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Association of concussion with high school academic standing: sex, school grade and race as stratifiers
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  1. Julian Takagi-Stewart1,
  2. Qian Qiu1,2,
  3. Brianna Mills1,3,
  4. Aspen D Avery1,4,
  5. Amy Muma1,4,
  6. Monica S Vavilala1,2,4,5
  1. 1 Harborview Injury Prevention & Research Center, Seattle, Washington, USA
  2. 2 Pediatrics, University of Washington, Seattle, Washington, USA
  3. 3 Epidemiology, University of Washington, Seattle, Washington, USA
  4. 4 Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
  5. 5 Neurological Surgery and Radiology, University of Washington, Seattle, Washington, USA
  1. Correspondence to Julian Takagi-Stewart, Harborview Injury Prevention & Research Center, Seattle, WA 98104, USA; juliantakagistewart{at}live.jp

Abstract

Introduction The purpose was to examine the association between concussion history and academic standing among high school students, and whether the association varies by sex, school grade and race/ethnicity.

Methods Data from the 2019 Youth Risk Behaviour Survey were used for our cross-sectional study. Exposure was self-reported history of concussions in the past 12 months. Outcome was self-reported academic standing in the past 12 months. Poisson regression was used to analyse the exposure–outcome association, and whether there were differences by our stratifying variables.

Results Having a history of concussion in the past 12 months was significantly associated with a higher risk of poor academic standing during the same period, and the association varied by race/ethnicity.

Discussion Youth with a history of concussion may be at risk for poorer academic standing, indicating to the importance of prevention. Future studies are needed to examine the interaction of race/ethnicity on the presented association.

  • concussion
  • school
  • health disparities

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Youth concussions can result in lasting physical, cognitive and emotional changes.

  • Demographic variables such as sex, age and race/ethnicity have been implied to be associated with various concussion outcomes.

WHAT THIS STUDY ADDS

  • The study contributes to the still inconclusive body of literature that examines the impact of concussions on academic performance by reporting an association between concussions and poor academic standing and a disparity of this association across racial/ethnic groups.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • The study inspires future investigations to explore explanations for the association of interest varying among different races and ethnicities.

Introduction

Approximately 1.1–1.9 million youth concussions occur annually in the USA.1 2 Youth can experience lasting physical, cognitive and emotional changes after concussion.3 4 These symptomatic changes may be attributed to neurochemical and metabolic changes in the brain which can worsen with increased cognitive demands, necessitating appropriate recovery before returning to normal activities.3 All 50 states have adopted return-to-play legislation mandating gradual return to normal levels of athletic participation.5 While the national Individuals With Disabilities Education Act mandates an assessment of the student with traumatic brain injuries by at least one school staff, by 2017, only 12 states had adopted return-to-learn legislation that requires school to implement protocols to reintegrate students with concussion into academic work.6 Lack of clear and standardised guidance across the nation leaves students without appropriate responses to mitigate adverse academic impacts of concussion.7 8

A recent scoping review found the association between student concussions and grades to be inconclusive.9 One prospective cohort study found that there was no significant change in grades between preconcussion and postconcussion.10 However, a study that used data from the 2017 Youth Risk Behaviour Survey (YRBS) found that self-reported grades were significantly lower among students with a history of one or more concussions in the past 12 months.11

The impact of concussion on academic standing may vary by school grade, sex and race/ethnicity. Impairments in grades among youth rugby player only manifest in the 12th grade compared with students playing non-contact sports.12 Female youth report more severe and numerous symptoms compared with males following a concussion.13 Lastly, individuals of Hispanic and African American race/ethnicities were reported to predict shorter return-to-play timelines.14 However, sex, school grade and race/ethnicity differences in postconcussion grades still warrants further investigation.

This study used a cross-sectional design to examine whether having a concussion is associated with academic standing, and whether the association varies by sex, school grade and race/ethnicity.

Methods

Study cohort

Data were extracted from the 2019 national YRBS, which monitors health risks among students across the USA. The 2019 survey was administered to a nationally representative sample of youth in public and private high schools, excluding schools in the states of Washington, Oregon, Wyoming and Minnesota.15 Students who (1) were not enrolled in grades 9 –12 and (2) did not report concussion history or academic grades on their survey were excluded.

Measures

The exposure variable was concussion history in the past 12 months and based on the question ‘During the past 12 months, how many times did you have a concussion from playing a sport or being physically active?’ Concussion history was examined in two ways: (1) binary (any concussion vs no concussion in past 12 months) and (2) categorical (0, 1 or 2+ concussions).

Outcome variable was academic standing and was based on the question ‘During the past 12 months, how would you describe your grades in school?’ The outcome was dichotomised as poor academic standing (1=mostly C’s, D’s, E’s or F’s) and good academic standing (0=mostly A’s or B’s).

Our three stratification variables were self-reported sex, school grade and race/ethnicity. Sex and school grade was inquired with the questions ‘What is your sex’ and ‘In what grade are you?’, respectively. Race and ethnicity were asked with two questions: ‘Are you Hispanic or Latino?’ and ‘What is your race?’. The seven possible race/ethnicity categories (American Indian or Alaska Native, Asian, black or African American, Hispanic/Latino, Native Hawaiian or Other Pacific Islander, white and multiple races) were aggregated into four stratifications (black or African American, Hispanic/Latino, white and other).

Statistical analyses

Student variables were first stratified by categorical concussion history. Data are presented as counts and weighted percentages that excludes counts of missing reports for categorical variables. Poisson regression was used to examine the association between concussion history and academic standing. Stratified Poisson regression was used to examine whether the association between concussion history and academic standing varies by the stratifying variables. Statistical significance of stratification was assessed by the Wald test for the interaction term between our exposure and each potential stratifier. Stata MP V.15 (Stata) was used for all analyses.

Results

A total of 10 756 of the 13 677 records constituted our study cohort. Distribution of participant characteristics described across concussion history is in table 1. Of the 10 756 adolescents, 14.9% (n=1601) reported having sustained at least one concussion in the preceding 12 months. Most adolescents who reported zero concussions were female (50.9%), while most who reported one or 2+ concussions were male (53.1% and 63.5%, respectively). Students who self-identified as black or African American represented a higher proportion of students with 2+ concussions (15.6%) compared with students with zero or one concussions (10.6% and 9.4%, respectively). A large majority of adolescents (78.8%) reported to be in good academic standing.

Table 1

Distribution of participant characteristics described across categorical concussion history

Relative risks from Poisson regression models are in table 2. Having at least one concussion within the past 12 months was significantly associated with higher risk of poor academic standing (RR 1.25; 95% CI 1.10 to 1.42). The association between a history of a single concussion in the past 12 months and poor academic standing was not significant (RR 1.11; 95% CI 0.95 to 1.29), but a history of two or more concussions was associated with higher risk of poor academic standing (RR 1.50; 95% CI 1.26 to 1.78).

Table 2

Association of academic standing and concussion history

Stratified Poisson regression results stratified by sex, school grade and race/ethnicity are in table 3. We did not find evidence that the association between concussion history and academic standing differed by sex or school grade. However, the association varied by race/ethnicity (Wald F=2.91; p=0.02). Students who are white with a history of 2+ concussions, and students of other races/ethnicities with a history of one concussion, were more likely to report poor academic standing compared with students with no concussion history (RR 2.08; 95% CI 1.67 to 2.57, RR 1.62; 95% CI 1.04 to 2.54, respectively). No statistically significant associations were found among students who are black or African American and Hispanic/Latino.

Table 3

Relationship between academic standing and concussion, by race/ethnicity, school grade and sex

Discussion

Approximately one in seven high school students reported to have at least one sports and activity related concussion in the past 12 months. Having a history of concussion in the past 12 months was associated with poor academic standing during the same period, and this association was stronger with a history of repeated concussions. These findings are generally consistent with prior literature using YRBS data from 2017, but also presents new findings.11 Most notably, this study found that racial and ethnic stratification presents disparate association of concussion history and academic standing among a nationally representative sample. This study further supplements the literature by presenting findings indicating that school grades did not present a significant difference to the association.

Compared with no concussion history, history of concussion(s) in the previous 12 months was associated with poor academic standing only among students who are white or of Other race/ethnicities. A myriad of explanations can be invoked to describe this finding, suggesting the need for caution in interpretation. First, there could be bias in the self-reported outcome measure.16 17 While self-reported grades have been reported to be highly correlated with their actual grades, in context of the reports of suggesting disparities in knowledge and recognition of concussions between African American and white parent/guardians,18 students with different racial/ethnic backgrounds may be estimating the impacts of a concussion on grades differently. Further, the finding may also be an issue of sample sizes across racial/ethnic groups. Future studies exploring the impact of concussion on academic standing across racial and ethnic stratifications are needed to understand and reduce this disparity of school outcomes.

There are study limitations. First, the survey structure prevented the ability to assess the change in academic standing before and after the reported concussions. Second, findings may not reflect current student experiences as data were collected prior to the onset of the COVID-19 pandemic in the USA. Third, the study was not able to incorporate socioeconomic variables such as family income and location of residence due to confidentiality of the dataset, which limited the ability to investigate further mechanisms of the association between history of concussion and academic standing. Lastly, both the primary exposure and outcome was self-reported by youth and was not cross-examined for verification. Future studies assessing academic standing may benefit from using metrics obtained from more objective sources such as school records.

Conclusions

History of concussion was significantly associated with poor academic standing and experiencing multiple concussions could be particularly harmful on student outcomes. Future studies are needed to examine the involvement of race and ethnicity in the association between concussions and school outcomes. School-based injury prevention efforts, including promotion of helmet use, school screening for concussions and adherence to return-to-play and return-to-learn guidelines, to reduce multiple concussion in sports, particularly for racial and ethnic groups most affected, may prove beneficial to students with concussion.

Ethics statements

Patient consent for publication

Ethics approval

The study is considered non-human subjects research by the University of Washington Institutional Review Board.

References

Footnotes

  • Contributors JT-S wrote the analysis plan and drafted and revised the paper. JT-S is the guarantor. QQ obtained data, supported the analysis plan, cleaned and analysed the data and drafted and revised the paper. BM supported the analysis plan, analysed the data and drafted and revised the paper. ADA analysed the data, and drafted and revised the paper. AM initiated the project, supported the analysis plan and revised the paper. MSV initiated the project, supported the analysis plan and revised the paper.

  • Funding This work was funded by the Centers for Disease Control and Prevention (Grant number: R49CE003087-03 (Vavilala PI))

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.