- Email: [email protected]
Pediatric Concussion Management in the Emergency Department: A National Survey of Parents
ARTICLE IN PRESS THE JOURNAL OF PEDIATRICS • www.jpeds.com
ORIGINAL ARTICLES
Pediatric Concussion Management in the Emergency Department: A National Survey of Parents Angela Zamarripa, MD1, Sarah J. Clark, MPH2,3, Alexander J. Rogers, MD2,4, Helena Wang-Flores, DO2,4, and Rachel M. Stanley, MD, MHSA5 Objective To examine parental expectations and beliefs about diagnosis and management of pediatric concussion. Study design We conducted a cross-sectional web-based survey of a nationally representative panel of US parents in March 2014. Parents of 10- to 17-year-old children responded to questions about their expectations and beliefs about diagnosis and management of pediatric concussion in the emergency department (ED). Weighted percentages for descriptive statistics were calculated, and c2 statistics were used for bivariate analysis. Results Survey participation was 53%, and of 912 parent respondents with a child 10-17 years of age who were presented with a scenario of their child having mild symptoms of concussion, 42% would seek immediate ED care. Parents who would seek immediate ED care for this scenario were more likely than parents who would consult their child’s usual provider or wait at home to “definitely expect” imaging (65% vs 21%), definitive diagnosis of concussion (77% vs 61%), a timeline for return to activity (80% vs 60%), and a signed return to play form (55% vs 41%). Conclusions Many parents who bring children to the ED following a possible concussion are likely to expect comprehensive and definitive care, including imaging, a definitive diagnosis, a timeline for return to activity, and a signed return to play form. To manage these expectations, healthcare providers should continue to educate parents about the evaluation and management of concussion. (J Pediatr 2016;■■:■■-■■). See related article, p •••
I
n 2011, the Center for Disease Control reported that sports and recreation related traumatic brain injury (TBI) visits to US emergency departments (EDs) increased by 62% between 2001 and 2009, with the highest rates among males aged 10-19 years.1-3 Recognizing the increased public concern, in 2012 the Institute of Medicine convened the Committee on SportsRelated Concussion in Youth.4 In their review of the most current literature, imaging of any kind for sports-related concussions in the absence of more serious TBI symptoms is not recommended. In addition, though there is no optimal time period, protecting youth athletes from Second Impact Syndrome and possible long-term sequela requires limiting physical and cognitive activity until symptom free. In 1991, the Colorado Medical Society Guidelines for the Management of Concussion in Sports issued guidelines based on grade of confusion, amnesia, and loss of consciousness. These guidelines had return to play recommendations, which were based on immediate postinjury concussive symptoms, and timelines which ranged from 20 minutes to 2 weeks.5,6 In 1998, Cantu6 published guidelines with stricter return to play time periods and cautions regarding total number of concussions in a season. It has since been recognized that concussion symptoms and recovery vary highly between individuals, making definitive diagnosis difficult, and long-term management plans imprecise.7 Current guidelines are tailored to the individual and recommend a stepwise gradual return to play after symptoms have resolved.7,8 It is unclear whether the key concepts from these earlier guidelines continue to shape the expectations and beliefs of parents. Myths about head injury and concussion may also shape parents expectations, though they are not supported by evidence. The objective of this study was to examine current parental expectations and beliefs regarding concussion management in the ED and the impact of various activities on postconcussion healing. We surveyed parents to determine parental From the 1Department of Emergency Medicine, Spectrum expectations of concussion management in the ED, parental interpretations of the Health/Helen DeVos Children’s Hospital, Michigan State negative impact that physical and mental activities can have on a child University, Grand Rapids, MI; 2Department of Pediatric; 3Child Health Evaluation and Research Unit; 4Department postconcussion, and belief in concussion myths. of Emergency Medicine, University of Michigan, Ann Arbor, MI; and 5Nationwide Children’s Hospital, Ohio State University, Columbus, OH
CT ED NPCH TBI
Computed tomography Emergency department National Poll on Children’s Health Traumatic brain injury
The C.S. Mott Children’s Hospital National Poll on Children’s Health is funded by the University of Michigan Health System. The authors declare no conflicts of interest. 0022-3476/$ - see front matter. © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org10.1016/j.jpeds.2016.10.071
1 FLA 5.4.0 DTD ■ YMPD8776_proof ■ November 16, 2016
THE JOURNAL OF PEDIATRICS • www.jpeds.com Methods In March of 2014, we conducted a cross-sectional web-based study of parents of children 10-17 years old. The University of Michigan Medical School Institutional Review Board approved the study. The survey was conducted in conjunction with the C.S. Mott Children’s Hospital National Poll on Children’s Health (NPCH), a recurring online survey of parents and nonparents. The NPCH is conducted using the webenabled KnowledgePanel (GfK Custom Research LLC, New York, New York), a probability-based panel that is representative of the US population.9 NPCH KnowledgePanel surveys have explored a variety of health-related issues, as documented in many national peer-reviewed publications. 10-14 The design for KnowledgePanel recruitment begins as an equal probability sample with several enhancements to improve efficiency, such as oversampling in census blocks with high-density minority communities. Since 2009, GfK has recruited KnowledgePanel participants by a random selection based mainly on residential addresses. Persons in selected households are then invited to participate in the web-enabled KnowledgePanel. For those who agree to participate who do not already have Internet access, a laptop and Internet connection is provided at no cost to the participant; those who already have a computer and Internet service use their own equipment. GfK develops demographic profiles for each panel member and sends periodic e-mails inviting them to participate in surveys, using unique login information to access surveys online. With all NPCH surveys, the introductory e-mail invites participation in a survey about child health, with no greater specification of survey topics. NPCH surveys are targeted to panel members identified in GfK profile data as being a parent of 1 or more children aged 0-17 years; the authors have no direct contact with the sample. To reduce the effects of any nonresponse and noncoverage bias in the overall KnowledgePanel membership, GfK applies a presampling poststratification adjustment based on demographic distributions from the current population survey. The survey was pilot tested with a separate convenience sample of 81 KnowledgePanel members, and the final survey was fielded in March 2014. The authors created a series of questions targeted to parents of children 10-17 years of age. The initial scenario was designed to represent the common situation where a child sustains a head injury with mild symptoms suggestive of a concussion: “Imagine the following situation: The school secretary calls, and says your [oldest child in target age range] child fell and hit his head during gym class or sports practice. Your child was not knocked out, but is a bit dizzy and has a headache. The secretary thinks it might be a concussion, but isn’t sure.” Parents were asked what they would do immediately after the call (response options: take child to emergency department, usual health provider, or home; call usual health provider; wait for end of school/activities; other). All parents were then asked: “For that same situation, if you take your child to
Volume ■■ the emergency room after the fall at school, how much do you expect that the ED doctors would do the following?” (response options: definitely expect, possibly expect, do not expect) The question presented four actions: take a magnetic resonance imaging, computed tomography (CT) scan, or radiograph; tell whether the child did or did not have a concussion; tell them how long the child should stay out of school or other activities; and sign a return to activity form for gym class or sports. Parents were then asked how much (response options: very much, some, not much) different activities would negatively affect their child’s recovery during the period where the child is still having symptoms of headache and dizziness. Additional questions, separate from the scenario, presented a series of statements about concussions in children, none of which have been substantiated by evidence, and asked parents to rate them as definitely true, probably true, probably false, or definitely false. Demographic questions included parents’ personal experience with concussion (“Has a person close to you [family or friend] ever had a concussion?”) Additional questions about parental concussion education were fielded and presented in a report of the NPCH.15 Data Analyses Census-based sampling weights provided by the Knowledge Networks were applied to the data to enable nationally representative inferences. Frequency distributions were calculated on all variables; c2 tests were performed to assess the associations between key outcomes (response to the concussion scenario; expectations of ED management; beliefs in concussion myths). Additional c2 tests were performed to assess the associations between key outcomes and parent demographic variables included in GfK profile data. All analyses were conducted with Stata v 10 (StataCorp, College Station, Texas). Results are presented as unweighted frequencies and weighted proportions.
Results The survey participation rate was 53%; 912 respondents had a child 10-17 years and completed the concussion questions. Demographic characteristics of respondents are presented in Table I. Over 94% of parents reported their child had a usual healthcare provider. In response to the scenario describing a head injury and possible concussion with mild symptoms that happened at school, 42% of parents reported that they would immediately take their child to the ED, whereas 44% would call or go to the child’s usual care provider and 14% would have child wait at school or take them home. Parental Expectations Table II demonstrates parents’ expectations of care in the ED after a head injury with mild concussion symptoms, regardless of the parents’ response as to where they would seek care. Two-thirds of parents would “definitely expect” a definitive diagnosis and timeline for return to activity, whereas nearly onehalf would “definitely expect” the ED physician to sign a return to play form.
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Table I. Sample characteristics (N = 912) Parent sex Female Male Parent age <40 y ≥40 y Parent race/ethnicity White African American Hispanic Other Parent education High school or less Some college College graduate Personal experience with concussion Yes No Selected child sex Girl Boy Selected child age 10-13 y 14-17 y
Unweighted N
Weighted %
511 401
59% 41%
260 652
36% 64%
689 64 118 41
65% 10% 19% 6%
297 282 333
38% 31% 31%
408 500
41% 59%
436 460
47% 53%
338 574
38% 62%
Unweighted N varies because of item nonresponse.
Neither parent age and sex, nor parents’ personal experience with concussion, nor specified child age and sex, were related to ED expectations. Race/ethnicity and parent education were related only for expectations around imaging, where black parents were more likely than white or Hispanic parents to “definitely expect” imaging (74% vs 33% vs 47%, P < .001), and college graduates were less likely than parents with less than high school or some college to “definitely expect” imaging (29% vs 46% vs 42%, P = .004). However, parental response to the concussion scenario was strongly related to ED expectations (Figure), with parents who would seek immediate ED care being significantly more likely to “definitely expect” all 4 ED actions, when compared with parents who would either consult the child’s usual provider or wait at home. Parental Beliefs on the Potential Negative Effect of Common Activities Although most parents identified strenuous physical activity as “very much” negatively effecting recovery (74%), fewer
parents felt playing video games (41%), texting/social media (27%), and reading/studying (17%) as “very much” negatively effecting recovery. Neither parent age and sex, nor specified child age and sex, were related to parental beliefs about negative effects on recovery. Parents with personal experience with concussion were more likely than those without experience to report that reading/studying (23% vs 14%, P = .002) would very much affect recovery. Myths With regards to myths about concussions, parents who indicated they would seek immediate ED care for the concussion scenario were more likely to rate the inaccurate statements as “definitely true” when compared with the parents who would either consult their child’s usual provider or wait at home (Table III).
Discussion In our survey, we found that parental expectations of concussion diagnosis and management often differed from current guidelines. The differences between guidelines and parental expectations were more prevalent in the subset of parents who chose to immediately seek ED care following a possible concussion with mild symptoms, compared with those who consulted their child’s usual provider or wait at home. Moreover, parents who sought immediate ED care were more likely to believe myths about concussions and concussion management that may influence their expectations. Healthcare providers are expected to use the best evidence to guide their practice, but also need to address the expectations of their patients and/or caretakers. Previous studies have looked at parental expectations and beliefs in the ED for other common complaints, such as fever.16-18 In those studies, it was hypothesized that parents expected antibiotics for febrile illnesses, though they found that parents’ expectations were more consistent with guidelines than anticipated. Unlike those fever studies, our survey demonstrated that parents do often expect imaging for their child after a head injury with mild concussive symptoms, particularly those parents who would seek evaluation for their child in the ED. CT scans have never been recommended to diagnose concussions.19,20 CT scans can be used to evaluate those
Table II. Parental expectations of actions to be performed by ED physicians following a child’s mild head injury
How much do you expect the ED doctors would Take an MRI, CT scan, or radiograph Tell whether the child did or did not have a concussion Tell them how long the child should stay out of school or other activities Sign a return to activity form for gym class or sports
Unweighted N
Definitely expect
Possibly expect
Do not expect
908 896 897 894
39% 68% 68% 47%
44% 30% 26% 33%
16% 3% 6% 20%
MRI, magnetic resonance imaging. Unweighted N varies because of item nonresponse.
Pediatric Concussion Management in the Emergency Department: A National Survey of Parents FLA 5.4.0 DTD ■ YMPD8776_proof ■ November 16, 2016
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THE JOURNAL OF PEDIATRICS • www.jpeds.com
Volume ■■
Figure. Percent of parents who definitely expect actions to be performed by ED providers, by parents’ care-seeking behavior in response to mild concussion scenario. MRI, magnetic resonance imaging.
patients with concussion that have features concerning for a clinically important TBI, such as an intracranial bleed or cerebral edema.7,8,19-21 In our hypothetical scenario presented in the survey, the patient had mild symptoms. However, more than one-third of parents surveyed definitely expected imaging. More importantly, of those parents who chose to use the ED for initial management, most would “definitely expect” imaging. ED physicians must be aware of these expectations to properly address parental concerns. Most parents visiting the ED after their child’s head injury expected a definitive diagnosis of concussion, a recovery timeline, and a signed return to play form. However, the nature of concussion symptom evolution makes definitive diagnosis difficult. A concussion is not a static process; symptoms can wax and wane and not present until the brain is stressed again.7 Kutcher and Giza7 describe the diagnosis of concussion by degree of certainty, with 3 categories; probably, likely, and possible. In many cases, symptoms can lead to a clear diagnosis of concussion. It is cases in which symptoms can be attributed to another cause or are simply not present at the time of the visit that would fall into the likely or possible categories that may need further explanation for the parents.7 Following an injury, parents often ask questions regarding the typical timeframe for return to play. A recent study showed
that the average time to symptom resolution is 13 days. However, even by day 90, 15% of patients still had concussive symptoms, with 12% of them having had no prior concussion.22 In prior years, guidelines suggested a standard recovery timeline for mild, moderate, and severe concussions.5,6 These categories are no longer used, and now timelines are patient specific and depend on that patient’s resolution of symptoms.7,8,20,23,24 This symptom-based recovery differs from the time-based expectation of many parents. This is maybe one of the most important expectations to address with a parent in the ED, emphasizing the variability of symptoms and time course and the importance of follow-up with an outpatient provider. All 50 states have youth concussion laws, and 48 states specifically require written medical clearance for any youth athlete before return to play. This often consists of having a physician sign a medical clearance form.25,26 ED physicians do not have the opportunity for follow-up, limiting their ability to employ symptom-based care27,28; as such, they are not in a position to sign return to play forms during the ED visit. However, many parents responding to this poll did expect ED providers to sign a return to play form, and this expectation was more common among parents who chose to seek immediate care in the ED for a possible concussion
Table III. Percent of parents who rate concussion myths as definitely true, by parents’ care-seeking behavior in response to mild concussion scenario Response to mild head injury scenario
In the first 24 hours after a concussion, a child should be woken up every few hours After 3 concussions, a child should stop playing contact sports altogether You need an MRI or CT scan to tell if someone has a concussion It is only a concussion if a child gets knocked out
Unweighted N
Seek immediate ED care (%)
Usual provider or wait at home (%)
P value
902 903 896 891
55 48 28 8
43 35 11 7
.027 .02 < .001 .675
Unweighted N varies because of item nonresponse.
4
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ORIGINAL ARTICLES
2016 with mild symptoms. As part of their ongoing education role, ED providers will need to explain to parents why return to play decisions are not made immediately following a possible concussion. This is particularly important to emphasize, as recent studies have shown that follow-up after ED visits for concussion are low (45%).29 Though follow-up with primary care physicians for concussion may be poor and parents may want expedited medical clearance, our results do suggest that parents have heard part of this message. Overall 74% thought that strenuous physical activity while their child was still having symptoms would “very much” have a negative impact on their child’s recovery. Many parents also realized that video games, texting, and social media, and reading and studying while still having symptoms could potentially “somewhat” have a negative effect on their children after a concussion. The extent to which cognitive rest should be implemented is still being evaluated.30 With the numerous and sometimes conflicting lay sources of information regarding concussion management available, as well as the evolution of medical guidelines over the past 2 decades, it is not surprising that concussion management myths are widely believed. One example is the common belief that a child with a concussion must be woken up every few hours. Even though there is no evidence to support this practice, about one-half of the surveyed parents felt this was true. Similarly, many parents believed that after 3 concussions, a child should never play contact sports again. This is similar to a prior recommendation based on the Cantu guidelines from 1998, which was not carried over to the current Zurich concussion guidelines.6,8 In the Cantu guidelines, 2 grade 3 concussions should terminate a player’s season and 3 grade 3 concussions should raise considerable deliberations as to whether the individual should be allowed to return to any contact or collision sport.6 More recently the American Academy of Neurology has stated that for amateur athletes there is no specific number of concussions that triggers “retirement.”7,19 Our survey may have been limited by participation bias. However, panel members were not aware of the specific topics before agreeing to participate, therefore, we do not anticipate bias because of systematic nonresponse based on specific content related to childhood concussion. As with any survey, there is always the possibility that respondents may have interpreted the same question in different ways or responded in a manner that they felt to be more socially desirable. However, even with inherent survey limitations, the KnowledgePanel is representative of the US population and, therefore, generalizable to the US population. ■ Submitted for publication Jun 16, 2016; last revision received Aug 20, 2016; accepted Oct 20, 2016 Reprint requests: Angela Zamarripa, MD, Department of Emergency Medicine, Michigan State University College of Human Medicine, 15 Michigan St NE, Grand Rapids, MI 49503. E-mail: [email protected]
References 1. Hanson HR, Pomerantz WJ, Gittelman M. ED utilization trends in sportsrelated traumatic brain injury. Pediatrics 2013;132:e859-64.
2. Bener A, Omar AO, Ahmad AE, Al-Mulla FH, Abdul Rahman YS. The pattern of traumatic brain injuries: a country undergoing rapid development. Brain Inj 2010;24:74-80. 3. Gilchrist J, Thomas KE, Xu L, McGuire L, Coronado V. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged
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THE JOURNAL OF PEDIATRICS • www.jpeds.com [updated 2010 Aug 30; 2015 Jun 20]. www.cdc.gov/concussion/headsup. Accessed November 9, 2016. 24. Guskiewicz KM, Broglio SP. Acute sports-related traumatic brain injury and repetitive concussion. Handb Clin Neurol 2015;127: 157-72. 25. Public Health Law Research. Law Atlas The Policy Surveillance Portal: Youth Sports Traumatic Brain Injury Laws Map [Internet]. Philadelphia PA: Robert Wood Johnson Foundation; 2009. [2015 May1, 2015 Jun 20]. http://www.lawatlas.org/query?dataset=sc-reboot. Accessed November 9, 2016. 26. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. Comparative analysis of state-level concussion legislation and review of current practices in concussion. Neurosurg Focus 2012;33:E11, 1-9.
Volume ■■ 27. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion. Pediatrics 2012;130:1120-5. 28. Meehan WP 3rd, Mannix R. Pediatric concussions in united states emergency departments in the years 2002 to 2006. J Pediatr 2010;157:88993. 29. Grubenhoff JA, Deakyne SJ, Comstock RD, Kirkwood MW, Bajaj L. Outpatient follow-up and return to school after emergency department evaluation among children with persistent post-concussion symptoms. Brain Inj 2015;29:1-6. 30. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015;135:213-23.
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Pediatric Concussion Management in the Emergency Department: A National Survey of Parents Angela Zamarripa, MD1, Sarah J. Clark, MPH2,3, Alexander J. Rogers, MD2,4, Helena Wang-Flores, DO2,4, and Rachel M. Stanley, MD, MHSA5 Objective To examine parental expectations and beliefs about diagnosis and management of pediatric concussion. Study design We conducted a cross-sectional web-based survey of a nationally representative panel of US parents in March 2014. Parents of 10- to 17-year-old children responded to questions about their expectations and beliefs about diagnosis and management of pediatric concussion in the emergency department (ED). Weighted percentages for descriptive statistics were calculated, and c2 statistics were used for bivariate analysis. Results Survey participation was 53%, and of 912 parent respondents with a child 10-17 years of age who were presented with a scenario of their child having mild symptoms of concussion, 42% would seek immediate ED care. Parents who would seek immediate ED care for this scenario were more likely than parents who would consult their child’s usual provider or wait at home to “definitely expect” imaging (65% vs 21%), definitive diagnosis of concussion (77% vs 61%), a timeline for return to activity (80% vs 60%), and a signed return to play form (55% vs 41%). Conclusions Many parents who bring children to the ED following a possible concussion are likely to expect comprehensive and definitive care, including imaging, a definitive diagnosis, a timeline for return to activity, and a signed return to play form. To manage these expectations, healthcare providers should continue to educate parents about the evaluation and management of concussion. (J Pediatr 2016;■■:■■-■■). See related article, p •••
I
n 2011, the Center for Disease Control reported that sports and recreation related traumatic brain injury (TBI) visits to US emergency departments (EDs) increased by 62% between 2001 and 2009, with the highest rates among males aged 10-19 years.1-3 Recognizing the increased public concern, in 2012 the Institute of Medicine convened the Committee on SportsRelated Concussion in Youth.4 In their review of the most current literature, imaging of any kind for sports-related concussions in the absence of more serious TBI symptoms is not recommended. In addition, though there is no optimal time period, protecting youth athletes from Second Impact Syndrome and possible long-term sequela requires limiting physical and cognitive activity until symptom free. In 1991, the Colorado Medical Society Guidelines for the Management of Concussion in Sports issued guidelines based on grade of confusion, amnesia, and loss of consciousness. These guidelines had return to play recommendations, which were based on immediate postinjury concussive symptoms, and timelines which ranged from 20 minutes to 2 weeks.5,6 In 1998, Cantu6 published guidelines with stricter return to play time periods and cautions regarding total number of concussions in a season. It has since been recognized that concussion symptoms and recovery vary highly between individuals, making definitive diagnosis difficult, and long-term management plans imprecise.7 Current guidelines are tailored to the individual and recommend a stepwise gradual return to play after symptoms have resolved.7,8 It is unclear whether the key concepts from these earlier guidelines continue to shape the expectations and beliefs of parents. Myths about head injury and concussion may also shape parents expectations, though they are not supported by evidence. The objective of this study was to examine current parental expectations and beliefs regarding concussion management in the ED and the impact of various activities on postconcussion healing. We surveyed parents to determine parental From the 1Department of Emergency Medicine, Spectrum expectations of concussion management in the ED, parental interpretations of the Health/Helen DeVos Children’s Hospital, Michigan State negative impact that physical and mental activities can have on a child University, Grand Rapids, MI; 2Department of Pediatric; 3Child Health Evaluation and Research Unit; 4Department postconcussion, and belief in concussion myths. of Emergency Medicine, University of Michigan, Ann Arbor, MI; and 5Nationwide Children’s Hospital, Ohio State University, Columbus, OH
CT ED NPCH TBI
Computed tomography Emergency department National Poll on Children’s Health Traumatic brain injury
The C.S. Mott Children’s Hospital National Poll on Children’s Health is funded by the University of Michigan Health System. The authors declare no conflicts of interest. 0022-3476/$ - see front matter. © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org10.1016/j.jpeds.2016.10.071
1 FLA 5.4.0 DTD ■ YMPD8776_proof ■ November 16, 2016
THE JOURNAL OF PEDIATRICS • www.jpeds.com Methods In March of 2014, we conducted a cross-sectional web-based study of parents of children 10-17 years old. The University of Michigan Medical School Institutional Review Board approved the study. The survey was conducted in conjunction with the C.S. Mott Children’s Hospital National Poll on Children’s Health (NPCH), a recurring online survey of parents and nonparents. The NPCH is conducted using the webenabled KnowledgePanel (GfK Custom Research LLC, New York, New York), a probability-based panel that is representative of the US population.9 NPCH KnowledgePanel surveys have explored a variety of health-related issues, as documented in many national peer-reviewed publications. 10-14 The design for KnowledgePanel recruitment begins as an equal probability sample with several enhancements to improve efficiency, such as oversampling in census blocks with high-density minority communities. Since 2009, GfK has recruited KnowledgePanel participants by a random selection based mainly on residential addresses. Persons in selected households are then invited to participate in the web-enabled KnowledgePanel. For those who agree to participate who do not already have Internet access, a laptop and Internet connection is provided at no cost to the participant; those who already have a computer and Internet service use their own equipment. GfK develops demographic profiles for each panel member and sends periodic e-mails inviting them to participate in surveys, using unique login information to access surveys online. With all NPCH surveys, the introductory e-mail invites participation in a survey about child health, with no greater specification of survey topics. NPCH surveys are targeted to panel members identified in GfK profile data as being a parent of 1 or more children aged 0-17 years; the authors have no direct contact with the sample. To reduce the effects of any nonresponse and noncoverage bias in the overall KnowledgePanel membership, GfK applies a presampling poststratification adjustment based on demographic distributions from the current population survey. The survey was pilot tested with a separate convenience sample of 81 KnowledgePanel members, and the final survey was fielded in March 2014. The authors created a series of questions targeted to parents of children 10-17 years of age. The initial scenario was designed to represent the common situation where a child sustains a head injury with mild symptoms suggestive of a concussion: “Imagine the following situation: The school secretary calls, and says your [oldest child in target age range] child fell and hit his head during gym class or sports practice. Your child was not knocked out, but is a bit dizzy and has a headache. The secretary thinks it might be a concussion, but isn’t sure.” Parents were asked what they would do immediately after the call (response options: take child to emergency department, usual health provider, or home; call usual health provider; wait for end of school/activities; other). All parents were then asked: “For that same situation, if you take your child to
Volume ■■ the emergency room after the fall at school, how much do you expect that the ED doctors would do the following?” (response options: definitely expect, possibly expect, do not expect) The question presented four actions: take a magnetic resonance imaging, computed tomography (CT) scan, or radiograph; tell whether the child did or did not have a concussion; tell them how long the child should stay out of school or other activities; and sign a return to activity form for gym class or sports. Parents were then asked how much (response options: very much, some, not much) different activities would negatively affect their child’s recovery during the period where the child is still having symptoms of headache and dizziness. Additional questions, separate from the scenario, presented a series of statements about concussions in children, none of which have been substantiated by evidence, and asked parents to rate them as definitely true, probably true, probably false, or definitely false. Demographic questions included parents’ personal experience with concussion (“Has a person close to you [family or friend] ever had a concussion?”) Additional questions about parental concussion education were fielded and presented in a report of the NPCH.15 Data Analyses Census-based sampling weights provided by the Knowledge Networks were applied to the data to enable nationally representative inferences. Frequency distributions were calculated on all variables; c2 tests were performed to assess the associations between key outcomes (response to the concussion scenario; expectations of ED management; beliefs in concussion myths). Additional c2 tests were performed to assess the associations between key outcomes and parent demographic variables included in GfK profile data. All analyses were conducted with Stata v 10 (StataCorp, College Station, Texas). Results are presented as unweighted frequencies and weighted proportions.
Results The survey participation rate was 53%; 912 respondents had a child 10-17 years and completed the concussion questions. Demographic characteristics of respondents are presented in Table I. Over 94% of parents reported their child had a usual healthcare provider. In response to the scenario describing a head injury and possible concussion with mild symptoms that happened at school, 42% of parents reported that they would immediately take their child to the ED, whereas 44% would call or go to the child’s usual care provider and 14% would have child wait at school or take them home. Parental Expectations Table II demonstrates parents’ expectations of care in the ED after a head injury with mild concussion symptoms, regardless of the parents’ response as to where they would seek care. Two-thirds of parents would “definitely expect” a definitive diagnosis and timeline for return to activity, whereas nearly onehalf would “definitely expect” the ED physician to sign a return to play form.
2
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Table I. Sample characteristics (N = 912) Parent sex Female Male Parent age <40 y ≥40 y Parent race/ethnicity White African American Hispanic Other Parent education High school or less Some college College graduate Personal experience with concussion Yes No Selected child sex Girl Boy Selected child age 10-13 y 14-17 y
Unweighted N
Weighted %
511 401
59% 41%
260 652
36% 64%
689 64 118 41
65% 10% 19% 6%
297 282 333
38% 31% 31%
408 500
41% 59%
436 460
47% 53%
338 574
38% 62%
Unweighted N varies because of item nonresponse.
Neither parent age and sex, nor parents’ personal experience with concussion, nor specified child age and sex, were related to ED expectations. Race/ethnicity and parent education were related only for expectations around imaging, where black parents were more likely than white or Hispanic parents to “definitely expect” imaging (74% vs 33% vs 47%, P < .001), and college graduates were less likely than parents with less than high school or some college to “definitely expect” imaging (29% vs 46% vs 42%, P = .004). However, parental response to the concussion scenario was strongly related to ED expectations (Figure), with parents who would seek immediate ED care being significantly more likely to “definitely expect” all 4 ED actions, when compared with parents who would either consult the child’s usual provider or wait at home. Parental Beliefs on the Potential Negative Effect of Common Activities Although most parents identified strenuous physical activity as “very much” negatively effecting recovery (74%), fewer
parents felt playing video games (41%), texting/social media (27%), and reading/studying (17%) as “very much” negatively effecting recovery. Neither parent age and sex, nor specified child age and sex, were related to parental beliefs about negative effects on recovery. Parents with personal experience with concussion were more likely than those without experience to report that reading/studying (23% vs 14%, P = .002) would very much affect recovery. Myths With regards to myths about concussions, parents who indicated they would seek immediate ED care for the concussion scenario were more likely to rate the inaccurate statements as “definitely true” when compared with the parents who would either consult their child’s usual provider or wait at home (Table III).
Discussion In our survey, we found that parental expectations of concussion diagnosis and management often differed from current guidelines. The differences between guidelines and parental expectations were more prevalent in the subset of parents who chose to immediately seek ED care following a possible concussion with mild symptoms, compared with those who consulted their child’s usual provider or wait at home. Moreover, parents who sought immediate ED care were more likely to believe myths about concussions and concussion management that may influence their expectations. Healthcare providers are expected to use the best evidence to guide their practice, but also need to address the expectations of their patients and/or caretakers. Previous studies have looked at parental expectations and beliefs in the ED for other common complaints, such as fever.16-18 In those studies, it was hypothesized that parents expected antibiotics for febrile illnesses, though they found that parents’ expectations were more consistent with guidelines than anticipated. Unlike those fever studies, our survey demonstrated that parents do often expect imaging for their child after a head injury with mild concussive symptoms, particularly those parents who would seek evaluation for their child in the ED. CT scans have never been recommended to diagnose concussions.19,20 CT scans can be used to evaluate those
Table II. Parental expectations of actions to be performed by ED physicians following a child’s mild head injury
How much do you expect the ED doctors would Take an MRI, CT scan, or radiograph Tell whether the child did or did not have a concussion Tell them how long the child should stay out of school or other activities Sign a return to activity form for gym class or sports
Unweighted N
Definitely expect
Possibly expect
Do not expect
908 896 897 894
39% 68% 68% 47%
44% 30% 26% 33%
16% 3% 6% 20%
MRI, magnetic resonance imaging. Unweighted N varies because of item nonresponse.
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Figure. Percent of parents who definitely expect actions to be performed by ED providers, by parents’ care-seeking behavior in response to mild concussion scenario. MRI, magnetic resonance imaging.
patients with concussion that have features concerning for a clinically important TBI, such as an intracranial bleed or cerebral edema.7,8,19-21 In our hypothetical scenario presented in the survey, the patient had mild symptoms. However, more than one-third of parents surveyed definitely expected imaging. More importantly, of those parents who chose to use the ED for initial management, most would “definitely expect” imaging. ED physicians must be aware of these expectations to properly address parental concerns. Most parents visiting the ED after their child’s head injury expected a definitive diagnosis of concussion, a recovery timeline, and a signed return to play form. However, the nature of concussion symptom evolution makes definitive diagnosis difficult. A concussion is not a static process; symptoms can wax and wane and not present until the brain is stressed again.7 Kutcher and Giza7 describe the diagnosis of concussion by degree of certainty, with 3 categories; probably, likely, and possible. In many cases, symptoms can lead to a clear diagnosis of concussion. It is cases in which symptoms can be attributed to another cause or are simply not present at the time of the visit that would fall into the likely or possible categories that may need further explanation for the parents.7 Following an injury, parents often ask questions regarding the typical timeframe for return to play. A recent study showed
that the average time to symptom resolution is 13 days. However, even by day 90, 15% of patients still had concussive symptoms, with 12% of them having had no prior concussion.22 In prior years, guidelines suggested a standard recovery timeline for mild, moderate, and severe concussions.5,6 These categories are no longer used, and now timelines are patient specific and depend on that patient’s resolution of symptoms.7,8,20,23,24 This symptom-based recovery differs from the time-based expectation of many parents. This is maybe one of the most important expectations to address with a parent in the ED, emphasizing the variability of symptoms and time course and the importance of follow-up with an outpatient provider. All 50 states have youth concussion laws, and 48 states specifically require written medical clearance for any youth athlete before return to play. This often consists of having a physician sign a medical clearance form.25,26 ED physicians do not have the opportunity for follow-up, limiting their ability to employ symptom-based care27,28; as such, they are not in a position to sign return to play forms during the ED visit. However, many parents responding to this poll did expect ED providers to sign a return to play form, and this expectation was more common among parents who chose to seek immediate care in the ED for a possible concussion
Table III. Percent of parents who rate concussion myths as definitely true, by parents’ care-seeking behavior in response to mild concussion scenario Response to mild head injury scenario
In the first 24 hours after a concussion, a child should be woken up every few hours After 3 concussions, a child should stop playing contact sports altogether You need an MRI or CT scan to tell if someone has a concussion It is only a concussion if a child gets knocked out
Unweighted N
Seek immediate ED care (%)
Usual provider or wait at home (%)
P value
902 903 896 891
55 48 28 8
43 35 11 7
.027 .02 < .001 .675
Unweighted N varies because of item nonresponse.
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ORIGINAL ARTICLES
2016 with mild symptoms. As part of their ongoing education role, ED providers will need to explain to parents why return to play decisions are not made immediately following a possible concussion. This is particularly important to emphasize, as recent studies have shown that follow-up after ED visits for concussion are low (45%).29 Though follow-up with primary care physicians for concussion may be poor and parents may want expedited medical clearance, our results do suggest that parents have heard part of this message. Overall 74% thought that strenuous physical activity while their child was still having symptoms would “very much” have a negative impact on their child’s recovery. Many parents also realized that video games, texting, and social media, and reading and studying while still having symptoms could potentially “somewhat” have a negative effect on their children after a concussion. The extent to which cognitive rest should be implemented is still being evaluated.30 With the numerous and sometimes conflicting lay sources of information regarding concussion management available, as well as the evolution of medical guidelines over the past 2 decades, it is not surprising that concussion management myths are widely believed. One example is the common belief that a child with a concussion must be woken up every few hours. Even though there is no evidence to support this practice, about one-half of the surveyed parents felt this was true. Similarly, many parents believed that after 3 concussions, a child should never play contact sports again. This is similar to a prior recommendation based on the Cantu guidelines from 1998, which was not carried over to the current Zurich concussion guidelines.6,8 In the Cantu guidelines, 2 grade 3 concussions should terminate a player’s season and 3 grade 3 concussions should raise considerable deliberations as to whether the individual should be allowed to return to any contact or collision sport.6 More recently the American Academy of Neurology has stated that for amateur athletes there is no specific number of concussions that triggers “retirement.”7,19 Our survey may have been limited by participation bias. However, panel members were not aware of the specific topics before agreeing to participate, therefore, we do not anticipate bias because of systematic nonresponse based on specific content related to childhood concussion. As with any survey, there is always the possibility that respondents may have interpreted the same question in different ways or responded in a manner that they felt to be more socially desirable. However, even with inherent survey limitations, the KnowledgePanel is representative of the US population and, therefore, generalizable to the US population. ■ Submitted for publication Jun 16, 2016; last revision received Aug 20, 2016; accepted Oct 20, 2016 Reprint requests: Angela Zamarripa, MD, Department of Emergency Medicine, Michigan State University College of Human Medicine, 15 Michigan St NE, Grand Rapids, MI 49503. E-mail: [email protected]
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2. Bener A, Omar AO, Ahmad AE, Al-Mulla FH, Abdul Rahman YS. The pattern of traumatic brain injuries: a country undergoing rapid development. Brain Inj 2010;24:74-80. 3. Gilchrist J, Thomas KE, Xu L, McGuire L, Coronado V. Nonfatal traumatic brain injuries related to sports and recreation activities among persons aged
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THE JOURNAL OF PEDIATRICS • www.jpeds.com [updated 2010 Aug 30; 2015 Jun 20]. www.cdc.gov/concussion/headsup. Accessed November 9, 2016. 24. Guskiewicz KM, Broglio SP. Acute sports-related traumatic brain injury and repetitive concussion. Handb Clin Neurol 2015;127: 157-72. 25. Public Health Law Research. Law Atlas The Policy Surveillance Portal: Youth Sports Traumatic Brain Injury Laws Map [Internet]. Philadelphia PA: Robert Wood Johnson Foundation; 2009. [2015 May1, 2015 Jun 20]. http://www.lawatlas.org/query?dataset=sc-reboot. Accessed November 9, 2016. 26. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. Comparative analysis of state-level concussion legislation and review of current practices in concussion. Neurosurg Focus 2012;33:E11, 1-9.
Volume ■■ 27. Zonfrillo MR, Master CL, Grady MF, Winston FK, Callahan JM, Arbogast KB. Pediatric providers’ self-reported knowledge, practices, and attitudes about concussion. Pediatrics 2012;130:1120-5. 28. Meehan WP 3rd, Mannix R. Pediatric concussions in united states emergency departments in the years 2002 to 2006. J Pediatr 2010;157:88993. 29. Grubenhoff JA, Deakyne SJ, Comstock RD, Kirkwood MW, Bajaj L. Outpatient follow-up and return to school after emergency department evaluation among children with persistent post-concussion symptoms. Brain Inj 2015;29:1-6. 30. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015;135:213-23.
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