By Nicholas Swim, Ehren Green, & Anthony Montanaro, from the University of Louisville
The number of youth sport participants who continue to experience concussions during sports participation is staggering. According to the University of Pittsburgh Medical Center (UPMC) the number of reported youth concussions ranges between 1.7 and 3 million annually. Additionally, it is estimated that half of concussions are unreported or undetected (UPMC, n.d.). Thus, the Center for Disease Control (CDC) now recognizes Traumatic Brain Injuries (TBIs) and concussions as a national public health issue (CDC, 2019). Specifically, youth athletes hold a greater risk for concussions in comparison to adults and may require longer recovery time due to their fragile and developing brain (Grady, 2010). Equally as troublesome, a recent study found youth athletes are one-and-a-half times more likely to sustain a second concussion when compared to adults (Brody, 2015). This issue has garnered national media attention (Drake, 2018) and is the subject of numerous lawsuits against sport governing associations such as Pop Warner Football (Archie v. Pop Warner), High School Athletic Associations (Bukal v. Illinois High School Ass’n), and the National Collegiate Athletic Association (NCAA Student-Athlete Concussion Litigation). In professional sports, the National Football League (NFL) settled a concussion litigation suit with former players worth upward of one billion dollars (NFL Players’ Concussion Injury Litigation, 2020). The combination of health and financial importance of concussion management within sport at all levels is evident (Carter, 2018). Acknowledging this crisis, sport and state leadership have acted, introducing significant changes to youth sport concussion education and management at the state level. To better understand these new changes and the legal considerations of the changes, we sought to explore how concussion management protocols were articulated in the handbooks of the state high school athletic associations.
State Concussion Legislation
At the federal level, concussion legislation to protect youth athletes has been proposed but to date has yet to be enacted (see, Youth Sport Concussion Act, 2014, S. 1014). This lack of federal protection, thrusts the responsibility of youth sport concussion management to the state level. Washington state was the first state to introduce a youth sport concussion legislation in 2009, with the Zackery Lystedt law (RCW 28A.600.190, 2009). This law, the first of its kind, addressed specific concussion management and protocol language for youth sport and focused on three key components, 1) education for athletes, coaches, and parents; 2) removal of play policies, with no return on same day; and 3) return-to-play restrictions, requiring clearance from a licensed healthcare provider (The Sport Institute, n.d.). Since 2009, all fifty states have adopted concussion legislation, using the Zackery Lystedt Law as a precedent. Howard (2019) highlights the importance of these state mandates and attributes the growth in education and awareness of concussions to a potential mitigation of concussion risks. However, each state’s adopted youth sport concussion legislation currently holds varying degrees of policies, procedures, and policing for their respected concussion protocols, leading to inconsistent standards of care (Kim et al., 2017; Swim et al., 2020).
In 2017, Kim et al. investigated each states legislation addressing youth sport concussions, with findings suggesting inconsistencies across states. For example, the results indicated state legislative requirements for education and training, removal of play, and return-to-play (RTP) varied significantly amongst the states. The variation among state legislative requirements may also lead to inconsistent standards of care to protect youth athletes from concussions. Furthermore, more recent findings from Swim et al. (2020) also highlight significant discrepancies in state legislation language related to requirements for return-to-academics (RTA) and parent notifications. Additionally, results discovered over half of the state’s high school associations (n=27) were mentioned in the state legislation to help develop, implement, and update their states youth concussion protocols. Thus, highlighting to the importance of understanding concussion management protocols and procedures at the state high school association level (Coxe et al., 2018; Yoanna, 2019).
High School & Concussion Protocols
To investigate state high school associations’ concussion protocols, in 2019, Yoanna analyzed specific school districts concussion protocols in the state of Colorado, with findings demonstrating similar inconsistencies to those found at the state legislation level. For example, the individual school districts had no concussion reporting system in-place, a vital step in developing rules, updating, and assessing current concussion protocols. Similarly, Coxe et al. (2018) investigated individual high schools across 26 states to determine if concussion protocols being implemented were consistent amongst language usage. Their findings indicated considerable variation amongst specific language in each protocol, potentially leading to differences in standard of care for athletes between home or away games. Therefore, state laws may just be acting as a proverbial buffer for school districts, schools, coaches, and athletic trainers to mitigate their risk of liability, rather than protecting their respective athletes (Coxe et al., 2018).
Currently, the National Federation of State High School Association’s (NFHS) mission statement states, “providing leadership for the administration of education-based high school athletics and activities through the writing of playing rules that emphasize health and safety, educational programs that develop leaders, and administrative support to increase opportunities and promote sportsmanship” (NFHS, n.d., para. 1), demonstrating the importance of health and wellness for their membership group. However, the past findings of Coxe et al. (2018) and Yoanna (2019) may shed light on inconsistencies across states in their concussion management protocols at the state high school association level. Expanding on Coxe et al. (2018) and Swim et al. (2020), the purpose of this study is to identify common or shared language and to address gaps in the state high school athletic association’s handbooks. Additionally, recommendations to improve concussion protocols within the high school athletics governance structure are provided.
Methods
A content analysis was conducted on each of the 50 states’ high school athletic associations’ handbooks (excluding Hawaii; including District of Columbia). Using similar variables identified in past studies regarding concussion protocols (Coxe et al., 2018; Kim et al., 2017; Swim et al., 2020) the researchers conducted a review of state high school athletic association handbooks, focusing on verbiage related to concussion protocol and management. Some of the variables addressed in the coding included, designated party for removal of athlete, return-to-play and return-to-academics, education and training, and concussion information sheet, while also including new variables of addressing liability, base-line testing, and penalties for non-compliance.
Findings
The initial findings revealed significant inconsistencies in concussion protocols in state high school association constitutions and bylaws. In total, 38 states contained language addressing concussion protocols. Of these states that included concussion information, the language varied significantly, for example, 7 of the 38 states only provided information regarding referee and coach training. However, the results also found some states with robust concussion protocol information. For example, the Florida High School Athletic Association (FHSAA) includes an entire section that thoroughly discusses concussion management including, removal of athlete, return-to-play, and education and training requirements (FHSAA, 2020). The results from this study also indicated 12 states with no specific language addressing concussions. For example, researchers were unable to locate any concussion information in the high school athletic association handbook in the state of Texas, even though the state legislation specifically identified the governing body of schools/recreation organizations as the responsible party for developing, implementing, and evaluating concussion protocols (Swim et al., 2020).
Education/Training & Designated Party for Removal
The most identified common language across the content analysis was the education and training of coaches. In total, we found 34 states require coaches to participate in concussion management education and 33 require subsequent concussion management training. However, in comparison to the state concussion legislation, the results here represent variability in education and training for other key stakeholder groups, including, athletes, parents/guardians, referees/officials, and health care providers (Swim et al., 2020). Furthermore, inconsistencies were identified in the designated party for removal of athletes. For example, the results in this study found the designated party for removal most identified was coaches which was included in 12 states handbooks, however, Swim et al. (2020) results indicated 25 state legislations included coaches as the designated party for removal. The inconsistency in designated party for removal also ties back to the education/training finding, as when there is no designated party for removal, all individual stakeholders have a responsibility to remove athletes, but these individuals are not required to be educated/trained on concussion management based on the findings from state high school association handbooks.
Penalties for Non-Compliance
The results from this study also indicated inconsistencies in penalties for non-compliance of concussion protocols. In total, only six states (n=6) provided any information on potential sanctions or penalties. As mentioned earlier, the FHSAA held strong concussion management information in their handbook, including non-compliance penalties (FHSAA, 2020). According to article 40.7 (Sanctions on Coaches) of the state’s athletic association handbook, any coach found in violation of the identified concussion management protocol will be sanctioned to a suspension. These suspensions held at three levels, with varying discipline at each level, Level I (two game suspension), Level II (six-week suspension), and Level III (1-year suspension). Since coaches in public schools are considered government employees, they may be subjected to immunity in case regarding concussions, unless they act in a grossly negligent or reckless manner, which gives families minimum options legally after poor concussion management. Therefore, the introduction of penalties for non-compliance of concussion management protocols, similar to other aspects in the state high school athletic association handbooks (e.g. recruiting penalties), may provide an extra layer of protection for youth athletes.
Recommendations
These results demonstrate a lack of commitment from state high school athletic associations to their youth athletes in providing proper concussion management protocols. We found high school associations handbooks are not providing the bare minimum language from their own state’s legislation on youth sport concussions. Therefore, the authors suggest that each high school association provide, at least, the state specific law on youth sport concussion management in their handbook. The adoption of such language in these governing documents will provide state high school associations the opportunity to align their mission of health and wellness to their actual practices in regards to concussion management.
Author Bios
Nicholas Swim is a sport administration doctoral student at the University of Louisville. His research examines gender and racial equity in high school and intercollegiate sport.
Ehren R. Green is a sport administration doctoral student at the University of Louisville. Her research focuses on human behavior in intercollegiate athletics.
Anthony Montanaro is a sport administration doctoral student at the University of Louisville. His research focuses on sports analytics.
References
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