Sports-Related Concussion Among Physically Active Adolescents in the Southeastern United States: Effects on Mental Health During the Pandemic

Abstract

Sports-related concussions (SRC) pose risks to young people’s physical and mental health. During the COVID-19 pandemic, we studied linkages between youths’ SRC experiences and internalizing problems (depression, self-harm, and suicidality) among a representative sample in Southeastern state (n = 4,668 total, n = 547 reported SRC experience). Logistic regressions indicated significant associations between youths’ SRC experiences and depression (AOR = 1.32, p < .05), suicidality (e.g., attempted suicide AOR = 2.68, p < .001), and self-harm (AOR = 1.97, p < .001) while controlling for being bullied or teased, gender, age, race, and COVID-19’s mental health impact. Contrary to prior findings: (1) SRC associations with self-harm and suicide attempts were consistent across genders; and (2) African American students with SRC were significantly more likely to experience depression, self-harm, suicide planning, and attempts than peers without SRC. Results indicated mental health resilience post-concussion for Latinx youth. Implications advocate population-specific health promotion measures that address vulnerabilities and protective factors while emphasizing SRC education for parents, coaches, and young athletes for timely psychological evaluation and support.

Introduction

Rates of Sports-Related Concussion (SRC) Among Youth in the U.S.

Team sports contribute positively to young people’s mental health by providing opportunities to: develop positive social relationships; join a community of support; and achieve a sense of higher purpose [1]. However, the darker side to youths’ team sports participation is increased injury risk, particularly for sports-related concussion (SRC) that produces known physical, mental, and psychological impairment. In the U.S., more than 1 million (1.1–1.9 M) sports- and recreation-related concussions happen to youth aged 18 and under in the U.S. [6], with annual prevalence rates range from 6.5 to 18.3% of 13 to 17 year olds [12], and 1 in 5 adolescent athletes in competitive sports reporting SRC annually [40]. Increases in SRC prevalence reports among young athletes over the past several decades are due to heightened awareness of problematic outcomes [43].

Contexts Affecting Prevalence of SRC

Sports injuries are a primary cause of concussions among adolescents [40]. Male-dominated competitive U.S. sports such as North American football, with an injury rate of 1.04 per 1000 athlete exposures [17], present the highest risk for concussion [2, 25, 36, 40]. SRCs are more likely to occur in competition than practice and are associated with certain sport-specific plays (e.g., football tackles as the most frequent cause) [10]. Medical professionals surmise higher SRC rates for females in basketball and soccer may be attributed to sex differences in head size and neck muscle strength [13]. And, although there were fewer reported traumatic brain injuries among adolescents playing school sports during COVID-19, other pandemic-related school policies (e.g., screen-based learning) were deemed disruptive for the healing process of young traumatic brain-injured athletes [38].

Psychological Correlates of SRC in Youth

As negative physical health effects of SRC remain of special concern in sports medicine, psychological correlates of SRC have received recent attention [11]. Less is known about linkages between youths’ SRC and psychological outcomes, such as suicidal intentions [22] and self-harm, also known as non-suicidal self-injury (NSSI). The psychological aftermath of SRC, such as mood changes, anxiety, and depression, was mistakenly attributed to youth being removed from sports participation, the arduousness of physical recovery and rehabilitation, and uncertainty with transitioning back to play [11]. A study of collegiate athletes found distinctively different psychological outcomes with SRC versus musculoskeletal injuries; those with SRC reported greater fatigue and negative mood post-injury than athletes with bodily injury, who experienced more anger [14]. Moreover, medical professionals support that concussion aftermath for adolescents includes mental health, cognitive, and somatic effects [33]. SRC and internalizing problem associations (depression, suicidal thoughts, and attempts) among state- and national-level representative samples of high schoolers were supported in recent studies [22, 42, 43]. Due to the cross-sectional design of these studies, we know SRC with internalizing problems associations are significant, yet cannot estimate causality with SRC experience as a precedent for developing internalizing problems. On the flip side, Stewart et al. [35] found that concussions more commonly occur among youth with mental health and processing disorders.

Study Justification: SRC and Suicidality

While suicide falls among the ten leading causes of mortality in the U.S. for all age groups [28], it is the third leading cause of death among adolescents, accounting for 16.9% of deaths among 15- to 24-year-olds [29]. During the pandemic suicide moved to third place from the second leading cause of death among young people, being supplanted by homicide [29]. However, a growing body of evidence indicates increases in adolescents’ reported and treated mental health problems during the pandemic [5, 19]. State-based studies [42, 43] using data from the Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance System (YRBSS) have found significant associations between adolescents’ self-reported SRC experiences and negative health outcomes of: depression, suicidal ideation, and suicide attempts pre-pandemic. The authors expanded on these findings to assess SRC in association with self-harming behaviors as an additional internalizing problem, and most important, examined the influence of the pandemic on adolescents’ mental health.

Self-Harm and Youth Suicide

Recent findings support overlap between self-harm and suicidal ideation/behaviors for a portion of adolescents [9]. Further, the use of the term non-suicidal self-injury (NSSI) is rendered inaccurate, as recent longitudinal findings support that self-harming behaviors precede suicide attempts and completions among youth. A systematic review with meta-analysis identified 29 longitudinal studies exploring the association between self-injurious thoughts and behaviors (SITB) and suicidality among 12-to 26-year-olds, with four of five studies defining self-harm as non-suicidal. Moreover, prior self-injurious thoughts or behaviors were associated with increased odds of suicide attempt, specifically more than threefold (OR = 3.48) across a larger subset of 29 examined studies [8]. Additionally, a longitudinal cohort study of over 100,000 youth from age 0 to 17 revealed NSSI associated with higher risks for suicide and additional problematic outcomes, in terms of hazard ratios [30]. These varied findings support how self-harm may be a precursor to, but not a necessary condition for, suicidal behavior. In this study, self-harm is considered a form of suicide behavior.

Specific to sports, a recent study compared collegiate athletes and nonathletes on NSSI, suicidal ideation, and suicide attempts [1]. The prevalence of internalizing problems was significantly higher for non-athletes, with stress as a significant predictor. Additionally, NSSI rates were higher for White non-athletes than other racial groups whereas race was unassociated with student athletes’ propensity to engage in NSSI. Also, difficulty with social relationships was related to suicide attempts for both groups, with higher coefficients for athletes than non-athletes [1]. Although their sample included college, students and did not measure SRC experience as a correlate, findings point to key psychosocial predictors of young athletes’ self-harm and suicide attempts [1].

SRC and Youth Self-Harm

Limited research examines SRC in association with youths’ self-harm. Yang and colleagues (2019) examined Nevada’s 2017 YRBSS data, finding physically active high schoolers who had experienced concussion were over 1.5 times more likely to report self-harm than peers who did not report SRC in the past year. Their work lacked a conceptual definition of self-harm and examination of its relationship with suicidality (i.e., as a key indicator of internalizing behavior or a risk factor for suicide). The authors merely stated the SRC self-harm association was indicative of “mental health risks beyond depressive feelings” [43], p. 263). Here we provide further exploration of the association between adolescents’ self-harm and SRC experience as it compares with SRC and suicidality. We intend to explore the associations between SRC, noted covariates, and a spectrum of internalizing problems to add dimensionality to our understanding.

Guiding Framework

A diathesis-stress model is applicable to an adolescent’s SRC experience that offsets a chain of brain-based processes leading to youths’ difficulty regulating moods, experiencing depression, and espousing suicidal ideation [35, 42]. Akin to a downward spiral, a diathesis-stress explanation of the effects of SRC on an adolescent entails negative impacts on multiple systems, for example, poor sleep, reduced mental state, somatic complaints, and cognitive impairment [33]. The effects of the pandemic further exacerbated youth mental health problems in general [5, 19] and, specifically, for students with traumatic brain injuries [38]. In the diathesis-stress model, the alternative to maladaptation is resilience [15]. Resilience requires two conditions: (1) adversity/risk; and (2) adaptation/protection, manifesting as achievement of positive life outcomes [23]. In this study, we aspire to identify characteristics that increase (risk factors) and decrease (protective factors) students with SRC experience vulnerability to internalizing problems.

Purpose of Study

The study examines the relationship between high schoolers’ concussion experience (SRC) and depressive symptoms with suicidality and self-harm during the pandemic in the beginning of 2021, at a time when school sports had been reinstated across the U.S. [24]. Furthermore, we aim to assess the extent to which SRC emerges as a significant factor in association with internalizing problems, above and beyond the influence of the pandemic on teens’ mental health.

The research aims to replicate others’ findings on the SRC-internalizing problems associations [22, 42, 43], with representative state-based data collected during the pandemic (January through March 2021) in a Southeastern state. What is unique about our study is inclusion of (and controlling for) perceived effects of the pandemic on adolescents’ mental health and examination of self-harm behaviors as an additional form of suicidality. Moreover, we explored differences by gender [7], and the less explored race/ethnicity differences, particularly among minority groups, to compare with broad-based findings on the national level [22] and other regions of the U.S. (see [43]). Others have compared the strength of the association between SRC and internalizing problems among different groups of high school aged youth, e.g., sexual minority status [34] and bullying victimization experience [3] which prompted our efforts to include these as control variables. These findings have potential implications for understanding risk and resilience among specific groups of adolescents who have experienced concussion due to sport participation.

Methods

Binary logistic regression using SAS (V 9.4) was used to explore the relation between SRC, selected covariates, and internalizing problems. The sample division by age, gender, and race/ethnicity was a means to examine the potential for increased vulnerability or resilience to internalizing problems for students who had experienced SRC.

Sample

The sample was extracted from de-identified statewide data collected from high schools, provided by the Centers for Disease Control, the Florida Dept. of Health (FL-DOH), and the Florida Dept. of Education (FL-DOE) from the 2021 YRBSS. Our university’s Institutional Review Board (IRB) approved the authors’ use of the secondary dataset to conduct the research. A three-stage cluster sampling method was used by CDC, FL-DOH, and FL-DOE. Targeted sample size was increased in 2021 to address reduced response rates as expected to occur during the COVID-19 pandemic. State-level data collection involved primary sampling units (PSUs), which consisted of counties, with secondary sampling units (SSUs) comprising schools with grades 9 through 12 within those counties. In the third stage of sampling, 1–2 classrooms per grade were selected from required classes or periods (e.g., homeroom) and were randomly sampled [27] to receive a 99-question scannable booklet during one class period. Students within selected classrooms were randomly assigned to receive one of three questionnaires, including the YRBSS. The total statewide sample was 4672 for which data on self-reported SRC yielded a total n = 4436 high school youth.

Measures

Dependent Variables

The YRBSS survey includes multiple single-item measures of demographic information, and individual and contextual variables that predispose youth to problem behaviors. The YRBSS lacks multi-item validated measures as indicators of mental and physical health status. Instead, it serves as a screening tool to assess health challenges among high schoolers in a portion of participating U.S. states. Findings regarding the validity of single-item measures of well-being, depression, suicidality, and NSSI are mixed, with some studies reporting poor sensitivity [18, 26] whereas others find it acceptable [16]. Despite these limitations, single-item measures can be particularly useful for screening within generalized populations [37], similar to the sample evaluated in this study. Hence, four dummy-coded items measuring depression and suicidality indicated internalizing problems. The depression item stated: “During the past 12 months did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?” Suicidal ideation was measured by two items as reported over the past 12 months: 1. “…did you ever seriously consider attempting suicide?” and 2. “…did you make a plan about how you would attempt suicide?” Suicidal behavior over the past 12 months was measured by an ordinal item, “how many times did you actually attempt suicide?” This item was recoded with a value of 0 as no attempt and 1 = self-reporting one or more attempts. The self-harm item asked, “During the past 12 months, how many times did you do something to purposely hurt yourself without wanting to die, such as cutting or burning yourself on purpose?” The ordinal item was recoded with 0 = no self-harm and 1 = having self-harmed at least once over the past year.

Additional Suicidality Item

An additional suicidal behavior item asked whether participants who had attempted suicide experienced injury as a result. The results are reported in Table 2 across the whole sample. Due to low responses on this item, it was not included in subsequent group comparisons on SRC.

Table 2.

Sports-related concussion association with risk factors for depression and suicidality among high school students: adjusted odds ratios logistic regression

	Felt sad or hopeless (n = 4198)	Considered suicide (n = 4187)	Made a suicide plan (n = 4182)	Attempted suicide (n = 3622)	Attempted suicide: injury (n = 3612)	Self-harm (NSSI) (n = 4196)
Sports-related concussion in past year
Once or More (No = Referent)	1.32* (1.06 – 1.65)	1.32* (1.02 – 1.72)	1.58** (1.20 – 2.08)	2.68*** (1.92 – 3.73)	5.76*** (3.48 – 9.54)	1.97*** (1.54 – 2.52)
Sex
Female (Male = Referent)	2.25*** (1.94 – 2.60)	1.77*** (1.46 – 2.13)	1.94*** (1.58 – 2.39)	1.64*** (1.24 – 2.17)	1.64 (0.98 – 2.76)	2.07*** (1.72 – 2.48)
Age
16–18 + years-old (12–15 yrs = Referent)	1.21* (1.05 – 1.40)	0.97 (0.81 – 1.17)	0.85 (0.70 – 1.03)	0.90 (0.70 – 1.17)	0.99 (0.61 – 1.60)	0.87 (0.73 – 1.04)
Race/Ethnicity (Exclusive Categories) (Non-Hispanic White = Referent)
Black/African American (Non-Hisp.)	1.16 (0.94 – 1.44)	1.19 (0.90 – 1.56)	1.46* (1.08 – 1.97)	2.87*** (1.95 – 4.23)	2.32* (1.11 – 4.85)	0.81 (0.61– 1.07)
Hispanic/Latinx	1.19* (1.00- 1.41)	1.10 (0.89- 1.36)	1.41** (1.12 – 1.77)	2.05*** (1.50 – 2.81)	1.88* (1.06 – 3.33)	1.19 (0.97 – 1.45)
Other/Multiracial (Non-Hispanic)	1.08 (0.82 – 1.40)	1.48* (1.09 – 2.01)	1.79*** (1.28– 2.49)	2.63*** (1.71 – 4.04)	2.17* (1.01 – 4.66)	1.07 (0.78 – 1.46)
Bullied in school
Yes (No = Referent)	2.36*** (1.88 – 2.98)	2.01*** (1.59 – 2.54)	2.32*** (1.82 – 2.96)	2.60*** (1.92 – 3.51)	4.12*** (2.45 – 6.93)	2.44*** (1.94 – 3.06)
Ever teased perceived as Lesbian/Gay
Yes (No = Referent)	2.67***	3.19***	2.93***	3.37***	2.61***	3.38***
	(2.09 – 3.40)	(2.53 – 4.03)	(2.30 – 3.73)	(2.50 – 4.53)	(1.54 – 4.43)	(2.69 – 4.25)
COVID-19 affected mental health
Yes (Most/All the Time) (No = Ref.)	5.72*** (4.91 – 6.65)	4.91*** (4.07 – 5.92)	3.99*** (3.24 – 4.90)	3.57*** (2.70 – 4.73)	3.39*** (1.97 – 5.84)	3.45*** (2.88 – 4.12)

Bold values indicate statistically significant results

*p < .05, **p < .01, ***p < .001

Independent Variables, Descriptors, and Covariates

Independent variables were coded with lower values indicating lower risk among categories. Participants were grouped by age and assigned a value of 0 for younger youth (age 12 to 15) and 1 for older youth (ages 16 to age 18 and above). Sex was coded as male = 0 and female = 1. Students were also asked, over the past year, whether they had “…ever been the victim of teasing or name calling because someone thought you were gay, lesbian, or bisexual?” (No = 0 and Yes = 1). Bullying victimization in school was assessed by a single item, “During the past 12 months have you ever been bullied on school property?” (No = 0 and Yes = 1). Selected covariates of sex (females’ greater propensity for internalizing problems), bullying victimization, and belonging to (or perceived as) sexual minority were based on prior findings of significant associations with suicidality among similar representative state high school samples [21, 22]. A combined and recoded item reflected more common combinations of race and ethnicity with exclusive categories of “White non-Hispanic” = 0, “Black/African American non-Hispanic” = 1, “Hispanic/Latinx, including multiracial Hispanic” = 2, and “Other race/multiracial/non-Hispanic” = 3. Last, the mental health during pandemic item stated, “During the COVID-19 pandemic, how often was your mental health not good?” with responses dummy coded with never to rarely = 0 and sometimes, most of the time, or always = 1.

Sports related concussion (SRC) was described on the survey in a short paragraph “…A concussion is when a blow or jolt to the head causes problems such as headaches, dizziness, being dazed or confused, difficulty remembering or concentrating, vomiting, blurred vision, or being knocked out.” The SRC item following this statement was, “During the past 12 months, how many times did you have a concussion from playing a sport or being physically active?” Responses on the SRC item were recoded as dummy variables (No SRC = 0 and 1 or more SRC in the past year = 1).

Analysis

Logistic regression models were run to examine associations between SRC and the four internalizing behaviors in the overall sample (see Table 2), as well as to compare the association between SRC and internalizing behaviors among the subsample of Latinx/Hispanic and Black, non-Hispanic youth (see Table 3), and among subsample of males and females (see Table 4).

Table 3.

Sports-related concussion associations with depression and suicidality among Black Non-Hispanic/Latinx students: adjusted odds ratios

	Felt sad or hopeless (n = 683/1504)	Considered suicide (n = 686/1498)	Made a suicide plan (n = 686/1496)	Attempted suicide (n = 550/1243)	Self-harm (n = 685/1502)
Sports-related concussion past year
Yes (No = Referent)	1.76* / 1.05 (1.04–2.96)/(0.73–1.51)	1.75 / 1.39 (0.87–3.51)/(0.91–2.14)	3.37** / 1.53 (1.63–6.98)/(0.98–2.39)	4.88*** / 2.54*** (2.10–11.39) /(1.50–4.32)	4.12*** / 1.38 (2.22–7.66)/(0.92–2.08)
Sex
Female (Male = Referent)	2.70*** / 2.20*** (1.78–3.64)/(1.73–2.81)	3.63***/ 2.09*** (2.10–6.29)/(1.51–2.89)	8.24*** / 1.92*** (4.08–16.65)/(1.36–2.72)	3.98*** / 1.46 (1.86–8.52)/(0.93–2.29)	2.72*** / 2.02*** (1.59–4.67)/(1.49–2.74)
Age
16–18 + years-old (< 12–15 years-old = Referent)	0.98 / 1.19 (0.69–1.40)/(0.93–1.52)	0.48** / 1.33 (0.30–0.79)/(0.98–1.81)	0.38*** / 1.01 (0.22–0.64)/ (0.73–1.40)	0.37** / 1.16 (0.19–0.70)/(0.76–1.76)	0.58* / 0.87 (0.36–0.95) /(0.65–1.16)
Bullied in school
Yes (No = Referent)	1.75 / 2.30*** (0.92–3.31)/(1.51–3.50)	2.44* / 2.10*** (1.23–4.84)/(1.37–3.22)	3.10** / 2.51*** (1.51–6.35)/(1.62–3.87)	3.61**/2.41** (1.64–7.93)/(1.43–4.06)	1.60 / 3.32*** (0.79–3.24)/(2.22–4.97)
Ever teased: perceived as L/G/B
Yes (No = Referent)	2.84** / 3.09*** (1.43–5.64)/(2.00–4.77)	4.81*** / 3.15*** (2.35–9.83)/(2.09–4.74)	3.29** / 2.60*** (1.52–7.11)/(1.70–3.96)	5.04***/3.73*** (2.20–11.55)/(2.29–6.10)	3.25** / 4.01*** (1.61–6.56)/(2.71–5.93)
Mental health affected COVID
Yes (No = Referent)	3.67*** / 5.66*** (2.49–5.40)/(4.40–7.28)	4.60*** / 5.05*** (2.82–7.49)/ (3.68–6.92)	3.48*** / 4.76*** (2.03–5.96)/(3.40–6.68)	2.50** / 3.43*** (1.30–4.80)/(2.19–5.37)	2.97*** / 3.09*** (1.79–4.94) / (2.31–4.14)

Bold values indicate statistically significant results

*p < .05, **p < .01, ***p < .001

Table 4.

Sports-related concussion associations with depression and suicidality among High School Male/Female students: adjusted odds ratios

	Felt sad or hopeless (n = 2208/1990)	Considered suicide (n = 2203/1984)	Made a suicide plan (n = 2201/1981)	Attempted suicide (n = 1858/1764)	Self-harm (n = 2208/1988)
Sports-related concussion past year
Yes (No = Referent)	1.31 / 1.35 (0.98–1.76)/(0.95–1.91)	1.82** / 1.02 (1.26–2.62)/(0.70–1.49)	1.58* / 1.67** (1.04–2.40)/(1.15–2.42)	3.88*** / 1.97** (2.39–6.31) /(1.23–3.16)	2.43*** / 1.59* (1.74–3.41)/(1.12–2.26)
Age
16 – 18 + years-old (< 12–15 yrs = Ref.)	1.56*** / 0.97 (1.26–1.94)/(0.79–1.19)	1.11 / 0.89 (0.82–1.49)/(0.71–1.12)	0.87 / 0.80 (0.62–1.21)/(0.63–1.02)	0.72 / 1.01 (0.46–1.12)/(0.73–1.39)	0.87 / 0.87 (0.65–1.15)/(0.70–1.09)
Race/Ethnicity (Exclusive Categories) (Non-Hispanic White = Referent)
Black/African American (Non-Hisp.)	1.05 / 1.28 (0.76–1.46)/(0.96–1.71)	0.66 / 1.63** (0.41–1.08)/(1.15–2.29)	0.53* / 2.20*** (0.28–1.00)/(1.53–3.17)	1.77 / 3.44*** (0.89–3.51)/(2.13–5.56)	0.69 / 0.87 (0.43–1.11)/(0.61–1.23)
Hispanic/Latinx	1.15 / 1.22 (0.90–1.46)/(0.96–1.54)	0.80 / 1.33* (0.57–1.12)/(1.01–1.74)	1.13 / 1.60** (0.78–1.65)/(1.19–2.13)	1.87* / 2.09*** (1.11–3.16)/(1.41–3.11)	1.08 / 1.25 (0.78–1.48)/0.97–1.61)
Other/Multiracial (Non-Hisp.)	0.97 / 1.18 (0.66–1.42)/(0.81–1.71)	1.15 / 1.73** (0.71–1.85)/(1.16–2.58)	1.64 / 1.85** (0.97–2.76)/(1.21–2.84)	1.76 / 3.14*** (0.82–3.77)/(1.86–5.31)	0.74 / 1.31 (0.43–1.26)/(0.88–1.95)
Bullied in school
Yes (No = Referent)	2.30*** / 2.39*** (1.63–3.23)/(1.74–3.27)	1.44 / 2.40*** (0.95–2.18)/(1.79–3.21)	1.84** / 2.51*** (1.18–2.86)/(1.86–3.38)	2.58*** / 2.65*** (1.50–4.45)/(1.83–3.82)	1.75** / 2.89*** (1.18–2.59)/(2.18–3.84)
Ever teased perceived as Lesbian/Gay
Yes (No = Referent)	2.91*** / 2.45*** (2.05–4.14)/(1.75–3.44)	3.64*** / 3.12*** (2.47–5.38)/(2.32–4.18)	4.03*** / 2.60*** (2.65–6.12)/(1.92–3.52)	3.27*** / 3.58*** (1.92–5.58)/(2.49–5.16)	4.10*** / 3.15*** (2.82–5.97)/(2.36–4.22)
Mental health affected COVID
Yes (No = Referent)	5.76*** / 5.81*** (4.59–7.23)/(4.73–7.13)	5.57*** / 4.59*** (4.16–7.45)/(3.59–5.86)	4.67*** / 3.71*** (3.35–6.52)/(2.86–4.82)	5.20*** / 2.81*** (3.31–8.17)/(1.98–3.98)	3.69*** / 3.33*** (2.77–4.92)/(2.65–4.20)

Bold values indicate statistically significant results

*p < .05, **p < .01, ***p < .00

Results

Over 12% (n = 547 or 12.3%) of the total sample (N = 4436) of high schoolers reported experiencing a SRC in the past 12 months. Table 1. differentiates the entire sample from adolescents with SRC experience on descriptors, independent variables, control variables, and dependent variables. Most participants were White non-Hispanic (n = 1749, 37.9%) and over one-third (n = 1675, 36.3%) identified as Hispanic/Latinx. Over half of the participants were male (n = 2452, n = 52.8%) and a smaller portion of the sample (n = 1082, 23.2%) reported a sexual orientation of lesbian, gay, bisexual, or unsure. Internalizing problems presented in significantly higher proportions (χ² values with p < 0.01) for adolescents with SRC. In the overall sample, after controlling for covariates (i.e., gender, age, race/ethnicity, sexual minority orientation, and bullying victimization experience), SRC experience remained significantly associated with six types of internalizing problems (see Table 2). Adjusted odds ratios (AORs) ranged from 1.32 times to 2.68 times greater likelihood of depression and suicidality for students experiencing SRC in the past year, as compared with their peers who did not report a concussion (Table 2). Additionally, those with SRC experience were over 5 times more likely (AOR = 5.76, p < 0.001) to have attempted suicide resulting in injury than high schoolers who had not experienced concussion in the past year.

Table 1.

Sample Characteristics, Experiences, Suicidality, and Self-Reported Concussion: Florida YRBSS 2021 (n = 4668)

	Values	Prevalence (Total sample)		Concussion (Yes) prevalence
		N	%	N	%
Total		4436	100.0%	547	12.3%
Sample characteristics / Experiences
Age	14 years old or younger	731	15.7%	73	13.4%
	15 years old	1330	28.5%	164	30.0%
	16 years old	1159	24.8%	141	25.8%
	17 to 18 + years old	1448	31.0%	168	30.8%
Grade	9th – 10th grade	2808	60.7%	339	61.8%
	11th – 12th grade	1815	39.3%	195	38.2%
Race / Ethnicity	American Indian/Alaska Native Asian/Pacific Islander/Hawaiian	15 126	0.3% 2.7%	2 5	0.4% 0.9%
	Black/African American (Non-H)	786	17.0%	94	17.4%
	White (Non-Hispanic)	1749	37.9%	192	35.6%
	Hispanic/Latinx (Inc. Multiracial)	1675	36.3%	209	38.7%
	Multiracial (Non-Hispanic)	269	5.8%	36	6.7%
Sex	Female	2189	47.2%	207	38.1%
	Male	2452	52.8%	336	61.9%
	Transgender (Nonexclusive Cat.)	78	1.7%	17	3.2%
Sexual minority	L/G/B/Unsure Straight/Heterosexual	1082 3572	23.2% 76.8%	101 433	18.9% 81.1%
Bullied at school	Yes	595	12.8%	111	20.4%
	No	4054	87.2%	432	79.6%
Teased bc seen as LGB	Yes	546	11.9%	96	17.9%
	No	4048	88.1%	441	82.1%
Internalizing mental health outcomes (in Past 12 months)
Sad or hope-less 2 weeks	Yes	1783	38.7%	239	44.3%
	No	2829	61.3%	300	55.7%
Considered suicide	Yes	805	17.5%	422	78.0%
	No	3798	82.5%	119	22.0%
Made suicide plan	Yes	632	13.7%	106	19.6%
	No	3966	86.3%	435	80.4%
Attempted suicide	Yes	351	8.8%	76	17.9%
	No	3622	91.2%	349	82.1%
Self-injury/NSSI	Yes No	849 3651	18.9% 81.1%	155 381	28.9% 71.1%
COVID-19 affect. MH	Yes (Mostly or Always)	1446	33.6%	351	67.1%
	No (Never, Rarely, Sometimes)	2863	66.4%	172	32.9%

As Hispanic/Latinx and Black non-Hispanic adolescents reported similar SRC rates (12% and 12.5%, respectively) and made up a sizable portion of the sample, we selected these two racial/ethnic groups for comparison. SRC experience and internalizing problems were more significantly associated for African Americans than Latinx adolescents (Table 3). African American high schoolers who experienced SRC were significantly more likely than their same-race peers without SRC to have: felt sad or hopeless (1.76 times, p < 0.05); made a suicide plan (3.37 times, p < 0.01); attempted suicide (4.88 times, p < 0.001); and self-harmed (4.12 times, p < 0.001). Latinx adolescents who experienced SRC were 2.54 times (p < 0.001) more likely than their same ethnicity peers to attempt suicide; other internalizing problems in association with SRC were non-significant for Latinx teens. Furthermore, beyond SRC, Latinx youth appear vulnerable to the effects of bullying in school and being teased for being a sexual minority on internalizing problems. Both racial/ethnic minority groups showed significant associations between bullying victimization in school and being teased due to being perceived as a sexual minority with suicidal thoughts and behaviors (Table 1).

Sex differences in SRC associations with internalizing problems were minimal (Table 4) wherein males with SRC were significantly more likely to have considered suicide than males without SRC; this was not the case for females with SRC. For both sexes, there were similarly significant associations between SRC and self-harm as well as SRC with making a suicide plan and attempting suicide. SRC was also not significantly associated with having felt sad or hopeless for 2 or more weeks in the past year for both males and females. Beyond SRC experience, males and females differed only in the association between being bullied at school and considering suicide, which was significant for females. Furthermore, across the total sample and subsample comparison, mental health was significantly affected during COVID-19 for a sizable portion of adolescents (refer to Table 1 and Table 2).

Discussion

The purpose of this study was to explore the association between sport-related concussion and essential mental health concerns in a statewide sample of high school students. Consistent with national and regional studies using YRBSS datasets, we found approximately 12% of high school students experienced at least one concussion in the last 12 months and these students were more likely to report internalizing problems than their peers without SRC experience. In the overall sample our findings suggest that, above and beyond the influences of known factors for depression and suicide among youths (gender, race/ethnicity, victimization for being perceived as a sexual minority, and bullying victimization in school, the COVID-19 pandemic), SRC plays a probable role in the etiology of internalizing behaviors of self-harm, depression, and suicidality.

Nonsignificant associations between SRC and depression for both males and females and a nonsignificant association between SRC and suicidal ideation for females contrasted with findings by Mantey and colleagues (2020). In their study, using YRBSS data in 2017 from 44 states, females who had experienced SRC had significantly greater odds of having felt sad and hopeless and suicidal ideations than their female peers without SRC. This disparity suggests possible regional differences particular to females in the Southeastern U.S., perhaps due to gender role expectations, for example, maintaining a positive outlook during challenging circumstances. Additionally, our results revealed that males did not show significantly higher likelihood of linking experiences of being bullied at school with considering suicide. This disparity could stem from gender differences in how bullying experiences are perceived. Beyond concerns raised with the validity of the “considered suicide” single item measure, the bullied at school one-item measure does not differentiate relational from physical bullying, which may lead to perceptual differences by gender. Recent national YRBSS reports on bullying support greater overall levels of relational, e.g. cyberbullying, compared to physical bullying [27].

We lack additional information as to severity of SRC reported and how specifically it occurred for females in the study, as research points to SRC causing more damage to females due to head size and bone structure. A growing body of research points to greater levels of physical symptomatology and compromised mental health for young female athletes’ post-concussion, as compared with males. Our finding with this Southeastern sample may be a case of resilience differentiating females from males; possible protective factors might include reduced stigma for young women to report concussion and seek medical help as well as seek support for internalizing problems. Perhaps women’s sports teams and venues of physical activity (e.g., group fitness classes) have coaches and staff making stronger preventative measures in practice and play, for example, taking symptoms seriously so that play does not continue through injury. On the other hand, mental health stigma, high pressure stakes in team sports, and valuing pushing through pain and injury for the sake of the team and the win may increase males’ vulnerability to internalizing problems in association with SRC experience [4].

Parenthetically, as Latinx adolescents who experienced concussion were more likely to attempt suicide than their peers who did not report concussion in the past year, social stigma may lessen likelihood of self-reporting on suicidal ideation. However, Latinx adolescents in the sample self-reported on suicide attempts that were likely to be associated with SRC experience. In numbers and proportions, more Latinx than white or African American adolescents self-reported SRC (12.5% vs. 11.0% and 12.0%, respectively) experience in the past year spanning from January and February 2020 through the time of data collection in early 2021. Future studies that examine how concussions occur, severity of SRC, and longitudinal analysis measuring SRC and internalizing problems, will benefit the current knowledge base of SRC effects on mental health by identifying and examining culturally relevant protective factors, as possible disruptors of the SRC-depression/suicidality association for Latinx students.

An interesting finding is that Black adolescents with SRC experience, like their Latinx peers, were not significantly more likely to “consider suicide.” Rather, evidence points to Black adolescents’ with SRC greater likelihood of making a suicide plan and attempting suicide, when compared to their peers without SRC. This may be explained by the use of one-item measures of internalizing behaviors that are not well-validated, with the exception of YRBSS use of a single NSSI item [26]. Item wording and phrasing may translate into unintended meanings by participants. For example, the Spanish verb considerar includes, beyond giving careful thought and analysis to an option, the concept of belief or creer en. A Latinx adolescent may be unlikely to respond affirmatively to believing in suicide. Other possibilities for how this item is regarded, in the speculative sense, might be the influence of religious faith as valued in family-oriented African American and Latinx populations and cultural norms prohibiting considering suicide as an option.

Further, identification of strengths-based cultural values and practices within African American communities such as collectivism and familism versus individualism, may translate into the provision of social support from adults and peers offering impactful community-based protection from mental health challenges. Moreover, with limited use of racial categories in the study, Black identifying adolescents may include African Americans and Caribbean Americans. These groups possess distinct cultural differences and unique strengths to further explore, with promise as census and other national representative studies are moving toward more nuanced measures of race and ethnicity within a resilience framework.

Finally, findings with the overall sample model and gender and race/ethnicity comparisons supported that SRC has significant ‘predictive power’ for suicidal behavior or attempt, over and above the effects of the COVID-19 pandemic on mental health. Regardless, each tested model (overall sample, African American Adolescents, Latinx Adolescents, Males, Females) indicated that poor mental health during COVID-19 was significantly associated (nearly 3 to 6 times more likely for those whose mental health was not or minimally affected during the pandemic) with likelihood of having internalizing problems. To add, the significant associations between SRC and NSSI for the whole sample, males and females, and Black youth are potentially meaningful. This aligns with findings from other studies [30] to aid our understanding of the relationship between self-harm and NSSI. Ohlis and colleagues (2020) identified three groups of young people: 1) those who self-harm and are not suicidal; 2) those who are suicidal but do not self-harm; and 3) those who are suicidal and self-harm.

Limitations

This study relies on youths’ one-time self-report on independent (identity and experience) and dependent (internalizing problems) variables. Self-report could be problematic with respect to stigma (e.g., cultural stigmas on mental health) and threat of loss specific to sports team settings causing underreporting of SRC. A recent systematic review provided ample evidence for adolescent athletes underreporting SRC experiences, with males more likely to do so [31]. Additional limitations involve the YRBSS not including measures of SRC severity and mechanisms for injury. Furthermore, limiting SRC experience and internalizing problems to self-report within the past year, does not include lifetime accrual as cumulative SRC effects are deleterious. A lack of externally valid clinical diagnoses of depression, self-harm, and suicidal ideation, also limits the depth and applicability of findings for mental health practitioners working with adolescents with SRC.

Given the cross-sectional nature of this study, we are unable to determine the temporal relationship between SRC and mental health outcomes. Although, like others, we treated SRC as the independent variable with internalizing symptoms as the outcomes, others have found youth with mental health disorders are more likely to experience concussion [35]. Longitudinal evaluations of young athletes that can isolate the timing of SRC from depression and suicidality experiences, will prove fruitful for estimating causality [43]. Last,

the use of single items as exogenous proxies for diverse identities and multidimensional experiences of young people within specific contexts, poses at best as preliminary descriptive research. As the findings in this study were significant, more in-depth qualitative and person-centered research is called for to understand what drives the differences found here.

Conclusion

Given the life-threatening implications of our findings for the 1 in 8 high schoolers who experienced concussion in the past year, timely psychological evaluation and supportive resources for student-athletes and their families should accompany the suspicion or diagnosis of SRC [43], p. 263). Moreover, certain groups may face heightened risks, which makes timely intervention even more critical. Our findings have implications for understanding vulnerability and resilience among specific groups of young people. Males and non-Hispanic youth may have greater susceptibility to the influence of SRC on their mental health. Targeting at-risk populations for selective intervention holds potential in youth sport and physical activity contexts within communities. Education is vital for adolescents in formal and semi-structured (intramural) sport, as well as their parents, coaches, and school personnel, on SRC prevention and symptom recognition. Having an appropriate protocol for immediate action and treatment is a key means to address the “concussion crisis in sport” [20]. Applying a “Knowledge-to-Action (KTA)” framework leverages the creation and dissemination of knowledge for policy-based action [32]. KTA applied to SRC could include a social marketing campaign to raise awareness of post-concussion symptoms and provide education to key stakeholders who promote adolescents’ physical activity by developing organizational action plans for SRC recognition and treatment. Sports organizations benefit from using KTA frameworks by: 1. identifying gaps in SRC knowledge; 2. developing, implementing, and evaluating educational outreach efforts; and 3, using evaluation of outcomes to inform policy decisions [32], p. 5). As an example of the latter, effective policies could prevent practice and play for a set period post-concussion while providing alternatives future affirming activities for adolescents. Moreover, while adolescents on sports teams usually have access to supports such as coaches, teachers, and medical personnel, they have limited access to sports-based mental health services [4]. A solution entails a holistic perspective that includes mental health. Van Slingerland and colleagues [39], as part of their position statement for the Canadian Centre for Mental Health and Sport (CCMHS), acknowledge that athletes are not immune to experiencing mental health challenges and disorders; sports organizations and coaches are obligated to foster and protect athletes’ mental health; and “specialized interdisciplinary mental health care team(s)” must serve the needs of competitive athletes seeking mental health care (p. 178). Although organizations like NCAA and CCMHS have made position statements on the importance of mental health support for athletes, these apply solely to elite athletes, excluding those participating in non-elite sports (e.g., intramural and pre-collegiate sports potentially on an elite track) [41]. A holistic perspective that integrates the physical and psychological well-being of young athletes within a KTA framework is one step toward the solution.

Summary

This study investigated the impact of sports-related concussions (SRC) on the physical and mental health of young individuals using data from the 2021 Youth Risk Behavior Surveillance System (YRBSS) in a Southeastern state during the COVID-19 pandemic. The analysis explores associations between youths’ SRC experiences and internalizing problems, including depression, self-harm, and suicidality. Across the representative state sample, findings supported others’ [22, 43] with significant associations between SRC experiences and depression (AOR = 1.32, p < 0.05), suicidality (e.g., attempted suicide AOR = 2.68, p < 0.001), and self-harm (AOR = 1.97, p < 0.001), after controlling for various covariates. Notably, no gender distinction was found in SRC’s association with self-harm, suicide planning, and attempts. African American students with SRC were found to exhibit a higher likelihood of experiencing depression, self-harm, suicide planning, and attempts compared to their peers without SRC. Our findings demonstrate the Latinx paradox for this growing ethnic group in the state, indicating mental health resilience post-concussion. Additionally, the study underscores the persistence of associations between SRC and internalizing problems beyond the pandemic’s effects on young people’s mental health. Implications highlight the need for health promotion, population-specific protection, and targeted interventions within young athletes’ and active adolescents’ communities to address vulnerabilities and provide comprehensive support for mental health and medical concerns.

Author Contributions

Kate Fogarty conceived the study, conducted the analysis, and drafted the manuscript. Jihee Song conceived the study, conducted the analysis, supervised the study, and revised the manuscript. Tara Counts contributed to revising the manuscript. Nicolette Grajo revised the manuscript. Dale Pracht and David Diehl contributed to the study design.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data Availability

The data of this study are publicly available and accessible via the U.S. Census Bureau.

Declarations

Competing Interests

The authors declare no competing interests.

Ethical Approval

No applicable.