Social Policy

Department of Social Policy

Faculty Adviser: Prof. Diane Schanzenbach, Ph.D.

Opinions in Flux:

An Exploration of the Perceptions of Concussions in Youth Sports

by Andrew Wayne

Introduction In 2015, it was estimated that over 1.23 million youth ages 6 to 12 regularly participated in tackle football in the United States.1 A dangerous narrative emerges,given that the annual concussion rates among football players ages 5 to 14 are just above 5%.2 Thus, youth football has become a breeding ground for head trauma. While many see football as a particularly contact-intensive and violent sport, concussion-related issues are not limited to football. Indeed, there are many sports played by myriad youth that involve the head as a point of contact, such as rugby, soccer, mixed martial arts, and baseball. Recent statistics indicate that in youth football roughly 3–5% of players per season suffer a concussion — the rates are virtually identical in other sports, such as soccer, hockey, lacrosse, and flag football.3 In the U.S. alone approximately 1.6 million to 3.8 million sports-related concussions occur each year across all age groups.4 Sports and recreational activities comprise a significant portion of annual concussions; at the high school level alone, organized sports are responsible for over 62,000 concussions annually.5

The proliferation and rampant nature of concussions in youth sporting leagues show that this injury is an issue that reaches far beyond football and professional leagues. The abundance and increasing evidence of risk and both short- and long-term health consequences seen in youth sports raises questions about the decision-making processes that go into enrolling a child in youth sports. The present study asks:

1 Farrey, T. (2016, April 17). Youth football participation increases in 2015; teen involvement down, data shows. Retrieved from http://www.espn.com/espn/otl/story/_/id/15210245/slight-one-year-increase-number-youth-playing-football-data-shows 2 Kurs, L. (2018, December 13). New Findings on Concussion in Football’s Youngest Players. Retrieved from https://pulse.seattlechildrens.org/new-findings-on-concussion-in-footballs-youngest-players/ 3 LaBella, C. (2019, April 01). Youth Tackle Football: Perception and Reality. Retrieved from https://pediatrics.aappublications. org/content/early/2019/03/28/peds.2019-0519 4 Sandel, Natalie & Henry, Luke & French, Jonathan & Lovell, Mark. (2014). Parent Perceptions of Their Adolescent Athlete’s Concussion: A Preliminary Retrospective Study. Applied neuropsychology. Child. 4. 1-6. 10.1080/21622965.2013.850692. 5 Guilmette TJ, Malia LA, McQuiggan MD. Concussion understanding and management among New England high school football coaches. Brain Inj. 2007;21(10):1039-1047.

The proliferation and rampant nature of concussions in youth sporting leagues show that this injury is an issue that reaches far beyond football and professional leagues.

(1) How has the emergence and proliferation of popular arenas for youth sports shaped instances of and narratives surrounding head trauma? (2) How do parents frame and understand their child’s involvement in a sport that could potentially result in head trauma? (3) How and to what extent do parents process and operationalize the medical knowledge and messaging from the healthcare industry?

Methods Data was collected using an online survey of parents of children who participate in youth sports (see Appendix). These parents were chosen to be survey takers because of their proximity to the issues investigated and their authority over their child’s activities. The survey captured the depth and breadth of parents’ perspectives regarding their child’s involvement in a sport. It also allowed for textual answers that enabled the research team to avoid limiting participants’ responses to a set of predetermined answers. The survey covered topics such as the parent’s beliefs about concussions generally, the risk associated with their child’s sport, whether the sport is safe or can be made safe, the safety of different sports, and how they are or are not using medical data released by the healthcare industry. The survey also asked about their child’s specific concussion treatment and recovery and their plans for sending their child back into the sport when applicable.

The research team collected 115 surveys to better understand the decisionmaking process associated with youth participation in sports. To identify and recruit potential participants, the research team sent surveys to select patient and employee populations at Lurie Children’s Hospital (LCH), a large academic, freestanding pediatric hospital in Chicago,

T Figure 1. Sports represented in survey.

S Figure 2. Concussion occurrence among respondents’ children.

Illinois. The research team also contacted various Chicagoland and national sporting leagues that have connections to LCH for assistance with disseminating the survey to relevant populations.

Results

Participants

We collected 115 surveys. Of the 115 surveys, 59 respondents identified as female and 56 respondents identified as male. Seventy of the 115 respondents indicated that they have one child, 27 indicated that they have two children, 13 indicated that they have three children, four indicated that they have four children, and one indicated that they have six children. The 115 surveys captured 186 children in total with an average age of approximately 11.8 years. The youngest and oldest children represented by this survey were 5 and 29. The survey included 18 sports: baseball, tee-ball, softball, football, hockey, field hockey, soccer, track & field, volleyball, basketball, tennis, golf, swimming, wrestling, competitive cheerleading, lacrosse, dance, and figure skating (Figure 1).

Analysis

When asked about concussion history, 29 respondents indicated that their child had suffered a diagnosed concussion as a direct result of a sport that they played, and 86 respondents answered that their child had not suffered a concussion as a result of playing organized sports (Figure 2).

Thus, approximately one-quarter (25.22%) of all respondents captured by the survey have a child that suffered a diagnosed concussion as a result of participating in organized sports. Out of the 29 participants who have a child with a history of concussion, 20 answered that the concussion occurred within the past 12 months. Hence, roughly 17.39% of respondents’ children suffered a concussion within the last season of play. This rate of concussion per season was far higher than estimates from the medical industry. Recent statistics indicate that in youth football and many other youth sports, roughly 3–5% of players per season suffer a concussion.6 The rate of concussions uncovered from the study is particularly worrisome as many concussions go unreported. Experts at the University of Pittsburgh Medical Center argue that 50% of all concussions go

S Figure 3. Mechanism of concussion occurrence among respondents’ children.

undetected and thus unreported.7 Concussion rates appear to be much higher in the contemporary world compared to figures distributed by the medical industry.

Respondents with a child who suffered a diagnosed concussion as a result of participating in organized sports were asked in the survey about the mechanism of injury (Figure 3). Nine respondents indicated that the concussion was the result of a collision during a game. Five indicated the concussion was due to a collision during practice. Four indicated that the concussion was caused by a fall during a game. Another four indicated that the concussion was due to the subject being struck by an object during practice. Three indicated that the concussion was the result of a fall during practice. Three others indicated that the concussion was due to the subject being struck by an object during a game. Lastly, one concussion was labeled as “other.”

Overall, 17 concussions occurred in a game setting, while 12 occurred during a practice for the sport. When comparing statistics on practice and concussion rates from the survey, an increase in practices per week appears to be positively correlated with the occurrence of concussions. For respondents with a child who suffered a diagnosed concussion as a result of participating in organized sports, the child who suffered the concussion went to, on average, 3.69 practices per week. Children who did not suffer a concussion went to approximately 2.80 practices per week. The p-value between the two practice groups was less than 0.0001, confirming the difference in responses between groups is statistically significant. Playing any organized sport carries risk of concussion. However, leagues with multiple practices per week may act as a mechanism enabling additional concussions and driving up the rate of concussions in youth sports. This finding has also been shown in other studies. According to the American Academy of Pediatrics, 62% of sportsrelated child injuries occur during practice.8 Given that concussions are more prevalent with higher numbers of practices per week and that 178 out of 186, or 95.69%, of respondents’ children attend at least one

7 UPMC Staff. (2019). Concussion Statistics and Facts | UPMC | Pittsburgh. Retrieved from https://www.upmc.com/services/ sports-medicine/services/concussion/facts-statistics 8 National SAFE KIDS Campaign, & American Academy of Pediatrics. (2019, April 17). Sports Injury Statistics. Retrieved from https://www.stanfordchildrens.org/en/topic/default?id=sports-injury-statistics-90-P02787

S Figure 4. Parents report which sport they believe has the highest concussion rate.

practice per week, incorporating additional practices has a clear risk in relation to concussion rates.

Despite the impacts that concussions may have later in life, parents in this study seemed unlikely to take extreme action when their child suffered a concussion. Respondents with a child who suffered a diagnosed concussion as a result of participating in organized sports were asked how their child’s concussion(s) has impacted their decision to let their child continue the sport. The question was answered with a numerical value between zero and 10, with zero representing no effect on continued participation in the sport, five representing some thought about discontinuing participation in the sport, and 10 representing a definitive decision to discontinue the sport. The average response from parents was 4.31, with a standard deviation of 2.12. That is, 95% of the data was centered between 0.07 and 8.55. Despite first-hand exposure to the symptoms and the potential long-term effects of concussions, no parent reported intending to remove their child from the sport in which they were injured. This finding may be explained by a subsequent question in the survey. Respondents were asked about the effect of their child’s wants and/or desires on the child’s selection of and/or participation in sports. This question was answered using a numerical scale between zero and 10, with zero representing no effect, and 10 representing the ultimate driving factor in the decision regarding sport participation. The average recorded response to this question was 8.07 with a standard deviation of 0.96. Thus, 95% of the data was between 6.15 and 9.99 and 99.7% of the data is in the upper half of the numerical scale used to answer the question. This highlights how influential children are in driving decisions regarding sport participation, potentially explaining why some parents may not make extreme decisions about their child’s participation in sports following a concussion.

Misconceptions about the risk of concussion in various sports exist among parents who have children actively participating in organized sports. In the survey, parents were asked what sport they believed has the highest concussion rate; 92 parents answered football, eight answered soccer, six answered hockey, three answered baseball, three answered basketball, and three answered “other” (Figure 4).

“An increase in practices per week appears to be positively correlated with the occurrence of concussions.”

Contemporary data indicate that ice hockey has the highest concussion rate, at 0.91 concussions per 1000 athlete-exposures for females and 0.41 concussions per 1000 athlete-exposures for males.9 These values of 0.91 and 0.41 are higher than the concussion rate for sports like football, which has a concussion rate of 0.37 per 1000 athlete-exposures. Thus, six out of 115 participants — or 5.21% of all participants — were able to identify the correct answer. Approximately 95% of participants answered the question incorrectly, showing how misconceptions regarding sport concussion rates have become entrenched in contemporary society. Misconceptions and incorrect narratives around youth sports can lead to increased injury rates and long-term health consequences.

Respondents were asked to rate the safety of their child’s primary sport compared to other youth sports in terms of concussions. This question was answered with a numerical value between zero and 10 with Zero representing that the primary sport the child plays is the safest option available, and 10 representing that the sport the child plays is the riskiest option available. Parents with a child who suffered a diagnosed concussion differed from other respondents in a multitude of ways. For example, parents of children who suffered a concussion recorded an average value of 5.82, while parents of children who did not suffer a concussion had an average value of 2.90 (Table 1). When a two-tailed test was applied to compare the means of the two groups, the p-value was less than 0.0001, confirming the difference in responses between groups is statistically significant. This indicates that parents of children who suffered a concussion perceive a higher risk of concussion from their child’s participation in a primary youth sport than parents of children who did not experience a concussion.

Another question asks about the effects of four factors on the parent’s decision involving their child’s/children’s participation in and/or selection of a sport. These four factors were popular media, social media, the child’s wants/desires, and the safety of the sport. These questions were answered with a numerical value between zero and 10, with zero representeing no effect and 10 representing an ultimate driving factor in the decision regarding sport participation. The responses to this question highlight a significant divide between parents who have a child who suffered a concussion and parents who do not (Table 1).

For the first factor, popular media (i.e., news, journals, online news), parents of children who suffered a concussion recorded an average response of 4.43, while parents of children who did not suffer a concussion recorded an average response of 1.86. A two-tailed test revealed a p-value less than 0.0001, showing the difference in responses between groups is statistically significant. Parents of children who suffered a concussion appear to place a higher value on the information obtained from

popular media when selecting a sport than parents of children who did not experience a concussion.

For the second factor, social media, parents of children who suffered a concussion recorded an average response of 4.85, while parents of children who did not suffer a concussion recorded an average response of 2.83. The p-value comparing the means of the two groups was less than 0.0001, confirming the gap in responses between groups is statistically significant. Parents of children who suffered a concussion appear to place a higher value on the information obtained from social media, in addition to popular media, when selecting a sport than parents of children who did not experience a concussion.

The third factor evaluated by parents was the effect of the child’s wants and desires on the sport selection process. Parents of children who suffered a concussion recorded an average response of 6.78, while parents of children who did not suffer a concussion recorded an average response of 8.38. When a two-tailed test was applied to compare the means of the two groups, the p-value was less than 0.0001, confirming the difference in responses between groups is statistically significant. Parents of children who suffered a concussion appear to value their child’s desires less in the sport selection process than parents of children who did not experience a concussion.

The last factor evaluated by parents was the effect of perceived safety on sport selection. Parents of children who suffered a concussion recorded an average response of 6.26, while parents of children who did not suffer a concussion recorded an average response of 4.07. A two-tailed test and a p-value of less than 0.0001 confirmed the difference in responses between groups is statistically significant. Parents of children who suffered a concussion appear to value the perceived safety of a sport more in the sport selection process than parents of children who did not experience a concussion. Overall, this survey shows that many differences exist in how a parent navigates the sport selection process when comparing parents of children who did not experi-

T Table 1. Parent evaluation of various factors related to sport safety compared by child’s concussion history.

Questions (Scale 0-10) Parents of children who suffered a concussion Parents of children who did not suffer a concussion Two-tailed t-test

Perceived safety of primary sport μ = 5.82 μ = 2.90 p < 0.0001

Effect of popular media on sport participation μ = 4.43 μ = 1.86 p < 0.0001

Effect of social media on sport participation

Effect of child’s desires on sport participation μ = 4.85

μ =6.78 μ = 2.83

μ = 8.38 p < 0.0001

p < 0.0001

Effect of perceived safety on sport selection μ = 6.26 μ =4.07 p < 0.0001

“Misconceptions and incorrect narratives around youth sports can lead to increased injury rates and long-term health consequences.”

ence a concussion and parents of children who did suffer a concussion.

An additional finding of this study is that there is a large difference between male and female parents in the way in which they select sports for their children. When asked about the impact of four different factors — popular media, social media, the child’s wants/desires, and the safety of the sport — males and females provided far different responses. These questions were answered with a numerical value between zero and 10, with zero represening no effect and 10 representing an ultimate driving factor in the decision regarding sport participation. The responses to this question highlight a significant divide between male and female parents (Table 2).

For the first factor, popular media, female respondents recorded an average response of 5.16, while males recorded an average response of 3.44. When a twotailed test was applied to compare the means of the two groups, the p-value was less than 0.0001, confirming the difference in responses between groups is statistically significant. This finding signifies that female respondents place a higher value on the information obtained from popular media when selecting a sport for their child than male respondents.

The second factor that parents were asked to evaluate was social media. When evaluating the effect of social media on the sport selection process, females recorded an average value of 4.71, while males recorded an average value of 1.56. The p-value between males and females for this question was less than 0.0001, confirming the difference in responses between groups is statistically significant. This finding suggests that male survey respondents rarely use information from social media to aid in selecting a sport for their child, while female survey respondents rely on it to some extent. Interestingly, despite the widespread use of social media today, popular media still has a greater impact on the decision-making of parents regarding sports selection for their children.

The third factor in this question is the effect of the child’s wants and desires. Female parents recorded an average value of 8.05, while male parents recorded an average value of 7.81. For both males and females, the child’s wants and desires seem to be a driving factor in the sports selection process, and the average response for this question is the highest numerically, for both males and females, of the four factors.

Lastly, the fourth factor gauges the effect of the perceived safety of the sport. For female respondents, the average value was 6.06, while males recorded an average value of 3.92. The p-value between males and females for this question was less than 0.0001, confirming the difference in responses between groups is statistically significant. When parents select a sport for their child, it seems that female respondents value the perceived safety of the sport more than their male counterparts.

Effect of popular media on sport participation

Effect of social media on sport participation

Effect of child’s desires on sport participation μ = 3.44

μ = 1.56

μ = 7.81 μ = 5.16

μ = 4.71

μ = 8.05 p < 0.0001

p < 0.0001

p = 0.4862

Perceived safety of primary sport μ =3.92 μ = 6.06 p < 0.0001

S Table 2. Parent evaluation of various factors related to sport safety compared by parent gender. Discussion This study of parents of children in youth sports has highlighted new information about how parents perceive sport safety, what information parents use to make decisions about their child’s participation in youth sports, and how these factors differ by the parent’s gender. Specifically, the results of the survey outline many key findings about the perception of concussions in contemporary youth sports. When divided into different groups and compared against one another, parents seemed to hold vastly different ideas regarding concussions and sport selection. When compared by their gender or the concussion history of their children, parents displayed statistically significant differences in factors, such as social/popular media influence when deciding a sport, perception of the safety of different sports, and how much their child’s wants and desires affect the sport selection process. This study also shows an alarming disconnect between concussion rate estimates from the medical industry and real-world rates. Recent statistics indicate that in many youth sports approximately 3–5% of players per season suffer a concussion.10 The survey population reflected a much higher rate with 17.39% of respondents reporting a child who suffered a concussion within the last season of play. This study also demonstrated a correlation between increased numbers of practices per week and concussion occurrences. Finally, the survey showed that many parents are not aware of the concussion rates across various youth sports. While the results are promising, the study has limitations. Concussions and parent perceptions are global issues, and this study was only able to capture under 200 children in the Chicagoland area. The survey data may also not be more representative of a larger population because the sample was partially recruited through the connections between LCH and sporting leagues and is, therefore, not truly random. Additionally, parent opinion is a fluid variable that can change substantially at any given moment. These surveys only captured parents’ opinions at one point in time. However, the greatest limitation of

“This study also shows an alarming disconnect between concussion rate estimates from the medical industry and real-world rates.”

this study is the sample collection procedure. Due to the study method employed, the team was unable to capture information about parents who removed their children from sports due to concussions. As the team only surveyed parents who have a child who actively participates in sports, parents who removed their children from sports due to concussion could not be assessed. Furthermore, children drop out of sports for a multitude of other reasons, such as their performance in the sport, their lack of desire to continue, or costs associated with the sport. This study was unable to capture these parents who no longer have children participating in sports. Finally, the high rate of concussions found in this study may reflect selection bias. It is possible that parents of children with recent concussions were more inclined to complete the survey.

Conclusion There is still much to learn regarding traumatic brain injuries and associated conditions, such as chronic traumatic encephalopathy. In addition, concussions are difficult to diagnose, as many of the symptoms can be invisible or connect to a plethora of other illnesses.11 Compounding the issue further is the fact that an objective test to diagnose concussions does not exist. Instead, medical professionals must rely on symptoms and patient history to make the diagnosis.12 The lack of general knowledge on concussions leads to misinformation and false narratives. These misconceptions and incorrect narratives regarding youth sports can lead to increased injury rates and long-term health consequences.

Further research regarding education and evaluation could reduce these misconceptions. Providing parents with contemporary statistics regarding concussion rates and examining how misconceptions persist could allow for more information on how parents of athletes digest information and select and/or avoid various sports. Further research could also examine how concussion rates are impacted by additional training and knowledge on concussion symptoms and recognition among coaches and parents. Lastly, additional research could estimate the effects of concussion-related legislation and how adherence to current legislation affects youth sport participation and concussion rates. Regardless of the exact approach used, it is clear that additional reliable information is needed in order for parents to make the most informed decisions regarding participation in youth sports and associated concussion risk. ■

11 American Association of Neurological Surgeons. (2019). Sports-related Head Injury. Retrieved from https://www.aans.org/ Patients/Neurosurgical-Conditions-and-Treatments/Sports-related-Head-Injury 12 Choe, M. C., MD, & Giza, C. C., MD. (2015). Diagnosis and Management of Acute Concussion. Seminars in Neurology, 35(1), 29-41. Retrieved from https://www.medscape.com/viewarticle/840665_4.

Appendix

Data Collection Instrument

IRB 2019-3043 - Parental Opinion on Concussions in Youth Sports

PI: Dr. Cynthia LaBella Research Coordinators/Primary Contacts: 1. Andrew Wayne, Orthopaedics, andrewwayne2020@u.northwestern.edu 2. Sina Malekian, Department of Surgery, smalekian@luriechildrens.org 3. Carly Strohbach, Department of Surgery, cstrohbach@luriechildrens.org 4. Jamie Burgess, Department of Surgery, jburgess@luriechildrens.org 5. Gina Johnson, Department of Surgery, ginajohnson2020@u.northwestern.edu

Survey Questions to be Asked

1. Please indicate your preferred gender identity a. Answered via a textbox that the participant will fill 2. How many children do you have? a. Answered via multiple choice selections: i. 1 ii. 2 iii. 3 iv. 4 v. 5 or more 3. Please list the age (s) of your child/children. What was the purpose of this training? What did it focus on? a. Answered via a textbox that the participant will fill 4. What sport (s) do/does your child/children play? (Please select more than one if applicable.) a. Answered via multiple choice selections: i. Basketball ii. Baseball/tee-ball/softball iii. Football iv. Soccer v. Volleyball vi. Track & field vii. Hockey/field hockey viii. Tennis ix. Golf x. Other (please list) 5. Please identify the primary sport your child/children plays. (For “primary sport” please identify the sport that your child/you put the most effort or time into.) a. Answered via multiple choice selections: i. Basketball ii. Baseball/tee-ball/softball iii. Football iv. Soccer v. Volleyball vi. Track & field vii. Hockey/field hockey viii. Tennis ix. Golf x. Other (please list) 6. How long has your child/children played in their primary sport? Please list the number of years or months a. Answered via multiple choice selections: i. 0-3 Months ii. 3-6 Months iii. 6-9 months iv. 9-12 Months v. 1-3 Years vi. 3-5 Years vii. 5-7 Years viii. 7+ Years 7. Identify the closest match to your child’s future expectations in their primary sport a. Answered via multiple choice selections: i. Playing for exercise ii. Playing for recreational purposes

iii. Playing to make social connections iv. Aiming to play/currently playing at a high school level v. Aiming to play at the university level vi. Aiming to play professionally 8. Has your child/have any of your children suffered a concussion, that was diagnosed by a medical professional, as a result of the sport (s) they play? A concussion is defined as: an injury to the brain or spinal cord due to jarring from a blow, fall, or other impact that results in a temporary impairment of brain function. a. Answered via multiple choice selections: i. Yes ii. No 9. What was the treatment plan prescribed for the head injury/injuries suffered? (Medication, time out of the sport/school, etc.)

Please describe the treatment plans for each head injury suffered a. Answered via a textbox that the participant will fill 10. How long ago did the head injury occur? (If multiple head injuries occurred, please select the most recent head injury.) a. Answered via multiple choice selections: i. In the last 3 months ii. 3-6 months ago iii. 6-12 months ago iv. 1-2 years ago v. 2+ years ago 11. How long did your child experience symptoms following the head injury? a. Answered via multiple choice selections: i. 1-7 days post injury ii. 7-14 days post injury iii. 2-6 weeks post injury iv. 6-12 weeks post injury v. 12+ weeks post injury 12. What specifically caused the head injury? a. Answered via multiple choice selections: i. A fall in game ii. A fall in game iii. A collision in practice iv. A collision in game v. Being struck by an object in game vi. Being struck by an object in practice vii. Other (please list) 13. How have your child’s injury/injuries impacted your child’s participation in their primary sport? a. Answered on a sliding scale from 0 to 4 with the labels: i. 0: No change in participation in the sport ii. 1: Slight decrease in participation in the sport iii. 2: Moderate decrease in participation in the sport iv. 3: Significant decrease in participation in the sport v. 100: Discontinued participation in the sport 14. How have your child’s injury/injuries impacted your decision to let your child participate in their primary sport? a. Answered on a sliding scale from 0 to 10 with the labels: i. 0 - No effect on continued participation in the sport ii. 5 - Some thought about discontinuing participation in the sport iii. 10 - definitive decision on discontinuing the sport 15. Do you believe the primary sport your child plays is safe for youth? a. Answered via multiple choice selections: i. Yes ii. No 16. What changes could make the primary sport your child plays safer in terms of head trauma? (You may select more than one option.) a. Answered via multiple choice selections: i. Rule Changes (i.e. removing elements of contact) ii. Additional training for coaches/supervisors iii. Presence of an athletic trainer at each game/practice iv. Redesign of equipment v. Redesign of concussion screening equipment vi. Better coaching of proper techniques vii. Safer actions conducted by the players viii. Other (Please List) 17. What factor, in your eyes, is the biggest roadblock to implementing changes to improve the safety in the primary sport your child plays? a. Answered via multiple choice selections: i. Cost ii. Difference of opinion from involved parties iii. Resistance to change from involved parties iv. Time

v. Lack of other resources vi. Difficulty enforcing changes vii. Other (please list) 18. For all the sports your child plays combined, how many practices do they attend per week? a. Answered via multiple choice selections: i. 0 Practices Per Week ii. 1 Practice Per Week iii. 2 Practices Per Week iv. 3 Practices Per Week v. 4 Practices Per Week vi. 5 Practices Per Week vii. 6 Practices Per Week viii. 7+ Practices Per Week 19. What specifically do you think contributes the most to head injury in the primary sport your child plays? a. Answered via multiple choice selections: i. Nature of the sport ii. How the game is played iii. How practices are run iv. Lack of supervision of coaches v. Lack of training/knowledge on head injury amongst players and coaches vi. Faulty equipment vii. Rules of the game viii. Other (Please List) 20. In comparison to other youth sports, how safe do you believe the primary sport your child plays is in terms of concussions? a. Answered on a sliding scale from 0 to 10 with the labels: i. 0- The primary sport my child plays is the SAFEST opinion available ii. 5- The primary sport my child plays is about average in terms of safety iii. 10 - The primary sport my child plays is the RISKIEST sport available to youth 21. How much of an effect have the following factors had on your decision involving your child’s/children’s participation and/or selection in sport? a. Answered via 2 sliding scales from 0-10: i. The first scale asks: please indicate the extent of the effect popular media (i.e. news, Facebook, Twitter) has had on your child’s selection and/or participation in sport ii. The second scale asks: Please indicate the extent of the effect social media (i.e. Facebook, Twitter) has had on your child selection and/or participation in sport iii. The third scale asks: please indicate the extent of the effect the desire/wants of your child/children has had on your child’s selection and/or participation in sport iv. Please indicate the extent of the effect the safety of the sport has had on your child’s selection and/or participation in sport b. The 2 scales have the labels: iii. 0 - My child’s participation and/or selection in sports was not impacted at all by this factor iv. 5 - My child’s participation and/or selection in sports was somewhat impacted by this factor v. 10 - My child’s participation and/or selection in sports was impacted greatly by this factor 22. Which sport (amongst youth) do you believe has the highest concussion rate? a. Answered via multiple choice selections: i. Basketball ii. Baseball/tee-ball/softball iii. Football iv. Soccer v. Volleyball vi. Track & field vii. Hockey/field hockey viii. Tennis ix. Golf x. Other (please list)

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