Research Forum, Chicago, Illinois, August 24-25, 2016. 0022-3476/$ - see front matter. © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org10.1016/j.jpeds.2017.01.048
1 FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
THE JOURNAL OF PEDIATRICS • www.jpeds.com lists (listservs) in June and July 2016. The e-mail provided a short description of the project and a hyperlink to the survey sent by the AAP section/council administrators. The exact number of e-mail recipients is unknown because membership in AAP sections change monthly, not all members have e-mail addresses, some opt out of the listserv, and others receive listserv e-mails to more than one address. On June 1, 2016, the AAP online directory listed 358 members of COSMF, 233 members of SOB, and 204 members of COIVPP. Of these 795 members, 2 members of the SOB and 1 member from COSMF and COIVPP were excluded because of involvement in the study, leaving 791 potential respondents. Data were collected with the electronic software Research Electronic Data Capture.11 The survey included multiple-choice and Likert-scale questions focused on 3 areas: (1) experience/practices; (2) attitudes; and (3) knowledge concerning concussion management and youth sports participation. Demographic data and selfdescribed competency rating regarding concussions also were collected. The survey was determined to be exempt by the University of Chicago institutional review board with consent implied by participation. Statistical Analyses Statistical analyses were performed with SPSS (version 24.0; IBM Corp, Armonk, New York). Standard descriptive summaries (frequencies for categorical variables) were obtained, and comparisons of categorical variables were examined with c2 tests. Comparisons between categorical and continuous variables were examined with one-way ANOVAs. To examine further associations regarding attitudes toward counseling, a binomial logistic regression with backwards elimination was performed including all independent variables with P value ≤ .10. Respondents who finished residency after 2010 were asked to estimate how many hours were spent in didactic sessions learning about head trauma/concussions. Participants’ responses to 9 knowledge questions were tallied to calculate a concussion knowledge score. Incomplete responses on the knowledge section were excluded. Collapsed Variables For certain Likert scale variables, the responses were collapsed into 2 categories for further statistical analysis. In 2 questions (“Are you seeing increased frequency of visits with regard to head trauma?” and “Have you noticed increased parental concern or awareness towards head trauma?”), responses of “a minimal amount,” “a moderate amount,” and “a lot” were combined into “increased” and contrasted with “no increase.” Questions comparing physician self-description of competency were collapsed into 2 variables; “some competence” included responses of “not at all competent,” “minimally competent,” and “mostly competent” vs “fully competent.” Age of tackling and checking offered age groups of “younger than 9 years,”“9-10 years,”“11-12 years,”“13-14 years,”“15-18 years,” “college,” and “never,” which were collapsed into 3 groups: “14 and younger,” “15 and older,” and “never.” Questions about checking policies in games offered 3 options and were collapsed into 2 groups: “checking should be permitted” if they
Volume ■■ responded that “checking should be permitted starting at the age of 14 years” or “checking should always be allowed” vs “checking should NEVER be allowed in youth ice hockey.” Questions about tackling and checking in practice were combined into 2 groups: “Should always be permitted to ensure proper technique” and “should be permitted at most practices at the coach’s discretion” were combined into “permissive,” and “checking should be limited” and “checking should be eliminated” were combined into “restrictive.” All questions offering “strongly agree” and “moderately agree” and “strongly disagree” and “moderately disagree” were collapsed into “agree” and “disagree,” respectively. Years in practice was divided into 2 groups: “under 15” included those “still in training,” “0-<5,” “5-<10,” and “10-<15 years” in practice, and “over 15” included those who self-described as “15-<20,” “20-<25,” and “25 years or more” in practice. Responses to “How often do you care for a patient with a concussion or head trauma?” were grouped into “minimal” (never, rarely [defined as less than 1× per month], and occasionally [defined as at least 1× per month]) vs “frequently” [defined as several times per month]). “How do you rate your knowledge about concussions?” combined “minimal” and “moderate” and combined “significant” and “expert” for comparison. Finally, questions about sports participation grouped all sports into “contact sports” vs “other sports,” as defined by the AAP.12 Contact sports on our survey included basketball, boxing, field hockey, football, ice hockey, lacrosse, martial arts, rugby, soccer, and water polo.
Results There were 227 complete or partial responses from 791 eligible providers (29% response rate). Twenty-nine answered less than 50% of the questions and were excluded from further analysis. Of the remaining 198 respondents, 35 affiliated with the SOB, 44 were with the COIVPP, 91 with the COSMF, and 28 did not provide their section membership affiliation. Demographics of the respondents are shown in Table I. No significant difference was found in sex, ethnicity, type of residency, number of children, or years in practice between sections. A greater proportion of COSMF respondents (74/91, 81%) were team physicians compared with either COIVPP respondents (7/44, 16%) or SOB respondents (1/35, 3%), P < .0001. COSMF respondents also were more likely to be youth sports coaches (COSMF 42/90, 47%; COIVPP 10/44, 23%; and SOB 11/35, 31%, P = .02), avid spectators (COSMF 63/91, 69%; COIVPP 26/42, 62%; and SOB 13/35, 37%, P = .004), and have participated in at least one sport (COSMF 85/91, 93%; COIVPP 36/42, 82%; and SOB 26/35, 74%, P = .011). COSMF respondents also were more likely to rate their own concussion knowledge as “expert” (COSMF 43/ 85, 51%; COIVPP 10/41, 24%; SOB 1/31, 3%, P < .0001). Overall, 85% (165/195) of participants reported treating patients who experienced concussions, with variation between AAP sections (51% of SOB members, 86% of COIVPP members, and 96% of COSMF members; P < .0001). More than one-half (58%) reported seeing patients with these complaints at least several times a month. Of the respondents who
2
Fishman et al FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
■■ 2017
ORIGINAL ARTICLES
Table I. Characteristics of survey respondents (N = 198) Respondents
n (%*)
Sex (female), n = 174 AAP section membership, n = 170 SOB CIVPP COSMF Ethnicity, n = 176 Asian Black Hispanic/Latino Native American White Other Years since completing professional school, n = 176 Less than 15 y 15 y or more Team physician, n = 181 Yes Parent/guardian, n = 175 At least one child
91 (52) 35 (21) 44 (26) 91 (54) 11 4 5 2 150 4
(6) (2) (3) (1) (85) (2)
92 (52) 84 (48) 87 (48) 140 (80)
*Percentages may not add up to 100% because of rounding.
take care of patients with concussions, 139 of 163 (85%) reported noticing an increase in frequency of concussionrelated visits, and 160 of 165 (97%) reported noticing an increase in parental concern or awareness toward head trauma in their practices in the last 5 years. The majority of respondents (137/165 or 83%) reported access to an established concussion protocol/guideline, with COSMF members reporting the best access (COSMF 79/86, 92%; COIVPP 30/38, 79%; SOB 10/18, 56%, P < .0001). Overall, 133 of 163 (82%) of respondents reported knowledge of their state’s law related to concussion management, with COSMF members reporting the
greatest awareness (COSMF 77/86, 90%; COIVPP 27/36, 75%; SOB 11/18, 61%, P = .007). Of the respondents who completed residency after 2010 (n = 36), the majority (n = 32, 89%) reported spending 3 or fewer hours annually during residency in didactic sessions learning about concussions. There was no difference between sections in terms of time spent in didactic sessions (P = .42). Respondents scored well on the 9 knowledge questions with an average correct score of 8.5 (94.5%). There was a statistically significant difference in knowledge score (P = .012), with members of COSMF scoring highest 8.6 (96.1%), followed by COIVPP members 8.4 (93.1%) and SOB members 8.2 (91.4%). Similarly, those who self-rated their knowledge as significant or expert scored an average of 96.1% (n = 116/150 [77.3%]) vs those who rated moderate or minimal (n = 44/150 [22.7%]) scored an average of 91.7% (P < .001). Table II reveals respondents’ attitudes toward youth participation in full-contact sports (football and ice hockey, specifically). The majority would not allow their child to participate in football (77%), with 33% reporting that tackling should be permitted no younger than 15 years of age and 15% reporting that tackling should be eliminated completely. In football practice, 81% reported that full-contact tackling in practice should be limited or eliminated. Section membership strongly correlated with opinions about the age at which tackling should be permitted (P < .0001). Members of COSMF were most strongly in support of permitting tackling younger than the age of 15 (64%), whereas few members of SOB supported the practice (29%); however, 76% of COSMF members supported restricting tackling in participants younger than the age of 13. With regard to ice hockey, 35% and 34% of
Table II. Attitudes toward youth participation in full-contact sports
Attitudes Participation of own child in tackle football, n = 183 Would allow Would not allow Age at which tackling should be permitted, n = 182† Younger than 15 y Older than 15 y. Never Full-contact tackling in practice, n = 176† Permit with proper technique/supervision Limit or eliminate Participation of own child in male ice hockey, n = 181† Would allow Would not allow Participation of own child in female ice hockey, n = 184† Would allow Would not allow Checking in ice hockey practice, n = 179† Permit with proper technique/supervision Limit or eliminate Appropriate for physicians to counsel against youth participation in full-contact sports, n = 180† Disagree Agree
AAP subsection membership, n (%*)
Total N (%*)
SOB
COIVP
COSMF
43 (24) 140 (77)
8 (23) 27 (77)
6 (14) 36 (86)
24 (26) 67 (74)
94 (52) 60 (33) 28 (15)
10 (29) 17 (49) 8 (23)
16 (38) 12 (29) 14 (33)
58 (64) 28 (31) 5 (6)
33 (19) 143 (81)
9 (26) 26 (74)
3 (7) 38 (93)
17 (20) 70 (81)
117 (65) 64 (35)
23 (66) 12 (34)
25 (58) 18 (42)
61 (69) 28 (32)
121 (66) 63 (34)
22 (62) 13 (37)
26 (59) 18 (41)
63 (69) 8 (31)
35 (20) 144 (80)
8 (24) 26 (77)
6 (14) 36 (86)
18 (20) 72 (80)
93 (52) 87 (48)
10 (29) 25 (71)
18 (42) 25 (58)
58 (65) 31 (35)
†
P .30 <.0001
.09
.50
.48
.58 <.0001
*Percentages may not add up to 100% because of rounding. †Denominator varies due to partial nonresponders.
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
3
THE JOURNAL OF PEDIATRICS • www.jpeds.com
Volume ■■
Table III. Factors that correlate with attitudes toward counseling against youth participation in full-contact sports It is appropriate for physicians to counsel against youth participation in full-contact sports Factors AAP section membership SOB, n = 35 COIVPP, n = 44 COSMF, n = 91 Attitude toward child participation in tackle football Would allow him to play, n = 42 Would not allow him to play, n = 136 Starting at what age should tackling be permitted? Younger than 15 y, n = 91 Older than 15 y, n = 59 Never, n = 28 Self-reported knowledge of concussions* Minimal or moderate, n = 43 Significant or expert, n = 119 Frequency of concussion care Never, rarely, or occasionally, n = 74 Often, n = 100 Competence dealing with concussed pediatric patient Not at all, moderately, or mostly competent Fully competent Team physician Yes, n = 86 No, n = 92 Youth sports coach Yes, n = 67 No, n = 110 Avid spectator of professional sports Yes, n = 107 No, n = 69
Disagree %
Agree %
29 42 65
71 58 35
83 42
17 58
74 36 14
26 64 86
40 55
61 45
47 54
53 46
45 59
55 41
66 37
34 63
66 43
34 57
57 42
43 58
P <.0001
<.0001 <.0001
.09
.38
.13 <.0001 .003
.05
*Percentages may not add up to 100% because of rounding.
respondents would not let their son or daughter participate, respectively. Eighty percent also reported that checking should be limited or eliminated during practice. Overall, respondents were divided evenly on whether it was their role to counsel against participation in youth fullcontact sports, with 48% agreeing that it was. Some of the factors that correlated with attitudes toward counseling against youth participation in full-contact sports are listed in Table III. Attitudes toward counseling against participation were correlated strongly with section membership (P < .0001). Most SOB members strongly leaned toward counseling patients against participation (71%), whereas only 35% of COSMF endorsed this practice. Whether the respondent would allow their child to play football was associated with counseling attitudes (P < .0001). The majority (84%) of those who would allow their child to play disagreed with counseling against participation. In contrast, 58% of those who would not allow their own child to play football agreed with counseling against participation. The age below which a physician thought tackling should be restricted also strongly correlated with counseling attitudes (P < .0001). Being a team physician (P < .0001) or a youth sports coach (P = .003) was associated with disagreeing to counseling against participation. Sex (P = .77), personal participation in contact sports (as defined by the AAP;12 P = .66), self-
reported concussion knowledge (P = .09), frequency of concussion care (P = .38), competence in dealing with concussions (P = .13), years in practice (P = .61), and being a parent or guardian (P = .24) had no effect on counseling attitudes. A binomial logistic regression was performed to ascertain the effects of beliefs regarding appropriate tackling age, attitude toward football participation, youth sports coach status, and AAP section membership on the likelihood that participants agreed with counseling against youth participation in full-contact sports (Table IV). Respondents who would allow their son to play football were about one-fifth as likely (OR 0.19, 95% CI 0.06-0.56, P = .003) to agree that counseling against participation is appropriate compared with those who would not allow their son to participate. Compared with those who supported tackling occurring at some age younger than 15, those who believed tackling should be restricted to 15 years of age or older and those who believed that tackling should be completely eliminated were 3.9 (95% CI 1.71-9.05, P = .003) and 10.6 (95% CI 2.84-39.21, P < .0001) times more likely to agree with counseling against participation, respectively. Compared with members of SOB, COSMF members were approximately one-fifth as likely to agree with counseling against youth participation (OR 0.21, 95% CI 0.07-0.66, P = .007).
4
Fishman et al FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
■■ 2017
ORIGINAL ARTICLES
Table IV. Logistic regression model of factors associated with attitudes toward counseling against youth participation in full-contact sports Factors AAP section membership SOB (reference) COIVPP COSMF Attitude toward own child participation in tackle football Would allow him to play (reference) Would not allow him to play Starting at what age should tackling be permitted? Younger than 15 y (reference) 15 y and older Never Frequency of concussion care Never, rarely, or occasionally (reference) Often Youth sports coach (past or currently) Yes (reference) No
OR*
95% CI
P
– 0.30 0.21
– 0.08-1.07 0.07-0.66
.03 – .06 .007
– 5.34
– 1.77-16.09
– .003 <.0001
– 3.93 10.56
– 1.71-9.05 2.84-39.21
– <.001 <.0001
– 2.13
– 0.89-5.09
– .09
– 2.00
– 0.90-4.45
– .09
*OR represents likelihood of agreeing with directive counseling.
Discussion Our survey found that most (85%) respondents from all 3 AAP sections treat patients with concussions. Virtually all (96%) report increased parental awareness and concern toward concussions, and most (86%) see an increased frequency of concussions within their practices. These data are consistent with a single-institution report that identified a 38% increase in concussion incidence in the emergency department between 2007 and 2011, mostly attributed to increases in sports-related concussions.13 Despite increased physician and public awareness, research continues to reveal the vast underreporting of this “silent” injury.5,14-16 A 2012 study found that only 28% of physicians had access to a protocol specific to concussions and almost 40% did not have discharge instructions.9 This contrasts with our finding that 83% of respondents now report having an established return to play concussion protocol, indicating increased access to such decision support tools (despite the lack of any current evidence-based protocols17). Not surprisingly, members of COSMF report seeing the highest frequency of concussion patients, having the best access to decision support tools, and being more likely to rate their own concussion knowledge as “expert.” Between 2009 and 2014, all 50 states passed youth sports concussion laws designed to promote safety in youth sports.10 Almost one-fifth of respondents (18%) reported no knowledge of their state concussion laws. Although members of COSMF were the most informed, approximately 10% reported no awareness. Overall knowledge, attitudes, and beliefs of pediatricians toward youth participation in full-contact sports were quite similar. The difference in average response to the knowledge quiz was less than one-half a question between the 3 AAP sections as well as between those who self-described as expert or
having significant knowledge vs those who self-described as having minimal or moderate knowledge. The vast majority (77%) of surveyed pediatricians would not allow their own child to participate in youth football, with more than 80% also reporting that full-contact tackling in practice should be limited or eliminated.Almost one-third (31%) of all respondents believe that tackling should be permitted only starting at 15 years, with 15% believing that tackling should be completely eliminated from youth football. In contrast, only 34% of physicians would not allow their son and 35% would not allow their daughter to participate in ice hockey, though 80% believed that checking should be limited or eliminated from practice. Comparing football and hockey, physicians were more reluctant to let their children play football. Although this may be explained partially by the difference in injury statistics between the 2 sports (boys’ ice hockey is second to football in injury rate), concussions make up a greater proportion of the total number of reported injuries in boys ice hockey (22%) than in any other sport.18 In addition, the proportion of severe injuries (6%-17% for boys’ ice hockey, 6%-12% for football) and the overall injury risk for concussion is comparable between the 2 sports, suggesting that media coverage and public awareness of the injury risks might be contributing factors in the discrepancy between the 2 contact sports.18-20 Despite overall consensus, there were some differences between the sections. Members of COSMF were generally the least supportive of directive counseling against youth participation in full-contact sports, whereas members of the COIVPP were generally the most supportive of reducing or eliminating tackling and checking. Attitudes seem to be driven by personal interest in sports, with members of COSMF significantly more likely to be team physicians, youth sports coaches, or avid spectators, which in turn were associated with greater acceptance of youth participation in full-contact sports. Two recent editorials encourage physicians to push for stronger recommendations against tackling and to counsel actively against youth participation, citing the lack of autonomy in children and adolescents and their inability to weigh fully the long-term risks and benefits of sports participation.17,21 A recent position statement from the American Academy of Neurology echoed the responsibility of the physician to safeguard the “current and future mental and physical health” of the concussed athlete.22 Our respondents, however, were divided on their role in counseling patients against participation in fullcontact sports, with personal attitudes and beliefs strongly influencing their clinical practice. This raises the question of whether physicians should disclose their biases and their decisions about their own children, given that it influences the advice they give to parents.23-26 Furthermore, this finding brings to question why there is a disconnect between the physician’s beliefs and practices regarding their own children vs what they recommend for their patients; whether or not withholding this information is being less than truthful (ie, intentionally withholding information that some/many parents would consider relevant and important in making their decision); and whether or not a parent would be distressed if he found out there was a disconnect.
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
5
THE JOURNAL OF PEDIATRICS • www.jpeds.com In 2000 and again in 2014, the AAP published a policy statement on boys’ youth ice hockey that called for the elimination of body checking for players 15 years or younger, citing the inherent injury risks.27 The AAP does not have a statement on girls’ youth ice hockey, probably because checking is, and always has been, prohibited. In contrast, the 2015 AAP policy statement on youth tackle football did not advocate for restrictions or elimination of tackling at any age despite the fact that the majority of our respondents recommended some form of age restriction. Rather, the policy statement encouraged only “zero tolerance” policies of illegal, head-first hits, efforts to improve proper tackling technique, and strengthening of cervical neck musculature, all of which lack any sort of definitive scientific support.28,29 Our study had some limitations. First, the overall low response rate allows for participation biases. These biases could be exacerbated by the decision to survey 3 specific sections, which could limit generalizability to other pediatricians. Second, we elected to collapse a number of variables because of the small sample size, which can exaggerate or mask some effects. Third, there was an unbalanced response rate among the 3 sections, and 14% of respondents did not report their section affiliation. Given the larger number of responses from COSMF, our results may be skewed toward their positions, which were the least supportive of directive counseling against participation in football. Fourth, our questions about whether there is increased parental concern and whether our respondents are seeing more patients with concussion concern are subject to recall bias; however, the responses are consistent with at least one other study.13 Based on current scientific evidence, the differential policymaking between ice hockey and football is inconsistent. The initial recommendation to restrict checking to boys older than 15 years came before any data existed, despite concerns that such a restriction would lead to improper technique and a subsequent increase in injuries once checking was introduced. Data now demonstrate that an earlier introduction to checking does not prevent injury,18,23,30,31 supporting the AAP’s policy change. To date, there are no studies that examine whether introducing tackling at a young age reduces subsequent injury in football. Our data support a pre-emptive AAP policy change to recommend reducing tackling in practice and/ or setting an age limit below which children should not be permitted to tackle with data being collected concomitantly to determine how effective (or not) these changes are in reducing concussions and other serious injuries. ■ We thank Anjie Emanuel and Bonnie Kozial of the American Academy of Pediatrics for their help in distributing the surveys and for their help in all that they do for the Section on Bioethics (A.E.), Council on Sports Medicine and Fitness (A.E.), and Council on Injury, Violence and Poison Prevention (B.K.). We also thank Matt Present for his review of an earlier draft. Submitted for publication Sep 27, 2016; last revision received Dec 1, 2016; accepted Jan 19, 2017 Reprint requests: Lainie Friedman Ross, MD, PhD, Department of Pediatrics, University of Chicago, 5841 S Maryland Ave, MC 6082, Chicago, IL 60637. E-mail: [email protected]
Volume ■■
References 1. Daneshvar D, Nowinski C, McKee A, Cantu R. The epidemiology of sportrelated concussion. Clin Sports Med 2011;30:1-17. 2. Centers for Disease Control and Prevention. Physical activity levels among children aged 9-13 years: United States, 2002. MMWR Morb Mortal Wkly Rep 2003;52:785-8. 3. Langlois J, Rutland-Brown W, Wald M. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006;21:375-8. 4. Halstead M, Walter K, Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report—sport-related concussion in children and adolescents. Pediatrics 2003;126:597-615. 5. Jinguji T, Krabak B, Satchell E. Epidemiology of youth sports concussion. Phys Med Rehabil Clin N Am 2011;22:565-75. 6. Guskiewicz K, McLeod T. Pediatric sports-related concussion. PM R 2011;3:353-64. 7. Metzl JD. Concussion in a young athlete. Pediatrics 2006;117:1813. 8. Arbogast KB, Curry AE, Pfeiffer MR, Zonfrillo MR, Haarbauer-Krupa J, Breiding MJ, et al. Point of healthcare entry for youth concussion within a large pediatric care network. JAMA Pediatr 2016;170:1-8. 9. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB, et al. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion. Pediatrics 2012;130:1120-5. 10. Rose SC, Weber KD, Collen JB, Heyer GL. The diagnosis and management of concussion in children and adolescents. Pediatr Neurol 2015;53:108-18. 11. Harrism PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational informatics support. J Biomed Inform 2009;42:377-81. 12. Rice SG, American Academy of Pediatrics, Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics 2000;107:1205-9. 13. Gaw CE, Zonfrillo MR. Emergency department visits for head trauma in the United States. BMC Emerg Med 2016;16:1-5. 14. Meehan WP, Mannix RC, Collins MW. The prevalence of undiagnosed concussions in athletes. Clin J Sport Med 2013;23:339-42. 15. Mihalik JK, Guskiewicz KM, McLeod TC, Marshall SW. Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study. J Athl Train 2013;48:645-53. 16. Anderson BL, Gittelman MA, Mann JK, Cyriac RL, Pomerantz WJ. High school football players’ knowledge and attitudes about concussions. Clin J Sport Med 2016;26:206-9. 17. Bachynski KE. Tolerable risks? Physicians and youth tackle. N Engl J Med 2016;374:405-7. 18. American Academy of Pediatrics, Council on Sports Medicine and Fitness. Safety in youth ice hockey: the effects of body checking. Pediatrics 2000;105:657-8. 19. American Academy of Pediatrics, Council on Sports Medicine and Fitness. Reducing injury risk from body checking in boys youth ice hockey. Pediatrics 2014;133:1151-7. 20. Kontos AP, Elbin RJ, Sufrinko A, Dakan S, Bookwalter K, Price A, et al. Incidence of concussion in youth ice hockey players. Pediatrics 2016;137:16. 21. Bachynski KE, Goldberg DS. Youth sports & public health: framing risks of mild traumatic brain injury in American football and ice hockey. J Law Med Ethics 2014;42:323-33. 22. Kirschen MP, Tsou A, Nelson SB, Russell JA, Larriviere D, Ethics, Law, and Humanities Committee, a Joint Committee of the American Academy of Neurology, American Neurological Association, and Child Neurology Society. Legal and ethical implications in the evaluation and management of sports-related concussion. Neurology 2014;83:3528. 23. Truog RD. Doctor, if this were your child, what would you do? Pediatrics 1999;103:153-4. 24. Ross LF. Why “doctor, if this were your child, what would you do?” deserves an answer. J Clin Ethics 2003;14:59-62.
6
Fishman et al FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
■■ 2017
ORIGINAL ARTICLES
25. Truog RD. Revisiting “doctor, if this were your child, what would you do?”. J Clin Ethics 2003;14:63-7. 26. Kon AA. Answering the question: “doctor, if this were your child, what would you do?” Pediatrics 2006;118:393-7. 27. American Academy of Pediatrics, Council on Sports Medicine and Fitness. Tackling in youth football. Pediatrics 2015;136:1419-30. 28. Benson BW, McIntosh AS, Maddocks D, Herring SA, Raftery M, Dvorak J. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med 2013;47:321-6.
29. Schneider DK, Grandhi RK, Bansal P, Kuntz GE, Webster KE, Logan K, et al. Current state of concussion prevention strategies: a systematic review and meta-analysis of prospective, controlled studies. Br J Sports Med 2016;1-11. 30. Mapherson A, Rothman L, Howard A. Body-checking rules and childhood injuries in ice hockey. Pediatrics 2006;117:143-7. 31. Hagel BE, Marko J, Dryden D, Couperthwaite AB, Sommerfeldt J, Rowe BH. Effect of bodychecking on injury rates among minor ice hockey players. CMAJ 2006;175:155-60.
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
7
ORIGINAL ARTICLES
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks Michael Fishman, BA1, Eleanor Taranto, AB1, Meryl Perlman, MD2, Kyran Quinlan, MD, MPH3, Holly J. Benjamin, MD4,5, and Lainie Friedman Ross, MD, PhD2,4 Objective To examine attitudes and practices of pediatricians toward sports-related head trauma and youth participation in tackle football and ice hockey. Study design A respondent-anonymous electronic survey was distributed 3 times to members of the American Academy of Pediatrics Section of Bioethics, Council on Injury, Violence, and Poison Prevention, and Council on Sports Medicine and Fitness. Results Of 791 eligible pediatricians, 227 (29%) responded. Most respondents (189/223; 85%) treat sportsrelated concussions, among whom 83% (137/165) reported access to an established return-to-play protocol within their practice. Virtually all (160/166; 96%) reported increased parental awareness/concern regarding concussions and 85% (139/163) reported increased visits for head trauma. Overall, 77% (140/183) would not allow their son to play tackle football and 35% (64/181) and 34% (63/184) would not allow their son or daughter, respectively, to participate in ice hockey. Most respondents endorsed limiting or eliminating tackling (143/176; 81%) and checking (144/ 179; 80%) from practice. Respondents were evenly divided in their support for counseling against youth participation in full-contact sports, with 48% in favor (87/180). Conclusions Most respondents would not allow their own child to play tackle football and endorsed limiting or eliminating tackling in practice. The American Academy of Pediatrics should consider recommending restrictions on tackling in football to support the current concussion concerns of its members. (J Pediatr 2017;■■:■■-■■). See related article, p •••
A
pproximately 44 million children (aged 5-18 years) participate in organized sports in the US, and this number is growing.1,2 Because of the number of youth sports participants, a large proportion of all sports-related concussions occur in children. Concussions, which account for almost 9% of all high school athletic injuries,3,4 occur mainly in tackle football (hereafter referred to as football) and ice hockey.5 There is a lack of reliable research, however, regarding the long-term effects of concussions in youth athletes and the appropriate duration of rest needed before safe return to play/ return to learn.6,7 Primary care pediatricians care for a significant proportion of children with concussions. In one pediatric network, 82% of concussed children and adolescents had their first visit with a pediatric primary care provider.8 Nevertheless, pediatricians believe that the current level of training and lack of formal guidelines are insufficient to treat adequately this “silent epidemic.”9,10 Given pediatricians’ front-line role in the treatment of children’s concussions, our primary goal was to determine their attitudes and clinical recommendations about participation in contact sports, with a focus on football and ice hockey. We examined further how these attitudes and recommendations may differ depending on the physician’s membership in the American Academy of Pediatrics (AAP) Section on Bioethics (SOB), Council on Injury, Violence, and Poison Prevention (COIVPP), or Council of Sports Medicine and Fitness (COSMF), as well as other demographic characteristics. These 3 sections were selected with the expectation that they would express a diverse range of concerns and attitudes regarding full-contact sports participation. From the 1Pritzker School of Medicine; 2MacLean Center
Methods A respondent-anonymous survey was distributed 3 times to members of the 3 AAP sections (SOB, COIVPP, and COSMF) who are subscribed to electronic mailing
AAP COIVPP COSMF SOB
American Academy of Pediatrics Council on Injury, Violence, and Poison Prevention Council on Sports Medicine and Fitness Section on Bioethics
for Clinical Medical Ethics, University of Chicago, Chicago, IL; 3Department of Pediatrics, Rush University Medical Center, Chicago, IL; 4Department of Pediatrics; and 5Department of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL Supported by the University of Chicago Pritzker School of Medicine Summer Research Project (to M.F. and E.T.). Also supported by National Institute of Diabetes and Digestive and Kidney Diseases (T35DK062719-29 [to E.T].). The authors declare no conflicts of interest. Portions of this study were presented at the University of Chicago Pritzker School of Medicine Summer Research Forum, Chicago, Illinois, August 24-25, 2016. 0022-3476/$ - see front matter. © 2017 Elsevier Inc. All rights reserved. http://dx.doi.org10.1016/j.jpeds.2017.01.048
1 FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
THE JOURNAL OF PEDIATRICS • www.jpeds.com lists (listservs) in June and July 2016. The e-mail provided a short description of the project and a hyperlink to the survey sent by the AAP section/council administrators. The exact number of e-mail recipients is unknown because membership in AAP sections change monthly, not all members have e-mail addresses, some opt out of the listserv, and others receive listserv e-mails to more than one address. On June 1, 2016, the AAP online directory listed 358 members of COSMF, 233 members of SOB, and 204 members of COIVPP. Of these 795 members, 2 members of the SOB and 1 member from COSMF and COIVPP were excluded because of involvement in the study, leaving 791 potential respondents. Data were collected with the electronic software Research Electronic Data Capture.11 The survey included multiple-choice and Likert-scale questions focused on 3 areas: (1) experience/practices; (2) attitudes; and (3) knowledge concerning concussion management and youth sports participation. Demographic data and selfdescribed competency rating regarding concussions also were collected. The survey was determined to be exempt by the University of Chicago institutional review board with consent implied by participation. Statistical Analyses Statistical analyses were performed with SPSS (version 24.0; IBM Corp, Armonk, New York). Standard descriptive summaries (frequencies for categorical variables) were obtained, and comparisons of categorical variables were examined with c2 tests. Comparisons between categorical and continuous variables were examined with one-way ANOVAs. To examine further associations regarding attitudes toward counseling, a binomial logistic regression with backwards elimination was performed including all independent variables with P value ≤ .10. Respondents who finished residency after 2010 were asked to estimate how many hours were spent in didactic sessions learning about head trauma/concussions. Participants’ responses to 9 knowledge questions were tallied to calculate a concussion knowledge score. Incomplete responses on the knowledge section were excluded. Collapsed Variables For certain Likert scale variables, the responses were collapsed into 2 categories for further statistical analysis. In 2 questions (“Are you seeing increased frequency of visits with regard to head trauma?” and “Have you noticed increased parental concern or awareness towards head trauma?”), responses of “a minimal amount,” “a moderate amount,” and “a lot” were combined into “increased” and contrasted with “no increase.” Questions comparing physician self-description of competency were collapsed into 2 variables; “some competence” included responses of “not at all competent,” “minimally competent,” and “mostly competent” vs “fully competent.” Age of tackling and checking offered age groups of “younger than 9 years,”“9-10 years,”“11-12 years,”“13-14 years,”“15-18 years,” “college,” and “never,” which were collapsed into 3 groups: “14 and younger,” “15 and older,” and “never.” Questions about checking policies in games offered 3 options and were collapsed into 2 groups: “checking should be permitted” if they
Volume ■■ responded that “checking should be permitted starting at the age of 14 years” or “checking should always be allowed” vs “checking should NEVER be allowed in youth ice hockey.” Questions about tackling and checking in practice were combined into 2 groups: “Should always be permitted to ensure proper technique” and “should be permitted at most practices at the coach’s discretion” were combined into “permissive,” and “checking should be limited” and “checking should be eliminated” were combined into “restrictive.” All questions offering “strongly agree” and “moderately agree” and “strongly disagree” and “moderately disagree” were collapsed into “agree” and “disagree,” respectively. Years in practice was divided into 2 groups: “under 15” included those “still in training,” “0-<5,” “5-<10,” and “10-<15 years” in practice, and “over 15” included those who self-described as “15-<20,” “20-<25,” and “25 years or more” in practice. Responses to “How often do you care for a patient with a concussion or head trauma?” were grouped into “minimal” (never, rarely [defined as less than 1× per month], and occasionally [defined as at least 1× per month]) vs “frequently” [defined as several times per month]). “How do you rate your knowledge about concussions?” combined “minimal” and “moderate” and combined “significant” and “expert” for comparison. Finally, questions about sports participation grouped all sports into “contact sports” vs “other sports,” as defined by the AAP.12 Contact sports on our survey included basketball, boxing, field hockey, football, ice hockey, lacrosse, martial arts, rugby, soccer, and water polo.
Results There were 227 complete or partial responses from 791 eligible providers (29% response rate). Twenty-nine answered less than 50% of the questions and were excluded from further analysis. Of the remaining 198 respondents, 35 affiliated with the SOB, 44 were with the COIVPP, 91 with the COSMF, and 28 did not provide their section membership affiliation. Demographics of the respondents are shown in Table I. No significant difference was found in sex, ethnicity, type of residency, number of children, or years in practice between sections. A greater proportion of COSMF respondents (74/91, 81%) were team physicians compared with either COIVPP respondents (7/44, 16%) or SOB respondents (1/35, 3%), P < .0001. COSMF respondents also were more likely to be youth sports coaches (COSMF 42/90, 47%; COIVPP 10/44, 23%; and SOB 11/35, 31%, P = .02), avid spectators (COSMF 63/91, 69%; COIVPP 26/42, 62%; and SOB 13/35, 37%, P = .004), and have participated in at least one sport (COSMF 85/91, 93%; COIVPP 36/42, 82%; and SOB 26/35, 74%, P = .011). COSMF respondents also were more likely to rate their own concussion knowledge as “expert” (COSMF 43/ 85, 51%; COIVPP 10/41, 24%; SOB 1/31, 3%, P < .0001). Overall, 85% (165/195) of participants reported treating patients who experienced concussions, with variation between AAP sections (51% of SOB members, 86% of COIVPP members, and 96% of COSMF members; P < .0001). More than one-half (58%) reported seeing patients with these complaints at least several times a month. Of the respondents who
2
Fishman et al FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
■■ 2017
ORIGINAL ARTICLES
Table I. Characteristics of survey respondents (N = 198) Respondents
n (%*)
Sex (female), n = 174 AAP section membership, n = 170 SOB CIVPP COSMF Ethnicity, n = 176 Asian Black Hispanic/Latino Native American White Other Years since completing professional school, n = 176 Less than 15 y 15 y or more Team physician, n = 181 Yes Parent/guardian, n = 175 At least one child
91 (52) 35 (21) 44 (26) 91 (54) 11 4 5 2 150 4
(6) (2) (3) (1) (85) (2)
92 (52) 84 (48) 87 (48) 140 (80)
*Percentages may not add up to 100% because of rounding.
take care of patients with concussions, 139 of 163 (85%) reported noticing an increase in frequency of concussionrelated visits, and 160 of 165 (97%) reported noticing an increase in parental concern or awareness toward head trauma in their practices in the last 5 years. The majority of respondents (137/165 or 83%) reported access to an established concussion protocol/guideline, with COSMF members reporting the best access (COSMF 79/86, 92%; COIVPP 30/38, 79%; SOB 10/18, 56%, P < .0001). Overall, 133 of 163 (82%) of respondents reported knowledge of their state’s law related to concussion management, with COSMF members reporting the
greatest awareness (COSMF 77/86, 90%; COIVPP 27/36, 75%; SOB 11/18, 61%, P = .007). Of the respondents who completed residency after 2010 (n = 36), the majority (n = 32, 89%) reported spending 3 or fewer hours annually during residency in didactic sessions learning about concussions. There was no difference between sections in terms of time spent in didactic sessions (P = .42). Respondents scored well on the 9 knowledge questions with an average correct score of 8.5 (94.5%). There was a statistically significant difference in knowledge score (P = .012), with members of COSMF scoring highest 8.6 (96.1%), followed by COIVPP members 8.4 (93.1%) and SOB members 8.2 (91.4%). Similarly, those who self-rated their knowledge as significant or expert scored an average of 96.1% (n = 116/150 [77.3%]) vs those who rated moderate or minimal (n = 44/150 [22.7%]) scored an average of 91.7% (P < .001). Table II reveals respondents’ attitudes toward youth participation in full-contact sports (football and ice hockey, specifically). The majority would not allow their child to participate in football (77%), with 33% reporting that tackling should be permitted no younger than 15 years of age and 15% reporting that tackling should be eliminated completely. In football practice, 81% reported that full-contact tackling in practice should be limited or eliminated. Section membership strongly correlated with opinions about the age at which tackling should be permitted (P < .0001). Members of COSMF were most strongly in support of permitting tackling younger than the age of 15 (64%), whereas few members of SOB supported the practice (29%); however, 76% of COSMF members supported restricting tackling in participants younger than the age of 13. With regard to ice hockey, 35% and 34% of
Table II. Attitudes toward youth participation in full-contact sports
Attitudes Participation of own child in tackle football, n = 183 Would allow Would not allow Age at which tackling should be permitted, n = 182† Younger than 15 y Older than 15 y. Never Full-contact tackling in practice, n = 176† Permit with proper technique/supervision Limit or eliminate Participation of own child in male ice hockey, n = 181† Would allow Would not allow Participation of own child in female ice hockey, n = 184† Would allow Would not allow Checking in ice hockey practice, n = 179† Permit with proper technique/supervision Limit or eliminate Appropriate for physicians to counsel against youth participation in full-contact sports, n = 180† Disagree Agree
AAP subsection membership, n (%*)
Total N (%*)
SOB
COIVP
COSMF
43 (24) 140 (77)
8 (23) 27 (77)
6 (14) 36 (86)
24 (26) 67 (74)
94 (52) 60 (33) 28 (15)
10 (29) 17 (49) 8 (23)
16 (38) 12 (29) 14 (33)
58 (64) 28 (31) 5 (6)
33 (19) 143 (81)
9 (26) 26 (74)
3 (7) 38 (93)
17 (20) 70 (81)
117 (65) 64 (35)
23 (66) 12 (34)
25 (58) 18 (42)
61 (69) 28 (32)
121 (66) 63 (34)
22 (62) 13 (37)
26 (59) 18 (41)
63 (69) 8 (31)
35 (20) 144 (80)
8 (24) 26 (77)
6 (14) 36 (86)
18 (20) 72 (80)
93 (52) 87 (48)
10 (29) 25 (71)
18 (42) 25 (58)
58 (65) 31 (35)
†
P .30 <.0001
.09
.50
.48
.58 <.0001
*Percentages may not add up to 100% because of rounding. †Denominator varies due to partial nonresponders.
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
3
THE JOURNAL OF PEDIATRICS • www.jpeds.com
Volume ■■
Table III. Factors that correlate with attitudes toward counseling against youth participation in full-contact sports It is appropriate for physicians to counsel against youth participation in full-contact sports Factors AAP section membership SOB, n = 35 COIVPP, n = 44 COSMF, n = 91 Attitude toward child participation in tackle football Would allow him to play, n = 42 Would not allow him to play, n = 136 Starting at what age should tackling be permitted? Younger than 15 y, n = 91 Older than 15 y, n = 59 Never, n = 28 Self-reported knowledge of concussions* Minimal or moderate, n = 43 Significant or expert, n = 119 Frequency of concussion care Never, rarely, or occasionally, n = 74 Often, n = 100 Competence dealing with concussed pediatric patient Not at all, moderately, or mostly competent Fully competent Team physician Yes, n = 86 No, n = 92 Youth sports coach Yes, n = 67 No, n = 110 Avid spectator of professional sports Yes, n = 107 No, n = 69
Disagree %
Agree %
29 42 65
71 58 35
83 42
17 58
74 36 14
26 64 86
40 55
61 45
47 54
53 46
45 59
55 41
66 37
34 63
66 43
34 57
57 42
43 58
P <.0001
<.0001 <.0001
.09
.38
.13 <.0001 .003
.05
*Percentages may not add up to 100% because of rounding.
respondents would not let their son or daughter participate, respectively. Eighty percent also reported that checking should be limited or eliminated during practice. Overall, respondents were divided evenly on whether it was their role to counsel against participation in youth fullcontact sports, with 48% agreeing that it was. Some of the factors that correlated with attitudes toward counseling against youth participation in full-contact sports are listed in Table III. Attitudes toward counseling against participation were correlated strongly with section membership (P < .0001). Most SOB members strongly leaned toward counseling patients against participation (71%), whereas only 35% of COSMF endorsed this practice. Whether the respondent would allow their child to play football was associated with counseling attitudes (P < .0001). The majority (84%) of those who would allow their child to play disagreed with counseling against participation. In contrast, 58% of those who would not allow their own child to play football agreed with counseling against participation. The age below which a physician thought tackling should be restricted also strongly correlated with counseling attitudes (P < .0001). Being a team physician (P < .0001) or a youth sports coach (P = .003) was associated with disagreeing to counseling against participation. Sex (P = .77), personal participation in contact sports (as defined by the AAP;12 P = .66), self-
reported concussion knowledge (P = .09), frequency of concussion care (P = .38), competence in dealing with concussions (P = .13), years in practice (P = .61), and being a parent or guardian (P = .24) had no effect on counseling attitudes. A binomial logistic regression was performed to ascertain the effects of beliefs regarding appropriate tackling age, attitude toward football participation, youth sports coach status, and AAP section membership on the likelihood that participants agreed with counseling against youth participation in full-contact sports (Table IV). Respondents who would allow their son to play football were about one-fifth as likely (OR 0.19, 95% CI 0.06-0.56, P = .003) to agree that counseling against participation is appropriate compared with those who would not allow their son to participate. Compared with those who supported tackling occurring at some age younger than 15, those who believed tackling should be restricted to 15 years of age or older and those who believed that tackling should be completely eliminated were 3.9 (95% CI 1.71-9.05, P = .003) and 10.6 (95% CI 2.84-39.21, P < .0001) times more likely to agree with counseling against participation, respectively. Compared with members of SOB, COSMF members were approximately one-fifth as likely to agree with counseling against youth participation (OR 0.21, 95% CI 0.07-0.66, P = .007).
4
Fishman et al FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
■■ 2017
ORIGINAL ARTICLES
Table IV. Logistic regression model of factors associated with attitudes toward counseling against youth participation in full-contact sports Factors AAP section membership SOB (reference) COIVPP COSMF Attitude toward own child participation in tackle football Would allow him to play (reference) Would not allow him to play Starting at what age should tackling be permitted? Younger than 15 y (reference) 15 y and older Never Frequency of concussion care Never, rarely, or occasionally (reference) Often Youth sports coach (past or currently) Yes (reference) No
OR*
95% CI
P
– 0.30 0.21
– 0.08-1.07 0.07-0.66
.03 – .06 .007
– 5.34
– 1.77-16.09
– .003 <.0001
– 3.93 10.56
– 1.71-9.05 2.84-39.21
– <.001 <.0001
– 2.13
– 0.89-5.09
– .09
– 2.00
– 0.90-4.45
– .09
*OR represents likelihood of agreeing with directive counseling.
Discussion Our survey found that most (85%) respondents from all 3 AAP sections treat patients with concussions. Virtually all (96%) report increased parental awareness and concern toward concussions, and most (86%) see an increased frequency of concussions within their practices. These data are consistent with a single-institution report that identified a 38% increase in concussion incidence in the emergency department between 2007 and 2011, mostly attributed to increases in sports-related concussions.13 Despite increased physician and public awareness, research continues to reveal the vast underreporting of this “silent” injury.5,14-16 A 2012 study found that only 28% of physicians had access to a protocol specific to concussions and almost 40% did not have discharge instructions.9 This contrasts with our finding that 83% of respondents now report having an established return to play concussion protocol, indicating increased access to such decision support tools (despite the lack of any current evidence-based protocols17). Not surprisingly, members of COSMF report seeing the highest frequency of concussion patients, having the best access to decision support tools, and being more likely to rate their own concussion knowledge as “expert.” Between 2009 and 2014, all 50 states passed youth sports concussion laws designed to promote safety in youth sports.10 Almost one-fifth of respondents (18%) reported no knowledge of their state concussion laws. Although members of COSMF were the most informed, approximately 10% reported no awareness. Overall knowledge, attitudes, and beliefs of pediatricians toward youth participation in full-contact sports were quite similar. The difference in average response to the knowledge quiz was less than one-half a question between the 3 AAP sections as well as between those who self-described as expert or
having significant knowledge vs those who self-described as having minimal or moderate knowledge. The vast majority (77%) of surveyed pediatricians would not allow their own child to participate in youth football, with more than 80% also reporting that full-contact tackling in practice should be limited or eliminated.Almost one-third (31%) of all respondents believe that tackling should be permitted only starting at 15 years, with 15% believing that tackling should be completely eliminated from youth football. In contrast, only 34% of physicians would not allow their son and 35% would not allow their daughter to participate in ice hockey, though 80% believed that checking should be limited or eliminated from practice. Comparing football and hockey, physicians were more reluctant to let their children play football. Although this may be explained partially by the difference in injury statistics between the 2 sports (boys’ ice hockey is second to football in injury rate), concussions make up a greater proportion of the total number of reported injuries in boys ice hockey (22%) than in any other sport.18 In addition, the proportion of severe injuries (6%-17% for boys’ ice hockey, 6%-12% for football) and the overall injury risk for concussion is comparable between the 2 sports, suggesting that media coverage and public awareness of the injury risks might be contributing factors in the discrepancy between the 2 contact sports.18-20 Despite overall consensus, there were some differences between the sections. Members of COSMF were generally the least supportive of directive counseling against youth participation in full-contact sports, whereas members of the COIVPP were generally the most supportive of reducing or eliminating tackling and checking. Attitudes seem to be driven by personal interest in sports, with members of COSMF significantly more likely to be team physicians, youth sports coaches, or avid spectators, which in turn were associated with greater acceptance of youth participation in full-contact sports. Two recent editorials encourage physicians to push for stronger recommendations against tackling and to counsel actively against youth participation, citing the lack of autonomy in children and adolescents and their inability to weigh fully the long-term risks and benefits of sports participation.17,21 A recent position statement from the American Academy of Neurology echoed the responsibility of the physician to safeguard the “current and future mental and physical health” of the concussed athlete.22 Our respondents, however, were divided on their role in counseling patients against participation in fullcontact sports, with personal attitudes and beliefs strongly influencing their clinical practice. This raises the question of whether physicians should disclose their biases and their decisions about their own children, given that it influences the advice they give to parents.23-26 Furthermore, this finding brings to question why there is a disconnect between the physician’s beliefs and practices regarding their own children vs what they recommend for their patients; whether or not withholding this information is being less than truthful (ie, intentionally withholding information that some/many parents would consider relevant and important in making their decision); and whether or not a parent would be distressed if he found out there was a disconnect.
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
5
THE JOURNAL OF PEDIATRICS • www.jpeds.com In 2000 and again in 2014, the AAP published a policy statement on boys’ youth ice hockey that called for the elimination of body checking for players 15 years or younger, citing the inherent injury risks.27 The AAP does not have a statement on girls’ youth ice hockey, probably because checking is, and always has been, prohibited. In contrast, the 2015 AAP policy statement on youth tackle football did not advocate for restrictions or elimination of tackling at any age despite the fact that the majority of our respondents recommended some form of age restriction. Rather, the policy statement encouraged only “zero tolerance” policies of illegal, head-first hits, efforts to improve proper tackling technique, and strengthening of cervical neck musculature, all of which lack any sort of definitive scientific support.28,29 Our study had some limitations. First, the overall low response rate allows for participation biases. These biases could be exacerbated by the decision to survey 3 specific sections, which could limit generalizability to other pediatricians. Second, we elected to collapse a number of variables because of the small sample size, which can exaggerate or mask some effects. Third, there was an unbalanced response rate among the 3 sections, and 14% of respondents did not report their section affiliation. Given the larger number of responses from COSMF, our results may be skewed toward their positions, which were the least supportive of directive counseling against participation in football. Fourth, our questions about whether there is increased parental concern and whether our respondents are seeing more patients with concussion concern are subject to recall bias; however, the responses are consistent with at least one other study.13 Based on current scientific evidence, the differential policymaking between ice hockey and football is inconsistent. The initial recommendation to restrict checking to boys older than 15 years came before any data existed, despite concerns that such a restriction would lead to improper technique and a subsequent increase in injuries once checking was introduced. Data now demonstrate that an earlier introduction to checking does not prevent injury,18,23,30,31 supporting the AAP’s policy change. To date, there are no studies that examine whether introducing tackling at a young age reduces subsequent injury in football. Our data support a pre-emptive AAP policy change to recommend reducing tackling in practice and/ or setting an age limit below which children should not be permitted to tackle with data being collected concomitantly to determine how effective (or not) these changes are in reducing concussions and other serious injuries. ■ We thank Anjie Emanuel and Bonnie Kozial of the American Academy of Pediatrics for their help in distributing the surveys and for their help in all that they do for the Section on Bioethics (A.E.), Council on Sports Medicine and Fitness (A.E.), and Council on Injury, Violence and Poison Prevention (B.K.). We also thank Matt Present for his review of an earlier draft. Submitted for publication Sep 27, 2016; last revision received Dec 1, 2016; accepted Jan 19, 2017 Reprint requests: Lainie Friedman Ross, MD, PhD, Department of Pediatrics, University of Chicago, 5841 S Maryland Ave, MC 6082, Chicago, IL 60637. E-mail: [email protected]
Volume ■■
References 1. Daneshvar D, Nowinski C, McKee A, Cantu R. The epidemiology of sportrelated concussion. Clin Sports Med 2011;30:1-17. 2. Centers for Disease Control and Prevention. Physical activity levels among children aged 9-13 years: United States, 2002. MMWR Morb Mortal Wkly Rep 2003;52:785-8. 3. Langlois J, Rutland-Brown W, Wald M. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006;21:375-8. 4. Halstead M, Walter K, Council on Sports Medicine and Fitness. American Academy of Pediatrics. Clinical report—sport-related concussion in children and adolescents. Pediatrics 2003;126:597-615. 5. Jinguji T, Krabak B, Satchell E. Epidemiology of youth sports concussion. Phys Med Rehabil Clin N Am 2011;22:565-75. 6. Guskiewicz K, McLeod T. Pediatric sports-related concussion. PM R 2011;3:353-64. 7. Metzl JD. Concussion in a young athlete. Pediatrics 2006;117:1813. 8. Arbogast KB, Curry AE, Pfeiffer MR, Zonfrillo MR, Haarbauer-Krupa J, Breiding MJ, et al. Point of healthcare entry for youth concussion within a large pediatric care network. JAMA Pediatr 2016;170:1-8. 9. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB, et al. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion. Pediatrics 2012;130:1120-5. 10. Rose SC, Weber KD, Collen JB, Heyer GL. The diagnosis and management of concussion in children and adolescents. Pediatr Neurol 2015;53:108-18. 11. Harrism PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational informatics support. J Biomed Inform 2009;42:377-81. 12. Rice SG, American Academy of Pediatrics, Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics 2000;107:1205-9. 13. Gaw CE, Zonfrillo MR. Emergency department visits for head trauma in the United States. BMC Emerg Med 2016;16:1-5. 14. Meehan WP, Mannix RC, Collins MW. The prevalence of undiagnosed concussions in athletes. Clin J Sport Med 2013;23:339-42. 15. Mihalik JK, Guskiewicz KM, McLeod TC, Marshall SW. Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study. J Athl Train 2013;48:645-53. 16. Anderson BL, Gittelman MA, Mann JK, Cyriac RL, Pomerantz WJ. High school football players’ knowledge and attitudes about concussions. Clin J Sport Med 2016;26:206-9. 17. Bachynski KE. Tolerable risks? Physicians and youth tackle. N Engl J Med 2016;374:405-7. 18. American Academy of Pediatrics, Council on Sports Medicine and Fitness. Safety in youth ice hockey: the effects of body checking. Pediatrics 2000;105:657-8. 19. American Academy of Pediatrics, Council on Sports Medicine and Fitness. Reducing injury risk from body checking in boys youth ice hockey. Pediatrics 2014;133:1151-7. 20. Kontos AP, Elbin RJ, Sufrinko A, Dakan S, Bookwalter K, Price A, et al. Incidence of concussion in youth ice hockey players. Pediatrics 2016;137:16. 21. Bachynski KE, Goldberg DS. Youth sports & public health: framing risks of mild traumatic brain injury in American football and ice hockey. J Law Med Ethics 2014;42:323-33. 22. Kirschen MP, Tsou A, Nelson SB, Russell JA, Larriviere D, Ethics, Law, and Humanities Committee, a Joint Committee of the American Academy of Neurology, American Neurological Association, and Child Neurology Society. Legal and ethical implications in the evaluation and management of sports-related concussion. Neurology 2014;83:3528. 23. Truog RD. Doctor, if this were your child, what would you do? Pediatrics 1999;103:153-4. 24. Ross LF. Why “doctor, if this were your child, what would you do?” deserves an answer. J Clin Ethics 2003;14:59-62.
6
Fishman et al FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
■■ 2017
ORIGINAL ARTICLES
25. Truog RD. Revisiting “doctor, if this were your child, what would you do?”. J Clin Ethics 2003;14:63-7. 26. Kon AA. Answering the question: “doctor, if this were your child, what would you do?” Pediatrics 2006;118:393-7. 27. American Academy of Pediatrics, Council on Sports Medicine and Fitness. Tackling in youth football. Pediatrics 2015;136:1419-30. 28. Benson BW, McIntosh AS, Maddocks D, Herring SA, Raftery M, Dvorak J. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med 2013;47:321-6.
29. Schneider DK, Grandhi RK, Bansal P, Kuntz GE, Webster KE, Logan K, et al. Current state of concussion prevention strategies: a systematic review and meta-analysis of prospective, controlled studies. Br J Sports Med 2016;1-11. 30. Mapherson A, Rothman L, Howard A. Body-checking rules and childhood injuries in ice hockey. Pediatrics 2006;117:143-7. 31. Hagel BE, Marko J, Dryden D, Couperthwaite AB, Sommerfeldt J, Rowe BH. Effect of bodychecking on injury rates among minor ice hockey players. CMAJ 2006;175:155-60.
Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks FLA 5.4.0 DTD ■ YMPD8970_proof ■ February 24, 2017
7