Sara Powell Dow Chrisman

This article aimed to examine the psychometric properties of a measure of youth fear-avoidance of concussive symptoms. Fear-avoidance is thought to be a risk factor for prolonged concussion recovery; however, current measures of fear-avoidance focus on pain rather than broader symptoms. We adapted the Fear of Pain Questionnaire to be relevant to concussion symptoms with a new version called the Fear of Concussive Symptoms Questionnaire (FOCSQ). We assessed the psychometrics of this scale with a sample of N = 115 youth with persistent postconcussive symptoms (M_age = 15.1 years, 58% female, 70% non-Hispanic White, 15% Hispanic, M = 79.2 days since injury), including reliability, construct validity, and cross-informant reliability. Exploratory factor analysis suggested a two-factor model was a good fit for youth report (fear and avoidance) and a three-factor model for parent proxy (fear, school/social avoidance, and movement avoidance). Reliability was excellent, with Cronbach's α for both youth report and parent proxy of 0.93 (95% CI [0.91, 0.95]). Construct validity indicated moderate correlation between youth-report FOCSQ and concussive symptoms 0.55 (95% CI [0.41, 0.66]), headache severity 0.37 (95% CI [0.19, 0.53]), depression 0.62 (95% CI [0.49, 0.72]), and anxiety 0.64 (95% CI [0.51, 0.73]). Criterion-related validity was supported by an inverse correlation between FOCSQ and the Pediatric Quality of Life Inventory: -0.64 (95% CI [-0.74, -0.52]). Youth report and parent proxy were moderately correlated, with Pearson's correlation coefficient r = 0.60 (95% CI [0.47, 0.71]). The FOCSQ is a reliable and valid measure of fear-avoidance in youth with concussion, and future research might explore whether this measure could be used to identify youth at risk for prolonged recovery. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

A significant portion of youth sustain a concussion every year, with around 30% experiencing persistent post-concussion symptoms (PPCS). Research has shown exercising just below the exertion level that provokes symptoms can lead to more rapid recovery. However, youth often struggle to adhere to exercise recommendations following concussion. We conducted structured qualitative interviews (n = 32) with concussed youth and their parents to examine factors influencing motivation to engage in exercise post-concussion. Questions were framed through the lens of Self-Determination Theory (SDT) and Thematic Analysis was used to code and analyze transcripts. Four primary factors appeared to motivate youth to exercise after receiving a concussion: 1) social support, 2) accountability, 3) goal setting, and 4) structure. Utilizing the lens of SDT, one could theorize that including social support and accountability helped fulfill the need of relatedness, setting goals helped fulfill the need of autonomy, and providing program structure helped fulfill the need for competence. Our results suggest that Self-Determination Theory may be a useful frame for examining exercise adherence post-concussion. Incorporating social support, accountability, goal setting and structure could increase the effectiveness of exercise prescription post-concussion and should be the focus of further study.

More than 44 million U.S. youth 6 to 17 years old participate in organized sports (Langhorst, 2016). While sports provide opportunities for social connection, physical activity and skill developmen...

Pediatric emergency departments (ED) are where many families receive post-concussion medical care and thus an important context for helping parents build skills to support their child after discharge. Develop a strategy for increasing parent provision of emotional and instrumental support to their child after discharge and conduct a pilot test of this strategy's acceptability. In a large pediatric ED in the United States, we partnered with parents (n = 15) and clinicians (n = 15) to understand needs and constraints related to discharge education and to operationalize a strategy to feasibly address these needs. This produced a brief daily text message intervention for parents for 10 days post-discharge. We used a sequential cohort design to assess the acceptability this intervention and its efficacy in changing parenting practices in the 2-weeks post-discharge (n = 98 parents). Parents who received the messaging intervention rated it as highly acceptable and had meaningfully higher scores for emotionally supportive communication with their child in the two weeks post-discharge than parents in the control condition (Cohen's d = 0.65, p = 0.021). This brief messaging intervention is a promising strategy for enhancing discharge education post-concussion that warrants further evaluation.

Context: Concussion research has primarily focused on sport-related mechanisms and excluded non–sport-related mechanisms. In adult populations, non–sport-related concussions (non-SRCs) demonstrated worse clinical outcomes compared with sport-related concussions (SRCs); however, investigations of non-SRCs in college-aged patients are limited. Objectives: To examine clinical outcomes in collegiate athletes with non-SRCs compared with SRCs and explore sex differences in outcomes among collegiate athletes with non-SRCs. Design: Prospective cohort study. Setting: Clinical setting. Patients or Other Participants: A total of 3500 athletes were included (n = 555 with non-SRCs, 42.5% female) from colleges or universities and service academies participating in the National Collegiate Athletic Association Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. Main Outcome Measure(s): Dichotomous outcomes (yes or no) consisted of immediate reporting, mental status alterations, loss of consciousness, posttraumatic amnesia, retrograde amnesia, motor impairments, delayed symptom presentation, and required hospital transport. Continuous outcomes were symptom severity, days with concussion symptoms, and days lost to injury. Data were collected within 24 to 48 hours of injury and at return to play. Adjusted relative risks (ARRs) compared the likelihood of dichotomous outcomes by mechanism and by sex within patients with non-SRCs. Multivariate negative binomial regressions were used to assess group differences in continuous variables. Results: Athletes with non-SRCs were less likely to report immediately (ARR = 0.73, 95% CI = 0.65, 0.81) and more likely to report delayed symptom presentation (ARR = 1.17, 95% CI = 1.03, 1.32), loss of consciousness (ARR = 3.15, 95% CI = 2.32, 4.28), retrograde amnesia (ARR = 1.77, 95% CI = 1.22, 2.57), and motor impairment (ARR = 1.45, 95% CI = 1.14, 1.84). Athletes with non-SRCs described greater symptom severity, more symptomatic days, and more days lost to injury (P < .001) compared with those who had SRCs. Within the non-SRC group, female athletes indicated greater symptom severity, more symptomatic days, and more days lost to injury (P < .03) than male athletes. Conclusions: Athletes with non-SRCs had worse postinjury outcomes compared with those who had SRCs, and female athletes with non-SRCs had worse recovery metrics than male athletes. Our findings suggest that further investigation of individuals with non-SRCs is needed to improve concussion reporting and management.

Objectives The purpose of this study was to determine sex differences in recovery trajectories of assessments for sport-related concussion using Concussion Assessment, Research and Education (CARE) Consortium data. Methods National Collegiate Athletic Association athletes (N = 906; 61% female) from sex-comparable sports completed a pre-season baseline assessment and post-sport-related concussion assessments within 6 h of injury, 24–48 h, when they initiated their return to play progression, when they were cleared for unrestricted return to play, and 6 months post-injury. Assessments included the Standardized Assessment of Concussion, Balance Error Scoring System, Brief Symptom Inventory-18, Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), Sport Concussion Assessment Tool-3 symptom evaluation, Clinical Reaction Time, King–Devick test, Vestibular Ocular Motor Screen, 12-item Short-Form Health Survey, Hospital Anxiety and Depression Scale, and Satisfaction with Life Scale. Results Only the Vestibular Ocular Motor Screen Total Symptom Score at the 24–48 h timepoint (p = 0.005) was statistically significantly different between sexes. Specifically, female athletes (mean = 60.2, 95% confidence interval [CI] 51.5–70.4) had higher Vestibular Ocular Motor Screen Total Symptom Scores than male athletes (mean = 36.9, 95% CI 27.6–49.3), but this difference resolved by the time of return-to-play initiation (female athletes, mean = 1.8, 95% CI 1.1–2.9; male athletes, mean = 4.1, 95% CI 1.5–10.9). Conclusions Sport-related concussion recovery trajectories for most assessments were similar for female and male National Collegiate Athletic Association athletes except for Vestibular Ocular Motor Screen symptoms within 48 h of sport-related concussion, which was greater in female athletes. Female athletes had a greater symptom burden across all timepoints, suggesting that cross-sectional observations may indicate sex differences despite similar recovery trajectories.

Assessing parent readiness to support their child's post-concussion management requires valid and reliable measures. Therefore, the objective of this study was to develop and conduct preliminary tests of reliability and validity of survey measures of parent concussion management knowledge and self-efficacy. Additionally, we tested the hypothesis that among parents of youth who had sustained a concussion, higher scores on measures of knowledge and self-efficacy would predict greater likelihood of engaging in recommended concussion management behaviors during their child's recovery. Measure development occurred with reference to parenting behaviors included in the Center for Disease Control and Prevention's Pediatric Mild Traumatic Brain Injury (mTBI) Management Guidelines. A multi-stage mixed- methods approach was employed, including expert review, cognitive interviews with parents, quantitative item reduction, and tests of reliability and validity. All participants were English-speaking parents of school-aged children in the United States. A stepwise measure development process was followed, with different participant groups across steps (including opt-in web-based survey panels and in-person recruitment from the population of parents of pediatric patients seen in a large pediatric emergency department). In total, 774 parents participated in study activities. The final knowledge index had 10 items, and the final self-efficacy scale had 13 items across four subscales (emotional support, rehabilitation support, monitoring, and external engagement). Internal consistency reliability was 0.63 for the knowledge index and 0.79–0.91 for self-efficacy sub-scales, and validation tests were in the hypothesized directions. In a test of predictive validity, we observed that among parents of youth patients with recent concussion, higher self-efficacy scores at the time of discharge from the pediatric emergency department were positively correlated ( r = 0.12) with greater likelihood of engaging in recommended support behaviors at 2-week follow-up. There was no association between concussion management knowledge at discharge and parenting behaviors at follow-up. Parents have the potential to play an important role in concussion management. The measures of knowledge and self-efficacy developed in this study can help identify parent needs and evaluate interventions aiming to support parenting post-concussion.

Background: Approximately half of concussions go undisclosed and therefore undiagnosed. Among diagnosed concussions, 51% to 64% receive delayed medical care. Understanding the influence of undiagnosed concussions and delayed medical care would inform medical and education practices. Purpose: To compare postconcussion longitudinal clinical outcomes among (1) individuals with no concussion history, all previous concussions diagnosed, and ≥1 previous concussion undiagnosed, as well as (2) those who have delayed versus immediate symptom onset, symptom reporting, and removal from activity after concussion. Study Design: Cohort study; Level of evidence, 2. Methods: Participants included 2758 military academy cadets and intercollegiate athletes diagnosed with concussion in the CARE Consortium. We determined (1) each participant’s previous concussion diagnosis status self-reported at baseline (no history, all diagnosed, ≥1 undiagnosed) and (2) whether the participant had delayed or immediate symptom onset, symptom reporting, and removal from activity. We compared symptom severities, cognition, balance, and recovery duration at baseline, 24 to 48 hours, date of asymptomatic status, and date of unrestricted return to activity using tests of parallel profiles. Results: The ≥1 undiagnosed concussion group had higher baseline symptom burdens ( P < .001) than the other 2 groups and poorer baseline verbal memory performance ( P = .001) than the all diagnosed group; however, they became asymptomatic and returned to activity sooner than those with no history. Cadets/athletes who delayed symptom reporting had higher symptom burdens 24 to 48 hours after injury (mean ± SE; delayed, 28.8 ± 0.8; immediate, 20.6 ± 0.7), took a median difference of 2 days longer to become asymptomatic, and took 3 days longer to return to activity than those who had immediate symptom reporting. For every 30 minutes of continued participation after injury, days to asymptomatic status increased 8.1% (95% CI, 0.3%-16.4%). Conclusion: Clinicians should expect that cadets/athletes who delay reporting concussion symptoms will have acutely higher symptom burdens and take 2 days longer to become asymptomatic. Educational messaging should emphasize the clinical benefits of seeking immediate care for concussion-like symptoms.

Objectives Determine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes. Methods A cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9–14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season. Results Of 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen’s d=0.35). Conclusions and relevance Pre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting. Trial registration number NCT04099329.

Athletics is the leading cause of pediatric concussion, and depression is a major comorbidity associated with concussion in the pediatric population. Prior studies have described the risk of depression after concussion in high school-, collegiate-, and elite-level athletes, but there is scarce data on younger athletes. Interpretation of existing research on the association of depression with concussions in youth athletes is complicated by diverse study designs, varying measures of depression, differing timelines for symptom development, and a lack of control groups. Furthermore, limited research exists on sex-related differences in the development of depressive symptoms following sports-related concussions (SRC) in younger athletes. This study used the Seattle Pediatric Concussion Research Collaborative (SPCRC) Data Repository to compare depressive symptoms between youth athletes at one month post-SRC and non-concussed age-matched controls by using a standardized measure of depressive symptoms: the Patient Health Questionnaire-9 (PHQ-9). The secondary goal was to compare PHQ-9 scores between males and females for both concussed and non-concussed groups. This study entailed a secondary analysis of data collected as part of the SPCRC Data Repository. We conducted a retrospective subgroup analysis of PHQ-9 scores at one month post-concussion for concussed youth athletes. We compared the PHQ9 scores of concussed youth athletes with PHQ-9 scores collected at the time of enrollment for non-concussed youth athletes. After random age-matching, a cohort of 266 patients (133 in the concussed group and 133 in the non-concussed control group) was included in the final analysis. The mean age was 13.8 years (range: 5-18 years). For the concussed group, a history of SRC was associated with a higher mean total PHQ-9 score at one month post-concussion compared with the control group at the time of enrollment (6.14 ±5.46 versus 1.53 ±1.81, respectively, p<0.0001). All nine subdomains of the PHQ-9 showed significantly higher scores in the concussion group compared with the control group (p<0.0001). Significantly higher scores were observed when comparing mean total PHQ-9 scores for male athletes in the concussion group with male athletes in the control group (7.03 ±5.72 versus 1.59 ±1.66, p<0.0001) and for female athletes in the concussion group compared with female controls (5.28 ±5.10 versus 1.49 ±1.92, p<0.0001). No significant differences were observed between sexes for total PHQ-9 scores or PHQ-9 subscores. At one month post concussion, youth with SRC demonstrated higher levels of depressive symptoms as measured by PHQ-9 compared with age-matched typically developing controls. No significant differences were identified in total PHQ-9 scores and subscores between male and female participants for either the concussion or control group. This study suggests that clinicians need to be vigilant and monitor for symptoms of depression in young athletes for at least one month post-concussion.