Parent knowledge of and attitudes towards youth sport-related concussion and associations with child and parent factors

Aim: This cross-sectional study aimed to better understand parental knowledge and attitudes regarding pediatric sport-related concussions, and association with parent/child biopsychosocial factors. Methods: A community sample of ninety families (n = 140 children) were included. Parental concussion knowledge and attitudes, concussion history, sport participation and social risk status score (SRS) were collected. Results: Parents scored an average of 76% accuracy on factual concussion knowledge, with 74% confidence in responses. Parents endorsed a favorable attitude toward concussion reporting and management. Low SRS had higher perceived accuracy of knowledge than medium or high SRS (p = 0.003). SRS influenced over-and-underestimations of factual knowledge (p = .04). Age at first sport and sport contact level influenced factual and perceived concussion knowledge. Conclusion: These findings identify common gaps in concussion knowledge in parents.

Youth sport participation is associated with numerous physical, psychological and sociological benefits [1]. Children who engage in sports are less likely to develop heart disease, obesity, diabetes, stroke and depression later in life [2][3][4]. Furthermore, sport participation has been linked to enhanced emotional regulation, social skills, athletic skills, building peer relationships and heightened self-esteem [5][6][7][8][9][10]. Despite these many benefits, there is growing concern about potential adverse aspects of sport participation, including the risk of sustaining one or multiple concussions. Although most youth athletes who sustain a sport-related concussion fully recover from their symptoms [11], a subset of youth experience more adverse outcomes such as cognitive, behavioural and socio-emotional difficulties [12]. For youth athletes, parents play a major role in identifying concussive symptoms, managing symptoms, at-home recovery and making initial decisions about return to play [13]. In this regard, the scope and accuracy of parental concussion knowledge can influence attitudes toward sport-related concussion and, in-turn, influence parental decisions about keeping youth in sport.
Current research has focused primarily on understanding the knowledge and attitudes toward sport-related concussion among adolescent and young adult athletes, and coaches [14][15][16]. The limited research examining parental knowledge of youth concussion has found that although the majority of parents have heard about concussion, only one-quarter of parents reported a basic understanding of concussion symptoms and diagnosis criteria [17]. Further, researchers in the USA reported that the average parent concussion knowledge score was 73%, with scores ranging from 24 to 96% (higher knowledge scores indicate more accurate knowledge about concussions), and the average parental concussion attitude score was 84%, representing a positive attitude toward concussion reporting and management [13,18]. Interestingly, research on parent and child concussion history and sport participation as moderators of parental knowledge or attitude scores remains equivocal [13]. A more comprehensive understanding Limited/no contact 41 (31%) † Six aspects of the social risk status score that are summed for total score: maternal age at birth (2 -Ͻ18 years old, 1 -18-21 years old, or 0 -Ͼ21 years old), language spoken at home (2 -no English, 1 -some English, 0 -only English), education of primary income earner (2 -less than high school diploma, 1 -high school, 0 -college, university, or graduate studies), employment status of primary income earner (2 -unemployed, 1 -part time, 0 -full time), occupation or primary income earner (2 -unskilled, 1 -semi-skilled, 0 -skilled/professional), and family living structure (2 -single caregiver, 1 -separated parents with dual custody or cared for by other intact family, 0 -two caregivers). One parent did not provide information on social risk factors. ‡ Collision included football, rugby, hockey and lacrosse; Contact included flag football, basketball, dodgeball, cheerleading, wrestling, and soccer; and Limited/no contact included baseball, volleyball, dance, equestrian sport, gymnastics, swimming, track and field and water polo.
complete at home where they completed the online written consent form and the study questionnaire. The study questionnaire was approximately 10-15 min in length and was developed at a Grade 5 literacy level.

Demographic, sport & concussion information
Parent and child demographic information was collected about both the parent and child. Parents answered questions about parental and child concussion history and child sport participation history (i.e., past and current sports, child's level of sport) and current parents' sport participation. Child sport participation included a variety of sports played within the community, school, or organized sport teams (Table 1), and they were categorized based on the level of contact (i.e. collision, contact, or limited/no contact, based on American Academy of Pediatrics guidelines [33]) for analysis purposes. For those enrolled in multiple sports, they were coded based on the highest level of contact of the sports they currently participate in.

Social risk score
Using specific demographic information, social risk was computed and categorized based on a previously validated rank system [21,22]. The total social risk score is a composite score comprised of six aspects of social status scored as low social risk (score of zero), medium social risk (score of one), or high social risk (score of two) based on follow-up studies of other medically at-risk children [21]: maternal age at birth (2 -less than 18 years old, 1 -18-21 years old, or 0 -more than 21 years old), language spoken at home (2 -no English, 1 -some English, 0 -only English), education of primary income earner (2 -less than high school diploma, 1 -high school, 0 -college, university, or graduate studies), employment status of primary income earner (2 -unemployed, 1 -part time, 0 -full time), occupation or primary income earner (2 -unskilled, 1 -semi-skilled, 0 -skilled/professional), and family living structure (2 -single caregiver, 1 -separated parents with dual custody or cared for by other intact family, 0 -two caregivers). The total social risk score (SRS) was calculated by summing the scores for the six aspects (Table 1). Each family was categorized as low social risk (total SRS = 0), medium social risk (total SRS = 1), or high social risk (total SRS = 2+).

Rosenbaum concussion knowledge & attitudes survey
The Rosenbaum concussion knowledge and attitudes survey (RoCKAS), is a 55 item, 5 section questionnaire examining concussion knowledge [34]. Sections 1, 2 and 5 from the RoCKAS were used to assess parental factual knowledge of concussions. A total factual concussion knowledge score was calculated by summing all of the points obtained in the three sections, with a higher score demonstrating more factual knowledge about concussions (total scores range from 12 to 25). This measure displays moderate psychometric properties (intraclass correlation coefficient of 0.67) [34].

Perceived knowledge
Participants were asked to rate how confident they feel about their answers to the factual knowledge sections from the RoCKAS on a 7-point Likert-scale (range 1-7). A total perceived knowledge score was calculated by summing their responses (total score range from 3 to 21). Higher scores represent more perceived knowledge about concussions.

Parent concussion survey
The parent concussion survey (PCS) is a questionnaire that assesses knowledge of and attitudes toward concussions [35]. For the purposes of this study, only parental attitudes questions were used from the PCS. Participants' attitudes about concussion were assessed by the nine 7-point Likert-scale questions, which asked about attitudes toward concussion management and return to play decisions. A total attitude score was calculated by summing the responses (total score range of 9-63). A higher score represents a more favorable attitude toward reporting concussions, importance of reporting a possible concussion and an overall positive view of concussion management [18]. This measure demonstrates good psychometric properties, specifically internal consistency has been found to be acceptable for the attitude construct, with Cronbach alpha beyond 0.70 [35].

Statistical analysis
Summary descriptive statistics were calculated to describe the sample characteristics, pattern of knowledge about concussions and attitudes toward concussion reporting and treatment. Discrepancy scores were calculated between the parental factual and perceived knowledge to examine over-and-underestimates of factual knowledge. Due to differences in scales, factual and perceived knowledge scores were converted to standardized t-score values and then the t-score values were subtracted from one another to create the discrepancy scores. Discrepancy scores were grouped into three different categories: underestimation, no/minimal discrepancy and overestimation of factual knowledge. Underestimation (i.e., high factual knowledge and low perceived knowledge) was defined as a t-score difference >5 in the positive direction. Accurate perceptions (i.e., no/minimal discrepancy between factual and perceived knowledge scores) was defined as a t-score difference within 5 points in either the negative or positive direction of zero. Overestimation (i.e., low factual knowledge and high perceived knowledge) was defined as a t-score difference >5 in the negative direction. Independent samples t-tests, analysis of variance and chi-square tests were used to examine the relationship between parental biopsychosocial factors and parental knowledge and attitudes.
Chi-square tests with odds risk ratios were used to examine parental biopsychosocial factors and discrepancy scores. Three linear regression models were used to examine associated child factors and parental knowledge and attitudes scores: model-1 factual knowledge, model-2 perceived knowledge and model-3 attitude score. To control for multiple children per parent, parent data was coded, and each parent was only included once in the analysis. In analyses that had both child and parent factors, each parent was only included once, and all children were included in child data analyses. Hair loss - † Indicates correct symptoms.
12 parents had missing data on this questionnaire and were excluded.
All data analyses were conducted with Statistical Package for the Social Sciences (SPSS) version 23 and 26 (IBM corp. Released, 2015 and 2019). Appropriate post-hoc analyses were conducted and effect sizes were reported for analyses. Bonferroni was used to control for multiple comparisons for each individual analysis, adjusting for the number of pairwise comparisons. All significant findings were evaluated for significance using the adjusted familywise error rate. For all analyses, two-tailed alpha values of less than 0.05 were considered statistically significant.

Ethical considerations
The study was approved by the Human Participants Review Sub-committee of York University's Ethics Review Board in Toronto, Ontario.

Results
Predominantly mothers completed the study questionnaire (73%). Parents were approximately 41 years old at the time of the study completion, and the average child age was 9.5 years. Eighty-nine percent of parents were Caucasian. Children were predominantly engaged in swimming (54%), soccer (39%), hockey (31%) and basketball (21%). There were six children that were not currently engaged in sport (See Table 1).
Parents scored an average of 76% accuracy on concussion factual knowledge (M average score = 21.29, SD = 2.44). Incorrect sign/symptoms of an acute concussion most commonly selected by parents were difficulty speaking (62%), panic attacks (31%), and reduced breathing rate (25%; See Table 2). There were three statements that were frequently answered incorrectly: 49% of parents indicated that "after a concussion occurs, brain imaging (e.g., CAT scan, MRI, x-Ray) typically show visible physical damage (e.g., bruise, bleed, blood clot)"; 89% of parents indicated that "an athlete who gets knocked out after getting a concussion is experiencing a coma"; and 82% of parents reported that "symptoms of a concussion typically last longer than 10 days", which were incorrect responses on the RoCKAS [34]. Please see Table 3.
Parents on average reported feeling confident in their responses about knowledge symptoms and recovery (i.e., 74% confident in their responses; range 38-100%). There were 14 (16%) parents that had overestimated their factual knowledge (higher perceived knowledge than factual knowledge; scores ranged from -8.83 to 36.84). Thirty-six (40%) parents had accurate perceptions of their factual knowledge, and there were 26 (29%) parents that had underestimated their factual knowledge (higher factual knowledge than they perceived; scores ranged from 6.19 to 33.40). Parents, on average, displayed a generally favorable attitude (high positive) toward concussion reporting and management (M = 48.45, SD = 4.46, range 36-54). There is rarely a risk to long-term health and well-being from multiple concussions 66 (93%) 5 (7%) There are some parents (n = 12) that did not complete every question and therefore, there are some missing data.
Twenty-eight parents (31%) reported that they had sustained a concussion in the past, with the number of concussions ranging from 1 to 5 (See Table 1). Number of children, parental age at study completion, sex of the informant and parental concussion history were not associated with parental factual or perceived knowledge, discrepancy scores, or attitudes on concussion reporting and management (p = 0.15 to p = 0.96). There were differences in level of perceived knowledge based on parental SRS (F(2,72) = 6.34, p = 0.003), with parents with low SRS having higher perceived accuracy of knowledge than those with medium SRS (p = 0.019, d = 0.96), or high SRS (p = .035, d = 0.95). There was also a significant difference for SRS groups and discrepancy scores (χ 2 (4) = 9.80, p = 0.04, Cramer's V = .26). Factual knowledge scores and attitude scores were similar across SRS groups (See Table 4). Families with medium SRS were 15-times more likely to underestimate their factual knowledge compared with families with low SRS (95% CI: 1.68-133.92); and families with high SRS were 2.7-times more likely to underestimate their factual knowledge compared with families with low SRS (95% CI: 0.62-11.53). Furthermore, families with medium SRS were 5.5-times more likely to overestimate their factual knowledge about concussions compared with families with low SRS (95% CI: 0.45-66.31); yet families with low and high SRS had relatively equal odds of overestimating their factual knowledge about concussion (OR: 0.068, 95% CI: 00.07-6.78).
Of the 140 children in the study, 16% had a history of concussion (number of concussions ranging from 1 to 3). Youth were relatively equally distributed among sport contact level with 37% engaging in collision level sports, 31% engaging in contact level sports and 31% engaging in limited or no contact level sports. Parental factual knowledge, perceived knowledge and attitude scores did not differ by the number of children in the home and therefore all children were included in the regression analyses. No child factors were significantly associated with discrepancies between parental perceived and factual knowledge (ps = .12-.63).
A series of linear regression models were conducted to examine child factors associated with parental factual knowledge, perceived knowledge and attitudes scores. The model examining factual knowledge was not significant (F(4,106) = 1.53, p = 0.20, R 2 = 0.06). However, age at which the children began playing sports was significant (β = -0.22, p = 0.03), with the younger age at which the children begin sports being correlated with higher factual knowledge. The model examining parental attitude scores and child factors was also not significant (F(4,105) = 1.20, p = 0.32, R 2 = 0.04). Although not significant (β = -0.19, p = 0.056), post-hoc analysis revealed that parents of children with a concussion history had a more favorable attitude about concussion reporting and management

Discussion
Parents demonstrated a moderate amount knowledge about concussion signs and symptoms, similar to rates found in prior literature including Public Health Agency of Canada (PHAC) [32], and other studies conducted in USA that used mixed samples [13,17,18,32,36]. A substantial proportion of parents incorrectly identify reduced breathing rate, difficulty speaking and panic attacks as signs/symptoms of an acute concussion and reported that they believed physical damage to the brain following a concussive injury can be observed on clinical brain scans (e.g., MRI, CT) [32]. These findings identify potential targets for education efforts to improve knowledge of concussion signs and symptoms for parents.
Despite it being an incorrect answer on the RoCKAS, 82% of parents agreed with the statement that concussion recovery typically takes longer than 10 days which is aligned with current literature and concussion education platforms. For example, education platform such as CDC-HEADS UP program and Parachute Canada provide more broad guidelines for concussion recovery (i.e., taking up to a couple of weeks) [37,38]. Emerging research also suggests longer recovery times for youth and high-school age children (∼15-20 days) [39,40], with even longer recovery times for cognitive symptoms [11,41,42]. Our research, thus, highlights the importance of disseminating consistent and accurate information about recovery trajectories that may vary across age, sex and various athlete and non-athlete populations.
In the current study, parents had similar factual knowledge scores about concussion signs/symptoms yet, families with higher SRS perceived themselves to have lower factual knowledge compared with families with lower SRS despite relative homogeneity of social status in the sample. Prior research demonstrates individual indicators of social status such as household income, parental education and stressors associated with lower SES (i.e., higher SRS) has a negative impact on parental attitudes about concussions and confidence in general [13,20,29,30]. Together these findings suggest that SRS may not be associated with actual knowledge rather there may be an opportunity to increase parental confidence and perceived knowledge among higher risk families within the communities in the current study. The current study highlights a need to explore types of psychoeducational approaches among various community samples, as well as other methods that would improve confidence among parents about concussion knowledge.
Parents who enrolled their children in sports at a younger age were more knowledgeable about concussions than parents who enrolled their children at an older age. It is possible that parents who have a child in sports for a longer period of time are more likely to seek out concussion information as it is directly relevant to their child's sport participation, and they are more likely to be exposed to concussion information through sport organizations [43,44]. Additionally, higher perceived knowledge was associated with parents with children in contact sports, and a more favorable attitude about concussion reporting and management was associated with a positive child concussion history. A positive attitude about concussion reporting and management is likely endorsed by parents of children with a history of concussion because they have utilized concussion management strategies in the past [44]. Parents who have children engaged in higher contact level sports receive more formal or informal information about concussions than parents of children within the limited or no contact sport groups. Importantly, more than half the parents in the Canadian PHAC baseline study believed that averting engagement in contact sports will prevent concussions [39]. It is important to ensure that concussion knowledge is disseminated equally across all levels of contact in order to provide parents with the tools and confidence to make informed decisions about sport participation and preserve engagement in youth sports of all levels.
There are additional avenues that that could not be addressed by the current study due to practical and other limitations. The study's participants were from a small sample of parents recruited from the GTA that are likely active in the community and/or have youth involved in sports, thus limiting the diversity and generalizability of the findings. Furthermore, the rate of refusal was unable to be accurately tracked and therefore was not able to be analyzed. Ninety-six percent of our sample of children were enrolled in sports which exceeds the national average of approximately 75% in Canada [45], despite our attempt to mitigate this issue and capture a more diverse sample by including public libraries, and community/recreational centers. Despite using a multifaceted robust measure of social risk, our sample was fairly homogeneous in nature. Nevertheless, we were able to find notable differences between social risk groups and perceived knowledge. However, the homogeneity of the groups poses a potential bias and future research is warranted to further understand these relationships within more diverse populations. Future research is also warranted to better understand how child sex can influence parent knowledge of concussions and attitudes toward concussion reporting and management, given our inability to examine this due to a lack of data related to youth sex.

Conclusion
Despite these limitations, the results from this study compliment the 2017 Berlin Consensus Statement on Concussion in Sport [41], and offer a breadth of information that may be useful for informing knowledge translation platforms and education initiatives in our community, adding to the pan-Canada goal of raising awareness for parents, coaches and athletes about concussion knowledge, recovery and treatment by the Ministry of Health and Ministry of Sport and Persons with Disabilities. This study offers unique insight into parental knowledge and attitudes of sport-related concussion in a small subset of Canadian parents (i.e., from the GTA). It identifies factors that encumber parental confidence, knowledge, and attitudes about concussion that may lead to a reduction in sport participation. This study also helps inform knowledge translation platforms and policies to increase parental factual and perceived knowledge about concussion, supporting youth sport engagement. Specifically, we can target misconceptions about concussion among all families within Ontario by providing accurate and upto-date information about concussions uniformly across parents. Furthermore, we can aim to increase parental perceived knowledge about concussions among families that experience high social risk factors. It is important to tailor education initiatives to increase knowledge, confidence and attitudes of parents due to the influence this has on youth flourishing socially and developmentally in community sports. There is variability about concussion management among health sectors in Canada [32], and this study helps to fill the gap by highlighting signs and symptoms that parents incorrectly identify, to support the national goal of creating a comprehensive pan-Canadian approach to concussion prevention, detection and management. Collectively, the results from the current study can be used as a stepping stone to inform future research and government bodies as they improve the quality, format and scope of concussion education through new initiatives or existing platforms, in order to promote active youth and their participation in sport.
Executive summary • The current cross-sectional study aimed to better understand parental knowledge and attitudes regarding paediatric sport-related concussions, and associations with parent and child biopsychosocial factors. • Parents scored an average of 76% accuracy on factual concussion knowledge, with 74% confidence in their responses. • Parents endorsed a favourable attitude towards concussion reporting and management. • Low SRS had higher perceived accuracy of knowledge than medium or high SRS. SRS influenced over-and-underestimations of factual knowledge. • This study offers a breadth of information that may be useful for informing knowledge translation platforms and education initiatives in our community, adding to the pan-Canada goal of raising awareness for parents, coaches, and athletes about concussion knowledge, recovery, and treatment by the Ministry of Health and Ministry of Sport and Persons with Disabilities. • It helps identify factors that encumber parental confidence, knowledge, and attitudes about concussion that may lead to a reduction in sport participation. We can aim to increase parental perceived knowledge about concussions among families that experience high social risk factors. It is important to tailor education initiatives to increase knowledge, confidence, and attitudes of parents due to the influence this has on youth flourishing socially and developmentally in community sports. • This study also helps inform knowledge translation platforms and policies to increase parental factual and perceived knowledge about concussion, supporting youth sport engagement. Specifically, we can target misconceptions about traumatic brain injury and concussion among all families within Ontario by providing accurate and up-to-date information about concussions uniformly across parents. • This study helps to fill the gap by highlighting signs and symptoms that parents incorrectly identify, in order to support the national goal of creating a comprehensive pan-Canadian approach to concussion prevention, detection, and management. • Collectively, the results from the current study can be used as a steppingstone to inform future research and government bodies as they improve the quality, format, and scope of concussion education through new initiatives or existing platforms, to promote active youth and their participation in sport.

Financial & competing interests disclosure
This work was funded by the Social Sciences and Humanities Research Council. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

Ethical conduct of research
The study was approved by the Human Participants Review Sub-committee of York University's Ethics Review Board in Toronto, Ontario.

Open access
This work is licensed under the Creative Commons Attribution 40.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/