Two Decades: Looking Back on Child Protection in Sports

1/ Creating a Safe Reporting Environment: Why the flurry of activity around #TeamUpSpeakUP #TeamUp4ConcussionSafety #BuddyUp , etc., and does it work?

MomsTEAM Institute just celebrated our 19th birthday on August 23. As we head towards our 20th birthday I want to spend the year reflecting on all that we have accomplished over the last two decades and highlight the work of organizations which have adopted and expanded on programs that MomsTEAM pioneered.

First up, due to the timing, is one of the MomsTEAM safety initiatives about which we are most proud: our 2015 #TeamUp4ConcussionSafety initiative. In the belief that imitation is the sincerest form of flattery, we were glad to see that, shortly after our program went live, our Boston neighbor, the Concussion Legacy Institute, launched its own national call to action called #TeamUpSpeakUp.

Six Pillars

In 2012, working with a team of prominent concussion experts and the parents, coaches, athletic trainers, and athletes at an Oklahoma high school, we piloted a concussion risk reduction program called The Six Pillars™ which saw encouraging high school football players to report concussion symptoms observed in their teammates to the coach or athletic trainer as one way to overcome the well-documented “culture of resistance” to concussion reporting among athletes at all levels of sport. Use of a concussion reporting “buddy system” was featured prominently in our 2013 PBS documentary, The Smartest Team Making High School Football Safer, which, unlike every concussion documentary before or since, offers real life, practical solutions to improving concussion safety in youth and high school football, but the concept of increasing honest self-reporting of concussions by athletes by creating an environment in which they felt safe in reporting actually had as its genesis a 2008 MomsTEAM article, revised numerous times since, titled Coaches: Improve Concussion Safety By Creating A Safe Environment For Athlete Self-Reporting [link].

Two years later, MomsTEAM was one of six winners of the NCAA-DoD Educational Mind Matters Grand Challenge grant for our proposal to create an interactive concussion education program specifically designed to overcome the resistance of athletes to report experiencing concussion symptoms by emphasizing the benefits to themselves and their team of honestly reporting symptoms, both theirs and their teammates. One of the judges reviewing Mind Matter’s grant applications was Chris Nowinski, the Chief Executive of Concussion Legacy Foundation.

Interestingly, it was not until we traveled to NCAA headquarters in Indianapolis in February 2016 that we learned that MomsTEAM’s #TeamUp4ConcussionSafety program was not the only Mind Matters Challenge Grant winner to utilize a buddy-type system: the program [link] developed by Chestnut Hill College also sought to change concussion reporting behavior by utilizing what it calls a ‘peer-to-peer’ model in which two student-athletes per team are trained to serve as peer concussion educators, teach their teammates about concussions, facilitate self-reporting and keep an eye out for teammates who may have suffered a head injury. William Ernst, a clinical neuropsychologist and assistant professor of psychology at Chestnut Hill, said the goal of its program is to change the culture surrounding concussion from inside the team rather than relying on outside experts to have a significant impact.

The Smartest Team buddies always checking in with each other

Jumping on the bandwagon

On August 15, 2016, we launched a new comprehensive concussion/brain injury safety website, SmartTeams Play Safe Brain Injury Prevention to make the new program, #TeamUp4ConcussionSafety, freely available for download by parents, coaches, athletic trainers, and athletes in all contact and collision sports carrying a risk of concussion.

Just four weeks later, the Concussion Legacy Foundation launched its own version of our campaign they call #TeamUpSpeakUp. While it is gratifying to know that CLF’s initiative, now in its fourth year, is bringing the team up for concussion safety concept that we pioneered in our program to a wider national level, we still think our #TeamUp4ConcussionSafety program is worth considering by schools and sports programs looking to improve self-reporting of concussion symptoms by athletes.

The home page of Smart Team Brain Injury Prevention program introduces the concept of teaming up for concussion safety through the use of an educational interactive infographic scroll. The goal is that, by the end of the scroll, players will begin to understand how important it is for team and individual success for them to have each other’s back, to be their teammates’ “buddy.” For those of us who learned about the buddy system in Red Cross junior lifesaving, the concept is a familiar one. What is new, however, is the use of a buddy system to increase honest concussion symptom reporting.

Home Page: educational interactive infographic scroll

Up to now concussion education has focused almost exclusively on teaching coaches, athletes, and parents about how to recognize the signs and symptoms of concussion and providing information about the health risks of concussion and repetitive head trauma, in the hopes that an athlete, knowing the symptoms of concussion, and knowing the risks from continuing to play, won’t be willing to risk further injury and will report their symptoms to you or an athletic trainer right away.

Unfortunately, such education hasn’t worked to change the concussion reporting behavior of athletes, with between 40 and 60 percent of all concussions — and a much higher percentage of so-called “bell-ringer” events — still going unreported.

Even though most athletes probably now recognize that continuing to play while concussed puts their health at risk, many athletes continue to hide concussion symptoms in order to keep playing.

Watch the interactive scroll to see what happens

Why?

Fifty-fifty

Research over the last decade reveals that the top ten reasons athletes consistently give for not immediately reporting concussion symptoms are that:

  1. They did not think they suffered a concussion;
  2. They did not believe, if it was a concussion, that it was serious enough to report;
  3. They were not aware of the potential negative health consequences from continuing to play with concussion;
  4. They believed that they could safely delay disclosure until their removal was less likely to affect game or practice play, or until the symptoms got so bad they could no longer be ignored;
  5. They did not want to be removed from the game or practice;
  6. They did not want to disappoint coaches, teammates, parents, and fans by coming out of the game;
  7. They felt pressure from coaches, teammates, parents, and fans to play injured;
  8. They believed that coaches, teammates, parents, and fans expected them to play injured;
  9. They feared suffering negative consequences if they reported concussion symptoms, such as loss of playing time or position as a starter, or having their toughness questioned;
  10. They thought, if they had a positive attitude toward concussion symptom reporting, was such attitude wasn’t shared by the coach, medical staff, and teammates, so that they hid their symptoms for fear of social disapproval.

What is striking about this list is that fully half of the ten have nothing to do with knowledge of concussion signs and symptoms or the health risks of concussions, but have everything to do with an athlete’s attitudes and beliefs about concussion reporting, what they think might happen to them if they report, and what they think are — and, in many cases, actually turn out to be — the negative attitudes of coaches, teammates, parents, and fans have towards concussion reporting.

Research also shows that:

  • Athletes who perceive that are receiving less support from coaches for appropriate concussion symptom reporting are more likely to continue playing with symptoms of concussion;
  • One in four college athletes experienced pressure from a teammate, coach, parent or fan to continue to play after a head impact during the previous season, with the greater the number of groups of stakeholders from whom an athlete experienced such pressure the less likely they were to report symptoms of a future suspected concussion;
  • That few coaches explicitly support playing through injury does not mean that athletes do not experience an implicit message that playing through injury is behavior they value because coaches can influence reporting behavior indirectly by shaping team attitudes about concussion safety, such as through their communications with team members about the importance of concussion safety, and through by their control over playing time, what athletes they pick as starters, and, at the Division I college level, over scholarships; and
  • A substantial majority (77%) of college athletes in one recent study perceived their own reporting attitudes to be safer than those of their teammates.

Attitude Adjustment Time

Based on this research, MomsTEAM’s #TeamUp4ConcussonSafety program tries something different — or, in the parlance of American football, a new game plan — to increase the rate at which athletes report concussion symptoms, one which recognizes that chronic under-reporting is not so much a result of an athlete’s lack of knowledge about concussion symptoms and the health risks of continuing to play with symptoms, as (1) a belief that they are expected to play through injury (even a head injury); (2) a belief that the coach, teammates, parents, and fans would be disappointed if they didn’t shake off the injury and stay in the game, and, (3) even if they thought reporting was the safer course, a belief that they would be violating the team’s code of silence and wouldn’t be viewed as a good teammate if they reported.

Like the Centers for Disease Control, and a growing consensus of concussion experts, SmartTeams™ believes that the best way to increase the rate at which athletes report concussion symptoms, either their own or their teammates, is for coaches, parents, medical staff to work as a team to change reporting behavior, to reshape the culture around concussions by changing individual and team reporting attitudes and norms and by creating a climate in which athletes feel comfortable reporting their symptoms.

The #TeamUp4ConcussionSafety™ program aims to increase reporting by athletes of concussion symptoms by engaging coaches, athletes, medical staff, and parents in a season-long program which emphasizes that immediate reporting of concussion symptoms not only reduces the risk of further injury — or, in rare cases, even death — but is actually helps a team’s chances of performing better and winning, not just that game, but, by giving athletes the best chance to return as quickly as possible from concussion, in future games, and by instilling in athletes a belief that honest reporting is a valued team behavior.

Five-Part Program

The SmartTeams™ #TeamUp4ConcussionSafety™ program consists of five steps:

1. Testing Knowledge and Attitudes

A growing body of scientific research leads SmartTeams™ to believe that athletes will be more likely to immediately and honestly report experiencing concussion symptoms, both their own and their teammates, if coaches, athletes, and parents know more, not just about concussions, but their own attitudes towards and beliefs about symptom reporting. (How, after all, can one’s attitudes be changed if one doesn’t know what they are in the first place?)

To find out what coaches know about concussions, and, more importantly, whether coaches view concussion symptom reporting in a positive or negative light, the program asks all stakeholders to take a series of quizzes:

2. Completing a Concussion Safety Course

While knowledge and awareness of concussion has increased substantially over the nearly twenty years that MomsTEAM/SmartTeams™ has been engaged in concussion education, research shows that there are still important gaps which need to be filled.

To fill in those gaps and continue the concussion education process, in Step Two of the #TeamUp4ConcussionSafety™ program stakeholders are asked to:

The Smartest Team: Making High School Football Safer (PBS)

3. Leading a Concussion Safety Meeting

Because studies show that one-off concussion education isn’t enough to change concussion symptom reporting behavior, Step Three in the SmartTeams™ #TeamUp4ConcussionSafety game plan calls for coaches, along with athletic trainers and team doctors, to hold a mandatory concussion safety meeting before every sports season at which athletes (and, at the high school level and below, parents) can learn in detail about the program’s commitment to creating a climate in which athletes feel comfortable about reporting concussion symptoms, both their own and their teammates, and how immediate concussion symptom reporting not only minimizes the risks concussions pose to an athlete’s short- and long-term health, but may actually increase the chances for individual and team success, both by ensuring that the concussed athlete does not compromise the team’s overall performance, not only in that game, but by minimizing the time the concussed athlete miss away from the team before being cleared to return to contact and the chances of a prolonged recovery, in future games as well.

Preseason meeting is essential for opening dialog and having questions addressed

4. Taking a Concussion Safety Pledge

Anecdotal evidence from NCAA Division I football programs suggests that the signing by athletes of pledges acknowledging their responsibility to report concussion symptoms may increase the rate of reporting by athletes, both of their own symptoms and those of teammates. Because SmartTeams™ views improving concussion safety as a team effort, we believe that all those with a stake in concussion safety should sign pledges, including coaches.

Step Four of our concussion safety game plan thus asks athletes, coaches, and parents to sign a concussion safety pledge at or shortly after the pre-season concussion safety meeting so as to demonstrate in a tangible way your shared commitment to creating a culture in which immediate reporting of concussion symptoms by athletes is considered a valued team behavior and an important responsibility of every team member. We ask that you provide a copy of your signed pledge to each member of the team, and also, if you are coaching at the high school level and below, to their parents.

Pledges may be downloaded from the Smart Teams website

5. Staying Involved/Sharing Success Stories

We know that change is not going to happen overnight. Because prevailing attitudes towards concussion symptom reporting and reporting behavior are deeply entrenched in our sports culture, SmartTeams™ strongly encourages all stakeholders to continue working together over the course of the sports season, and beyond, towards creating and maintaining an environment in which athletes feel comfortable in immediately reporting concussion symptoms (both their own and their teammates) and in which immediate symptom reporting is considered a valued team behavior.

You can do that by sharing and reinforcing positive messages about the importance of immediate concussion symptom reporting with your team before every game, during team meetings and via social media (we encourage sharing success stories and positive messages @SmartTeams on Twitter,via YouTube, and/or your favorite social media smartphone app, and by maintaining open lines of communication and engaging in an ongoing dialog with athletes and parents about concussion safety throughout the season.

Four Key Takeaway Messages

The goals of the SmartTeams™ #Teaming Up4Concussion Safety™ program are to instill the following four key messages:

  1. In honestly and immediately self-reporting concussion symptoms, and encouraging teammates to do the same, athletes are not letting the coach, teammates, parents, and fans down, but are helping the team’s chances of success;
  2. Honestly and immediately self-reporting concussion symptoms, and encouraging teammates to do the same, are hallmarks of a good team player;
  3. Delaying the reporting of concussion symptoms — or hiding them completely — puts an athlete’s health and even those of their teammates at risk by exposing their already injured brain to further damage, potentially even death; by prolonging the time it takes for them to recover by almost a week; and by doubling their chances of needing 8 or more days to be cleared to return to contact practice; and
  4. Not honestly and immediately reporting concussion symptoms can hurt an individual’s and the team’s performance, not just in the game in which the athlete sustains a concussion, but in future games in which the athlete is unable to play as a result of a prolonged recovery.

While we are aware that young athletes are not reporting their injuries as this tweet illustrates, perhaps because of no buddy system ,,

,,, We believe with consistent messaging and constant reinforcement of the value of immediate concussion reporting in achieving your team’s performance goals, and by making athletes feel comfortable in reporting, we believe that, not only will attitudes and beliefs about concussion reporting begin to change, but the concussion reporting behavior of your athletes will start to change as well, and that, over time, the culture of resistance to concussion symptom reporting will be replaced by a sports culture of concussion safety.

Brooke de Lench is Executive Director of MomsTEAM Youth Sports Safety Institute, Director of the Smart Teams project, Founder and Publisher of MomsTEAM.com, Producer/Director of The Smartest Team: Making High School Football Safer (PBS), and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins). You can follow Brooke on Twitter @brookedelench @MomsTeam @SmartTeams and send her an email at delench@MomsTeam.com

Additional Links:

Mind Matters Challenge research winners announced

NCAA-DoD Mind Matters Judging panel

Additional Articles:

Creating A Culture Of Concussion Safety Requires Teamwork All Season Long, Not Just One Day by Brooke de Lench

A New Game Plan: #TeamUp4ConcussionSafety by Brooke de Lench

Culture of Resistance To Concussion Reporting Must Change by James MacDonald, MD

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Brooke de Lench

Brooke de Lench

Child Athlete Safeguards & Rights Pioneer, Author, Film Producer (PBS)