European Journal of Special Education Research
ISSN: 2501 - 2428
ISSN-L: 2501 - 2428
Available on-line at: www.oapub.org/edu
10.5281/zenodo.61493
Volume 1│Issue 2│2016
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES:
A COMPARISON OF TRAUMATIC BRAIN INJURY
AMONG ADOLESCENTS
Brittany McNeal, Savannah O’Brien,
Benjamin P. Schade, Karen H. Larwini
Youngstown State University, Youngstown, Ohio, United States of America
Abstract:
Depression is a common post-concussion symptom. The depressive symptoms and its
effects seemingly appear to be more long term, with some patients still reporting three
months to nine years’ post-concussion. School apathy post head trauma can negatively
influence prognosis and essentially make the condition worse. Student disruptions post
head trauma will result in an inability to reason, problem-solve, set goals, self-monitor,
initiate or inhibit response behavior, and effectively execute purposeful behavior. The
current investigation examines the effects of traumatic brain injury (TBI) among schoolaged athletes (ages 13- to 18-years-old) compared to same-aged athletes who did not have
a diagnosis/history of TBI. A Multivariate analysis and t-test are utilized to address the
self-reported data in relation to students’ feelings, disruption, and school apathy with and
without head trauma. It is expected that the results will show adverse effects in those
student athletes who had reported head trauma when examining their feelings,
disruptions, and school apathy when compared to those student athletes without head
trauma.
Keywords: tramatic brain injury, concussions, perceptions of education
Introduction
According to the Centers for Disease Control & Prevention (CDC; 2015), over 2.5 million
cases of traumatic brain injuries (TBIs) were reported in hospitals throughout the United
i
Correspondent author: email khlarwin@ysu.edu
Copyright © The Author(s). All Rights Reserved
Published by Open Access Publishing Group ©2015.
90
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
States in 2010. TBIs are relatively common and a potentially life-threatening injury among
children and adolescents; this risk is perhaps most hazardous for student-athletes. Yet,
due to the internal nature of the injury, and the failure of athletes to report concussive
symptoms to the proper authorities, many concussions and cases of TBI go undiagnosed.
Estimated casualties amongst athletes have ranged from 300,000 (Marar, Mcilvain, Fields,
& Comstock, 2012) to 1.6-2.3 million, with the upper range appearing inflated partially due
to the fact that up to half of all concussions may go undiagnosed (Bailes, 2009).
Literature concerning high school athletes has suggested potentially longer
recovery times among adolescents (Lovell et al., 2003). Fortunately, many of these
concussions appear to be considered mild in nature (Mobayed & Dinan, 1990). However,
more severe concussions have a tendency to be marked by particular symptoms that may
include prolonged fatigue (Mollayeva et al., 2014), sleep disturbances (Kostyun, Milewski,
& Hafeez, 2014), headaches and migraines (Kontos et. al, 2013), anterograde amnesia
(Colins et al., 2003), retrograde amnesia, and loss of consciousness (Dougan, Horswill, &
Geffen, 2014). Even in non-concussed depressed patients, research has suggested
impairment during certain cognitive abilities, such as search and recall (Isley, 1994).
A lesser-common side effect following concussions among school-aged children is
depression (Chrisman & Richardson, 2014). Depression is estimated to occur in
approximately 180,000 of all concussed Americans (Kontos, Covassin, Elbin, & Parker,
2012). Heightened levels of depressive symptoms and emotional disturbances have been
reported among athletes who have experienced one or more concussions; notably, athletes
have been found to be most common reporters of concussions and related symptoms
(Roiger, Weidauer, & Kern, 2015).
At this time, there can be no conclusive stance taken to suggest that experiencing
depressive symptoms results from sustaining a concussion or TBI. Researchers cannot rule
out alternative factors regarding the elicitation of depressive symptoms as school-aged
youth, especially student-athletes in this age group, may experience undue pressures there
from parents, coaches, peers, and often the athlete himself to return to play (Kroshus,
Garnett, Hawrilenko, Baugh, & Calzo, 2015); this can adversely lead to further
psychological stress and negative perceptions of an athlete’s self-image and/or quality of
life (Kissick & Johnston, 2005).
Risk factors or predictors of post-concussion depression symptoms (PCDS) have
been identified. These include the individual(s) being of a younger age, having a personal
or family history of psychological concerns, a history of previous or current substance use
or abuse, and/or lower education levels of the patient and his/her family. One notable
category that has not been commonly investigated includes sports-related factors.
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
91
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
Individuals who experience a head trauma resulting in a TBI can experience
somatic symptoms (e.g., headaches, stomachaches), cognitive difficulties (e.g., memory
loss), sleep disturbance, and altered mood. These types of symptoms affect academic
performance and the ability to perform at their maximum potential (Iadevaia, Roiger, &
Zwart, 2015). Surveys of students reporting head trauma state that anywhere from 27% to
9 % of students’ report trouble doing and/or finishing their homework (Wasserman,
Bazarian, Mapstone, Block, & Van Wijngaarden, 2016). Students may require a brief
absence from school post-TBI, temporarily altering their ability to keep up with their
school curriculum (Ransom, Vaughan, Pratson, Sady, McGill, & Gioia, 2015). Notably,
lower standardized test scores were correlated increased difficulty returning to school,
such that the lower students’ standardized test scores were, the more difficulties they
experienced once they have returned to school (Baker et al., 2015).
Jones, Robinson, and Larwin (2015) found that students who have sustained a TBI,
especially those who were received special education services related to their TBI, have
reported strong feeling of association with their schools. However, a sense of apathy
toward school and schoolwork has been found to be a common result of sustaining a TBI
(Jantz & Coulter, 2007). Apathy in this context refers to the development of positive
teacher and/or peer interaction, acceptance of limitations, controlling anger, and appearing
to be apathetic. The degree of apathy can negatively influence prognosis and increase the
extent of the condition. An individual’s lack of self-monitoring, self-correcting, selfregulating may cause students to become inflexible and ridged or easily frustrated or
anxious when things do not go as planned resulting in disruptive behaviors (Jantz &
Coulter, 2007). While post-concussion recovery times vary for each individual, impaired
academic performance, emotional regulation, and behavior self-management may persist
for undetermined periods of time, resulting in a need for collaboration among service
providers to align their efforts for serving those who have sustained a concussion or TBI
(Iadevaia, Roiger, & Zwart, 2015).
In conducting interviews with adolescent student-athletes, researchers have
identified four components related to post-concussion quality of life for these adolescents:
significant effect of symptoms; feelings of frustration; influence on school attendance and
activities; and nature of interpersonal and team relationships (Iadevaia et al., 2015, p.
1182). Further, it was noted that greater post-concussion symptoms resulted in greater
functional impairments and impacts on quality of life (Iadevaia et al., 2015). To address
these concerns, various service providers, such as school-based professionals and related
clinicians have worked to provide services on a continuum of care for school-age students
who have sustained concussions and TBIs (Glang et al., 2015; Hotz, 2014). Focusing on
student-athletes at the high school level, one study implemented a county-wide initiative
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
92
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
that sought to improve data tracking, preventative efforts, and monitoring of students
who have sustained a concussion (Hotz, 2014), while another implemented an online
concussion training system for students and their families (Glang et al., 2015). Results of
the latter study suggest that easily accessible references provides knowledge and
application strategies for post-concussion management, as well as resources for referrals
when warranted (Glang et al., 2015).
Due to findings that approximately one-third of students-athletes experience
difficulties returning to school following a sports-related concussion (Baker et al., 2015),
other studies have focused on school-based professionals’ and related service providers’
perceptions of strategies and accommodations for serving students who have sustained
TBIs or concussions. Notable school-based professionals and clinicians in the literature
have included school principals (Heyer, Weber, Rose, Perkins, & Schmittauer, 2015),
school nurses (Weber, Welch, Parsons, & Valovich McLeod, 2015), and school-serving
athletic trainers (Kasamatsu, Cleary, Bennett, Howard, & Valovich McLeod, 2016;
McGrath, 2010; Williams, Welch, Parsons, & Valovich McLeod, 2015).
Due to the paucity of research on comparison groups of athletes who have not
suffered a TBI, the purpose of the current study is to examine the effects of TBI on schoolaged (13- to 18-years-old) athletes compared to school-aged athletes who have not
sustained a TBI. It is hypothesized that there will be a significant relationship between
both academic and behavioral factors when compared with head trauma. Further, it is
expected that there will be significant correlations when examining students’ reported
feelings, disruptions, and school-related apathy in relation to whether they have sustained
head trauma versus never having sustained a head trauma. With the addition of this
research, there will be ample evidence regarding how head trauma adversely affects
academic and behavioral performance of school-aged athletes.
METHODS
Participants
The inclusion criteria for concussed participants would be a medical diagnosis of a
concussion within the past six months to one year. The inclusion criteria for the nonconcussed participants would be no prior medical diagnosis of a concussion. The student
surveys were gathered from the Add Health National Database and involved a nationally
representative sample of 299 students, 13-18 years of age. A total of 110 participants
indicated that they did not have a head trauma (n = 110). Thirteen individuals responded
that they did have a head trauma (n = 13).
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
93
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
Instrumentation
The National Longitudinal Study of Adolescent to Adult Health (Add Health, 2016) is a
longitudinal study of youth ranging from grades 7-12 in the United States. Add Health
links survey data on respondents’ social and psychological well-being with related data on
the family, school, friendships, and peer groups. This provides exclusive ways to study
how social environments and feelings in youth are associated to health, education, and
achievement.
The
study
information
can
be
located
at
http://www.cpc.unc.edu/projects/addhealth
Procedures
The factors studied in this research are students’ disruptions, feelings, school apathy, and
head trauma. These factors were computed by taking the mean value across a number of
individual items that each participant responded in the ADHealth (2016) battery of
inventories.
The factor of students’ feelings (Feelings) was constructed using these items: HAPPY
AT YOUR SCHOOL, BOTHERED BY THINGS, HAD THE BLUES, TROUBLE KEEPING
MIND FOCUSED, FELT DEPRESSED, TOO TIRED TO DO THINGS, HOPEFUL ABOUT
THE FUTURE, LIFE HAD BEEN A FAILURE, FEARFUL, HAPPY, FELT LONELY, and
LIFE NOT WORTH LIVING.
The factor of student’s disruptions (Disruptions) was constructed using these items:
TROUBLE GETTING ALONG WITH TEACHERS, TROUBLE PAYING ATTENTION,
TROUBLE GETTING HOMEWORK DONE, and TROUBLE WITH OTHER STUDENTS.
Lastly, the factor of students’ school apathy (School Apathy) was constructed using
these items: FREQUENT EXCUSED ABSENCE FROM SCHOOL, and FREQUENT
SKIPPED SCHOOL.
Results
The descriptive statistics of the factors
Feelings, Disruptions, School Apathy and Head
Trauma for all individuals included in the current investigation are presented in Table 1.
Table 1: Descriptive Data and t-test results
No Head Trauma
Yes Head Trauma
Mean
SD
Mean
SD
t
0.950
0.960
0.923
1.552
.089
0.738
0.330
0.576
0.105
4.244*
Disruptions
0.884
0.549
0.423
0.438
2.708*
GPA
2.079
.732
2.026
.726
0.242
School Apathy
Negative Feelings
Note: The
1
indicates that an adjustment was made due to violation of homogeneity of variance prior to
conducting the t test analysis. * Indicates significant results at the α<. 5 level.
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
94
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
In addition to the descriptive data, Table 1 provides the outcomes from t tests comparing
the responses from students in each group (head trauma or no head trauma) on the three
constructed factors. Results indicate significant differences on the Feelings and the
Disruptions factors, but not on the Apathy factor or on student GPA.
A zero-order correlation was conducted to assess the appropriateness for the
multivariate analysis. The results of this analysis are presented in Table 2.
Table 2: Correlation of School Apathy, Disruption, and Feelings Factors
Variable
(1) School Apathy
(2) Disruptions
1
2
3
4
5
.
.705**
.308**
.413**
.459**
.
.249**
.165**
.241**
.
.154**
.038
(3) Negative Feelings
Note: * indicates p < .05; ** indicates p < .01.
Since there were significant correlations found between the three constructed factors, a
Multivariate Analysis of Variance was performed to examine more precisely the impact of
students with head trauma across the related factors. Results indicate that when these
correlated factors are considered simultaneously, the results indicate that there is a
significant difference across the two groups, F(3, 119) = 3.173, p = .027. These results
indicate that the differences in reporting across the three significantly correlated factors
are significant, however, it is the students who have not experiences a head trauma that
are endorsing the apathy, negative feelings, and disruptions more highly relative to the
students who experienced a head trauma. While sampling might explain these findings,
the results suggest that student which experience head trauma can have experiences
similar to those of their peers who have had not head traumas.
DISCUSSION
According to the examined data, one can conclude that those student athletes with head
trauma versus those student athletes with no reported head trauma were not adversely
affected in the areas of their feelings, disruptions, and school apathy. These findings are
consistent with Jones, Robinson, and Larwin (2015), however the non-significant finding
contradicts the findings of Jantz & Coulter, (2007). This difference could be due to the
impact of time and repeated trauma on those who experience head traumas (Bailey, 2009).
The time since injury is unknown for the data in the current investigation. While
based on a limited sample, the reported data and statistical analysis do not support the
original hypotheses. Based on the findings of the current investigation, the students in the
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
95
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
head trauma endorsed the factors at a lower level relative to the non-head trauma group,
indicating less negative feelings, less apathy, and fewer disruptions in their school
experiences. This could reflect time, as indicated above, or appropriate supports for
students receiving this type of injury.
Recommendations for the Future
Studies that involve the self-reporting of participants should present a caution to the
reader. One should take this type of data as a case by case basis as the manifestations of
such factors like reported feelings, disruptions, and school apathy can be different even
among those individuals with a TBI at similar times; each individual is going to self-report
differently than the next. This type of research did not take into account for those students
who were receiving specific interventions for their TBI as those interventions could have
adversely affected the presented data, in particular, school apathy. In addition, teachers
should be more cognizant of TBI manifestations and should not misinterpret them for
intense, emotional behaviors or dismiss them within the student’s developmental context.
Lastly, the current investigation does not take into account when the student experiences
the head trauma. Time can have a considerable impact on the students functioning post a
head trauma.
References
1. Bailes, J. (2009). Sports-related concussion: What do we know in 2009
A
neurosurgeon’s perspective. Journal of the International Neuropsychological Society, 15,
509-509.
2. Baker, J. G., Leddy, J. J., Darling, S. R., Rieger, B. P., Mashtare, T. L., Sharma, T., &
Willer, B. S. (2015). Factors associated with problems for adolescents returning to
the classroom after sport-related concussion. Clinical Pediatrics, 54(10), 961-968.
3. Chrisman, S., & Richardson, L. (2014). Prevalence of diagnosed depression in
adolescents with history of concussion. Journal of Adolescent Health, 54, 582-586.
4. Collins, M., Field, M., Lovell, M., Iverson, G., Johnston, K., Maroon, J. & Fu, F.
(2003). Relationship between postconcussion headache and neuropsychological test
performance in high school athletes. The American Journal of Sports Medicine, 31(2),
168-173.
5. Centers for Disease Control and Prevention. (2015, January 12). Injury Prevention
and Control: Traumatic Brain Injury. Retrieved from http://www.cdc.gov/
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
96
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
6. Dougan, B., Horswill, M., & Geffen, G. (2013). Do injury characteristics predict the
severity of acute neuropsychological deficits following sports-related concussion? A
meta-analysis. Journal of the International Neuropsychological Society, 20, 81-87.
7. Glang, A. E., Koester, M. C., Chesnutt, J. C., Gioia, G. A., McAvoy, K., Marshall, S.,
& Gau, J. M. (2015). The effectiveness of a web-based resource in improving postconcussion management in high schools. Journal of Adolescent Health, 56, 91-97.
8. Heyer, G. L., Weber, K. D., Rose, S. C., Perkins, S. Q., & Schmittauer, C. E. (2015).
High school principals’ resources, knowledge, and practices regarding the
returning student with concussion. The Journal of Pediatrics, 166(3), 594-599.
9. Hotz, G., Quintero, A., Crittenden, R., Baker, L., Goldstein, D., & Nedd, K. (2014). A
countywide program to manage concussions in high school sports. The Sport
Journal. Retrieved from http://thesportjournal.org/article/a-countywide-program-tomanage-concussions-in-high-school-sports
10. Iadevaia, C., Roiger, T., & Zwart, M. B. (2015). Qualitative examination of
adolescent health-related quality of life at 1 year postconcussion. Journal of Athletic
Training, 50(11), 1182-1189.
11. Jantz, P. B., & Coulter, G. A. (2007). Child and adolescent traumatic brain injury:
Academic, behavioural, and social consequences in the classroom. Support for
Learning, 22(2), 84-89.
12. Jones, B. A., Robinson, L., & Larwin, K. H. (2015). Identification with school and
head trauma: Parental perceptions on student’s experiences. International Journal of
Evaluation and Research in Education, 4(3), 112-117.
13. Kasamatsu, T., Cleary, M., Bennett, J., Howard, K., & Valovich McLeod, T. (2016).
Examining academic support after concussion for the adolescent student-athlete:
Perspectives of the athletic trainer. Journal of Athletic Training, 51(2), 153-161.
14. Kissick, J., & Johnston, K. (2005). Return to play after concussion. Clinical Journal of
Sport Medicine, 15(6), 426-431.
15. Kontos, A., Covassin, T., Elbin, R., & Parker, T. (2012). Depression and
neurocognitive performance after concussion among male and female high school
and collegiate athletes. Archive Physical Medical Rehabilitation, 93, 1751-1756.
16. Kontos, A., Elbin, R., Lau, B., Simensky, S., Freund, B., French, J., & Collins, M.
(2013). Posttraumatic migraine as a predictor of recovery and cognitive impairment
after sport-related concussion. The American Journal of Sports Medicine, 41(7), 14971504.
17. Kostyun, R, Milewski, M, & Hafeez, I. (2014). Sleep disturbance and neurocognitive
function during the recovery from a sport-related concussion in adolescents. The
American Journal of Sports Medicine, 43(3), 633 640.
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
97
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
18. Kroshus, E., Garnett, B., Hawrilenko, M., Baugh, C. M., & Calzo, J. P. (2015).
Concussion under-reporting and pressure from coaches, teammates, fans, and
parents. Social Science & Medicine, 134, 66-75.
19. Lovell, M. R., Collins, M. W., Iverson, G. L., Field, M., Maroon, J. C., Cantu, R…Fu,
F. H. (2003). Recovery from mild concussion in high school athletes. Journal of
Neurosurgery, 98, 295-301.
20. Marar, M., Mcilvain, N., Fields, S., & Comstock, R. (2012). Epidemiology of
concussions among United States high school athletes in 20 sports. The American
Journal of Sports Medicine, 40(4), 747-755.
21. McGrath, N. (2010). Supporting the student-athlete’s return to the classroom after a
sport-related concussion. Journal of Athletic Training, 45(5), 492-498.
22. Mobayed, M., & Dinan, T. (1990). Buspirone/prolactin response in post head injury
depression. Journal of Affective Disorders, 19, 237-241.
23. Mollayeva, T., Kendzerska, T., Mollayeva, S., Shapiro, C. M., Colantonio, A.,
Cassidy, J. D. (2014). A systematic review of fatigue in patients with traumatic brain
injury: The course, predictors and consequences. Neuroscience and Biobehavioral
Reviews, 47, 684-716.
24. Roiger, T., Weidauer, L., & Kern, B. (2015). A longitudinal pilot study of depressive
symptoms in concussed and injured/nonconcussed National Collegiate Athletic
Association Division I student-athletes. Journal of Athletic Training, 50(3), 256-261.
25. Wasserman, E. B., Bazarian, J. J., Mapstone, M., Block, R., & Wijngaard., E. (2016).
Academic dysfunction after a concussion among U.S. high school and college
students. American Journal of Public Health, 106(7), 1247-1253.
26. Weber, M. L., Welch, C. E., Parsons, J. T., & Valovich McLeod, T. C. (2015). School
nurses’ familiarity and perceptions of academic accommodations for studentathletes following sport-related concussion. The Journal of School Nursing, 31(2), 146154.
27. Williams, R. M., Welch, C. E., Parsons, J. T., & Valovich McLeod, T. C. (2015).
“thletic trainers’ familiarity with and perceptions of academic accommodations in
secondary school athletes after sport-related concussion. Journal of Athletic Training,
50(3), 262-269.
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
98
Brittany McNeal, Savannah O’Brien, Benjamin P. Schade, Karen H. Larwin –
ACADEMIC AND BEHAVIORAL EFFECTS IN ATHLETES: A COMPARISON OF
TRAUMATIC BRAIN INJURY AMONG ADOLESCENTS
Creative Commons licensing terms
Authors will retain the copyright of their published articles agreeing that a Creative Commons Attribution 4.0 International License (CC BY 4.0) terms will be
applied to their work. Under the terms of this license, no permission is required from the author(s) or publisher for members of the community to copy,
distribute, transmit or adapt the article content, providing a proper, prominent and unambiguous attribution to the authors in a manner that makes clear
that the materials are being reused under permission of a Creative Commons License. Views, opinions and conclusions expressed in this research article are
views, opinions and conclusions of the author(s). Open Access Publishing Group and European Journal of Special Education Research shall not be
responsible or answerable for any loss, damage or liability caused in relation to/arising out of conflict of interests, copyright violations and inappropriate or
inaccurate use of any kind content related or integrated on the research work. All the published works are meeting the Open Access Publishing
requirements and can be freely accessed, shared, modified, distributed and used in educational, commercial and non-commercial purposes under a
Creative Commons Attribution 4.0 International License (CC BY 4.0).
European Journal of Special Education Research - Volume 1 │ Issue 2 │ 2016
99