Substance Use & Misuse

2022, VOL. 57, NO. 4, 504–515

https://doi.org/10.1080/10826084.2021.2019779

ORIGINAL ARTICLE

Sports- and Physical Activity-Related Concussions, Binge Drinking and

Marijuana Use among Adolescents: The Mediating Role of Depression and
Suicidal Ideation
Philip Baidena , Mark A. Morganb and Matthew W. Loganc
a
School of Social Work, The University of Texas at Arlington, Arlington, Texas, USA; bDepartment of Criminal Justice & Security Studies,
University of Dayton, Dayton, Ohio, USA; cSchool of Criminal Justice & Criminology, Texas State University, San Marcos, Texas, USA

ABSTRACT KEYWORDS
Background: Although past studies have examined the adverse impact of sports- and physical Sports- and physical
activity-related concussions (SPACs) on health and mental health outcomes, there is a dearth of activity-related concussions;
research investigating the association between SPACs and binge drinking and marijuana use. traumatic brain injury;
binge drinking;
Objective: The objective of this study is to examine the cross-sectional association between SPACs
marijuana use;
and binge drinking and marijuana use among adolescents and whether symptoms of depression depression;
and suicidal ideation mediate this association. Methods: Data for this study came from the 2017 suicidal ideation;
and 2019 National Youth Risk Behavior Survey. An analytic sample of 17,175 adolescents aged adolescents
14–18 years (50.2% male) was analyzed using binary logistic regression. Results: Of the 17,175
adolescents, 13.7% engaged in binge drinking and 19.3% used marijuana 30 days preceding the
survey date. Approximately one in seven (14.1%) adolescents had SPACs during the past year.
Upon controlling for the effects of other factors, adolescents who had SPACs had 1.74 times higher
odds of engaging in binge drinking (AOR = 1.74, p<.001, 95% CI = 1.47–2.06) and 1.42 times higher
odds of using marijuana (AOR = 1.42, p<.001, 95% CI = 1.24–1.62) than those who did not have
SPACs. Symptoms of depression and suicidal ideation explained 12% of the association between
SPACs and binge drinking, and 19% of the association between SPACs and marijuana use.
Conclusions: Understanding the association between SPACs and substance use and mental health
could contribute to early identification of adolescents who may engage in substance use.

1. Introduction
Sports- and physical activity-related concussions (SPACs)
among adolescents in the United States (U.S.) has been
identified as a major public health issue over the past
decade, owing to its potentially serious consequences and
rising prevalence (Anderson et al., 2016; Coronado et al.,
2015; Sarmiento et al., 2019). The highest rates of SPACs
occur in contact sports, such as football and ice hockey for
boys (Pfaller et al., 2019) and soccer for girls (Ling et al.,
2020; Pfister et al., 2016). Data show that between 1.6 to
3.8 million SPACs occur every year across the U.S., partic-
ularly among adolescent athletes (Castile et al., 2012; Giza
& Kutcher, 2014; Langlois et al., 2006; Tremblay et al., 2013).
The actual prevalence of SPACs is likely to be much higher
due to lack of knowledge about SPACs and reluctance to
report symptoms (Anderson et al., 2016; Williamson &
Goodman, 2006).
SPACs can result in traumatic brain injury (TBI) and
can have a lasting effect on brain development (Casper,
2018; Daneshvar et al., 2011; Irwin et al., 2020). Although
some individuals with SPACs may experience neurologic
changes for a short time and recover quickly and fully,
within 7 to 10 days (Haider et al., 2018), some may have
prolonged symptoms lasting for weeks, months, or even
years (Lowry et al., 2021; McCrory et al., 2013). Empirical
research on the short- and long-term consequences of SPACs
is well-documented (Beauchamp et al., 2011; Eyolfson et al.,
2020; Muscara et al., 2009; Wahlquist & Kaminski, 2021).
In recent years, however, scholars have focused their atten-
tion on the prevalence of SPACs sustained by athletes during
sporting events, especially among adolescents (Baillargeon
et al., 2012; DePadilla et al., 2020; Guerriero et al., 2012;
Halstead et al., 2018; Lowry et al., 2021; Veliz et al., 2019).
Studies show that SPACs among adolescents increase the
likelihood of stress and depressive symptoms (Chrisman &
Richardson, 2014; Irwin et al., 2020; Sarmiento et al., 2020),
attention-deficit hyperactivity disorder (ADHD; Narad et
al., 2018; Yang et al., 2019), violence and aggressive behav-
iors (Ilie et al., 2017; Roy et al., 2017), and suicidal behav-
iors (Knell et al., 2020; Mantey et al., 2020, 2021; Wangnoo
et al., 2020; Yang et al., 2019). Sarmiento et al. (2020) found
that compared to adolescents with no history of SPACs,

CONTACT Philip Baiden philip.baiden@uta.edu School of Social Work, The University of Texas at Arlington, 211 S. Cooper St., Box 19129, Arlington,
Texas 76019, USA.
© 2021 Taylor & Francis Group, LLC

adolescents with a history of SPACs were 1.4 times more
likely to have experienced symptoms of depression. Similarly,
Mantey et al. (2020) found that compared to adolescents
with no history of SPACs, adolescents with a history of
SPACs were 1.25 times more likely to have experienced
suicidal ideation, 1.6 times more likely to have attempted
suicide, and 2.35 times more likely to have reported a sui-
cide attempt that resulted in an injury requiring medical
attention during the past year.
There is also compelling empirical evidence that suggests
depression and suicidal behaviors are co-occurring mental
problems among individuals who have sustained SPACs
(Chrisman & Richardson, 2014; Covassin et al., 2017;
Mantey et al., 2020; Sarmiento et al., 2020), the symptoms
of which present themselves in various combinations (Rogers
& Read, 2007). These comorbid mental health problems
have the potential to adversely affect the risk of engaging
in substance use. For example, a longitudinal study by Kaup
et al. (2019) found that early onset of depression post-TBI
was a significant predictor of substance use at follow-up.
Other studies have found that individuals with a history of
head injury may experience symptoms of depression and
self-medicate with alcohol and illicit substances to assuage
the affective states they find painful or traumatic (DePadilla
et al., 2020; Lowry et al., 2021; Veliz et al., 2021). Systematic
reviews and meta-analyses have also highlighted the need
for additional extensive research examining possible path-
ways through which SPACs might be associated with ado-
lescent health risk behaviors such as substance use (Covassin
et al., 2017; Manley et al., 2017; Rice et al., 2018).
Past research has documented an established a link between
SPACs and alcohol use by employing a general measure of
alcohol use that involves any level of use within the past
30 days (DePadilla et al., 2020). Given the high prevalence of
alcohol use among adolescents from the U.S. (Farmer et al.,
2016; Seeley et al., 2019), it is vital to examine excessive
patterns of alcohol use. Thus, in this study, we focus on binge
drinking, an excessive form of alcohol use that puts adoles-
cents at increased risk for adverse outcomes (Priesman et al.,
2018). The National Institute on Alcohol Abuse and
Alcoholism (NIAAA) has defined binge drinking as a pattern
of drinking alcohol that brings blood alcohol concentration
to 0.08 g/dl or above (NIAAA, 2004). This typically occurs
after four drinks for females and after five drinks for males
within approximately two hours (NIAAA, 2004).
In addition, past studies on SPACs and drug use have
focused on illicit drugs such as methamphetamine (El Hayek
et al., 2020), ecstasy (Warren et al., 2006), cocaine (Sacks
et al., 2009), and opioids (Cottler et al., 2011). Other schol-
ars have also combined marijuana use with other types of
illicit drugs to measure “substance use” more broadly (Sami
et al., 2015). Importantly, however, marijuana is the most
widely used illicit substance among adolescents in the U.S.
(Hammond et al., 2020; Sharma et al., 2018; Substance
Abuse & Mental Health Services Administration, 2019;
Wadsworth & Hammond, 2019). Findings from the
Monitoring the Future National Survey Results on Drug
Use, 1975–2018, showed that in 2018, about 36% of high
school seniors used marijuana during the past year
Substance Use & Misuse 505
(Schulenberg et al., 2020). Similarly, Jones et al. (2020) ana-
lyzed data from the 2019 Youth Risk Behavior Survey
(YRBS) and found that about 22% of adolescent high school
students reported using marijuana in the past 30 days. They
also found that rates of lifetime marijuana use among ado-
lescents increased from 36.8% in 2009 to 40.7% in 2013
(Jones et al., 2020).
Finally, recognizing the potential for differential effects,
we examine the interaction between sex and SPACs on sub-
stance use. Findings from the available literature indicate
that although adolescent males are more likely to sustain
SPACs (Brooks et al., 2018; Lowry et al., 2021), adolescent
females have prolonged recovery and worse outcomes after
sustaining SPACs (Covassin et al., 2012, 2013; Dillard et al.,
2017; Henry et al., 2016; Howell et al., 2017; Miller et al.,
2016; Ono et al., 2016). Whereas male and female differ-
ences in alcohol consumption have declined over the past
few years, the prevalence of binge drinking is still higher
among males relative to females (White et al., 2015). Studies
have also found that adolescent males outnumber their
female counterparts when it comes to marijuana use (Baiden
et al., 2014; Schulenberg et al., 2020; Substance Abuse &
Mental Health Services Administration, 2019). The sex dif-
ferences in prolonged recovery and worsening mental health
after sustaining SPACs are likely to affect adolescent sub-
stance use behaviors. Yet, to date, there is a dearth of obser-
vational studies examining whether the association between
SPACs and substance use differs for adolescent males relative
to their female counterparts. It is therefore important to
investigate and better understand sex differences in the asso-
ciation between SPACs and substance use (Rice et al., 2018),
including binge drinking and marijuana use.
1.1. Current study
This study is informed by self-medication theory (SMT;
Khantzian, 1985, 1997). SMT posits that the decision to use
a particular substance is not happenstance; but rather, it is
chosen based on its pharmacological potency and efficacy
in relieving feelings or symptoms of distress that accompany
certain traumatic events (Khantzian, 1985, 1997). For
instance, individuals suffering from depression may use sub-
stances – such as cocaine and other selective serotonin
reuptake inhibitors (SSRIs) – which serve to induce an eva-
nescent state of euphoria and (temporarily) buffer persistent
symptoms of hopelessness, worthlessness, and exhaustion
(Groenman et al., 2017). Applying the SMT to the present
study, binge drinking and marijuana use may be viewed as
a response to the trauma arising from the SPACs. More
importantly, prior research shows that SPACs is related to
symptoms of depression (Chrisman & Richardson, 2014;
Irwin et al., 2020; Sarmiento et al., 2020) and suicidal ide-
ation (Knell et al., 2020; Mantey et al., 2020, 2021; Wangnoo
et al., 2020; Yang et al., 2019), and research shows that
adolescents with these mental health problems turn to alco-
hol and marijuana to self-medicate (Baiden et al., 2014;
Kaasbøll et al., 2018; Park & Wu, 2017; Zullig et al., 2015).
Several studies (Austin & Shanahan, 2018; Baiden & Tadeo,
506 P. BAIDEN ET AL.
2019; Darke, 2013; Garland et al., 2013; Gomez et al., 2015),
systematic reviews (Lemyre et al., 2019; Maniglio, 2015; Park
& Wu, 2017), and meta-analysis (Gualano et al., 2015) have
used the SMT in understanding substance use behaviors
among adolescents with a history of trauma.
The objective of this study was to examine the
cross-sectional association between SPACs and binge drink-
ing and marijuana use among adolescents using data from
a nationally representative sample of adolescents. Based on
a review of the extant literature and its theoretical presup-
positions, we hypothesized that: (1) there would be an asso-
ciation between SPACs and binge drinking and marijuana
use among adolescents, and (2) symptoms of depression and
suicidal ideation would attenuate the association between
SPACs and binge drinking and marijuana use. We further
hypothesized that sex would moderate the association
between SPACs and binge drinking and marijuana use.
2. Methods
2.1. Data source
Data for this study were obtained from the Youth Risk
Behavior Survey (YRBS). The YRBS is a cross-sectional
school-based national survey conducted by the Centers for
Disease Control and Prevention (CDC) every two years to
examine health-risk behaviors that contribute to the leading
causes of death and disability among youth in the U.S. The
objectives, methodology, and sampling procedure for the
YRBS have been described elsewhere (Brener et al., 2013;
Kann et al., 2018; Underwood et al., 2020) and in other
publications by the authors (Baiden & Tadeo, 2019, 2020;
Baiden et al., 2019, 2020, 2021). In brief, the YRBS utilized
a three-stage cluster sample design to recruit 9th to 12th
graders from both public and private schools to complete
self-administered surveys. A nationally representative sample
of schools and a random sample of classes within those
schools were selected to participate in the 2017 and 2019
YRBS. First, schools were selected systematically with prob-
ability proportional to enrollment in grades 9 through 12
using a random start from primary sampling units (PSUs),
made up of entire counties, groups of smaller adjacent coun-
ties, or parts of larger counties. PSUs were categorized into
different strata based on their metropolitan statistical area
status (e.g., urban or rural) and the percentages of
non-Hispanic Black (Black) and Hispanic students in each
PSU. For the second-stage sampling, secondary sampling
units were sampled with probability proportional to school
enrollment size. The third and final stage of sampling com-
prised of a random sampling of one or two classrooms in
each of grades 9 through 12 from either a required subject
(e.g., English or social studies) or a required period (e.g.,
homeroom or second period). All students in sampled
classes were eligible to participate. Schools, classes, and
students who refused to participate were not replaced in
the sampling design. The YRBS have been used in several
studies and the measures have been found to have strong
psychometric properties (Brener et al., 2013). The YRBS
was approved by the CDC’s Institutional Review Board
(IRB), and the de-identified data are publicly available. The
current study was exempted from IRB approval by the lead
author’s institution. We followed Strengthening the Reporting
of Observational Studies in Epidemiology (STROBE) guide-
lines in the conduct of this study (Von Elm et al., 2007).
2.2. Sample
For the purposes of this study, data from high school stu-
dents from the 2017 and 2019 national YRBS were combined
to obtain a sufficient sample size to examine the association
between SPACs and binge drinking and marijuana use, and
how symptoms of depression and suicidal ideation mediate
this association. The school response rates for the 2017 and
2019 national YRBS were 75.0% and 75.1%, respectively;
student response rates were 81% and 80.3%, respectively;
and overall response rates, a product of the school and
student response rates for each cycle, were 60% for both
years (Kann et al., 2018; Underwood et al., 2020). The initial
sample size for the 2017 and 2019 national YRBS was 14,765
and 13,677, respectively. The resulting sample size for the
combined 2017 and 2019 national YRBS was 28,442 high
school students. Imputation of missing data is not recom-
mended for studies using the YRBS (Brener et al., 2013);
hence, the analyses presented in this study were restricted
to adolescents who had complete data on all the variables
included in the analysis. This resulted in a final analytic
sample of n = 17,175. The sample was evenly distributed by
sex (50.2% female). About 86% of the adolescents
self-identified as heterosexual, 2.2% as gay or lesbian, 8.3%
as bisexual, and 4% indicated they were not sure about their
sexual identity. A little over half (53%) of the adolescents
self-identified as White, 10.7% as Black/African American,
25.3% as Hispanic, and 10.6% as other.
2.3. Variables
2.3.1. Outcome variables
The outcome variables examined in this study were current
binge drinking and marijuana use, and were both measured
as binary variables. Binge drinking was measured based on
response to the question, “During the past 30 days, on how
many days did you have four or more drinks of alcohol in
a row (if you are female) or five or more drinks of alcohol
in a row (if you are male)?” with response options ranging
from 0 days to 20 or more days. Following the recommen-
dation of the CDC and other scholars (Edwards et al., 2020;
Scheer et al., 2021), adolescents who had four or more
alcoholic drinks (for a female) or five or more alcoholic
drinks (for a male) in a row at least once during the past
30 days were considered to have engaged in binge drinking
and were coded as 1; otherwise, they were coded as 0.
Current use of marijuana was measured based on response
to the question, “During the past 30 days, how many times
did you use marijuana?” with response options ranging from
0 times to 40 or more times. Adolescents who reported

using marijuana at least once during the past 30 days were
coded as 1, whereas adolescents who did not use marijuana
during the past 30 days were coded as 0.
2.3.2. Explanatory variables
The main explanatory variable examined in this study was
SPACs and was measured based on response to the question,
“During the past 12 months, how many times did you have
a concussion from playing a sport or being physically
active?” 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, vom-
iting, blurred vision, or being knocked out. The initial
response options were “0 times”, “1 time”, “2 times”, “3
times”, and “4 times”. Consistent with other studies (DePadilla
et al., 2020; Lowry et al., 2021; Sarmiento et al., 2020),
adolescents who have a concussion from playing a sport or
being physically active at least once during the past
12 months were recoded as 1, whereas adolescents who did
not have a concussion from playing a sport or being phys-
ically active were coded as 0.
2.3.4. Mediator variables
Symptoms of depression and suicidal ideation were examined
as potential mediators of the association between SPACs
and binge drinking and marijuana use. Symptoms of depres-
sion were measured with the question, “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?” Adolescents who answered “yes” were
coded as 1, whereas adolescents who answered “no” were
coded as 0. Suicidal ideation was measured based on
response to the question, “During the past 12 months, did
you ever seriously consider attempting suicide?” Adolescents
who answered “yes” were coded as 1, whereas adolescents
who answered “no” were coded as 0.
2.3.5. Demographic and control variables
Playing on a sports team, academic performance, age, sex,
sexual identity, and race/ethnicity were also included in the
analysis as control variables. Playing on a sports team was
measured based on response to the question, “During the
past 12 months, on how many sports teams did you play?
(Count any teams run by your school or community
groups.)” Adolescents who played on at least one sports
team during the past 12 months were recoded as 1, whereas
adolescents who did not play on a sports team during the
past 12 months were coded as 0. Academic performance was
measured as a binary variable by grouping students who
described their grades in the current school year as mostly
As or Bs and coded as 1 and contrasted with students who
described their grades as neither A’s nor B’s who were coded
as 0. Age was measured in years, whereas sex was coded
as “0 = Female” and “1 = Male.” Sexual identity was coded as
a nominal variable into “0 = Heterosexual”, “1 = Gay or les-
bian”, “2 = Bisexual”, and “3 = Not sure.” Race/ethnicity was
coded as a nominal variable into the following categories
Substance Use & Misuse 507
“0 = non-Hispanic White”, “1 = non-Hispanic Black/African
American”, “2 = Hispanic”, and “3 = Other race/ethnicity.”
2.4. Data analyses
The data analyses involved the use of descriptive, bivariate,
and multivariable analytic techniques. First, the general dis-
tribution of all the study variables was examined using fre-
quencies and percentages. Second, using Pearson chi-square
test of association, we then examined the bivariate association
between SPACs and the demographic factors, playing on a
sports team, and academic performance. The main analysis
involved the use of binary logistic regression to examine the
association between SPACs and the outcome variables (i.e.,
current binge drinking and marijuana use), while simultane-
ously controlling for symptoms of depression, suicidal ide-
ation, playing on a sports team, academic performance, and
demographic factors. For each outcome variable, two hierar-
chical logistic regression models were fitted. In Model 1, we
regressed binge drinking and marijuana use on SPACs while
controlling for demographic factors, playing on a sports team,
and academic performance given their a priori importance.
Model 2 consists of variables in Model 1 plus symptoms of
depression and suicidal ideation. To assess the extent to which
symptoms of depression and suicidal ideation attenuates the
association between SPACs and binge drinking and marijuana
use, we use the explained fraction (EF) based on the equation
below (Lynch et al., 1996):
EF   OR base model    OR adjusted  /  OR base model  1
where the base model is the model including only SPACs
and demographic variables and playing on a sports team,
and the adjusted model is the model that also included
symptoms of depression and suicidal ideation. This approach
has been used by other scholars in assessing mediation
(Fuller‐Thomson et al., 2016; Kim et al., 2010; Piccinelli
et al., 2018; Yngwe et al., 2001). We also examined a
two-way interaction effect between SPACs and sex on binge
drinking and marijuana use. Adjusted odds ratios (AOR)
are reported together with their 95% Confidence Intervals
(CI). Variables were considered significant if the p-value
was less than .05. Stata’s “svyset” command was used to
account for the weighting and complexity of the cluster
sampling design employed by the YRBS. All analyses were
performed using Stata version 14.
3. Results
3.1. Sample characteristics
Table 1 shows the general distribution of the study variables.
Of the 17,175 adolescents, 13.7% engaged in binge drinking
508 P. BAIDEN ET AL.

Table 1. Sample characteristics (N = 17,175). Table 2. Bivariate association between demographic characteristics
Variables Frequency (Weighted %) and sports- or physical activity − related concussions (N = 17,175).
Outcome variables % that had a sports- or
 Currently binge drink alcohol physical activity-related
  No 14,818 (86.3) Variables concussions Chi-square (sig)
  Yes 2,357 (13.7)  Age in years 9.45 (p = .372)
 Currently use marijuana    13 years or younger 28.0
  No 13,869 (80.7)   14 years 14.4
  Yes 3,306 (19.3)   15 years 14.6
Explanatory variable   16 years 13.9
Had a sports- or physical activity-related   17 years 14.2
concussions   18 years 13.1
  No 14,753 (85.9) Sex 24.65 (p < .001)
  Yes 2,422 (14.1)   Female 12.8
Mediators   Male 15.4
Had symptoms of depression Sexual identity 1.89 (p = .715)
  No 11,422 (67.5) Heterosexual 14.2
  Yes 5,753 (33.5)
Past year suicidal ideation    Gay or lesbian 12.3
  No 14,126 (82.2)   Bisexual 14.0
  Yes 3,049 (17.8)   Not sure 13.0
Control variables Race/ethnicity 5.00 (p = .299)
 Age in years   Non-Hispanic White 14.5
   13 years or younger 40 (0.2)   Black/African American 14.8
  14 years 1,948 (11.3)   Hispanic 13.4
  15 years 4,232 (24.6)   Other 13.2
  16 years 4,414 (25.7) Played on a sports team 472.34 (p < .001)
  17 years 4,161 (24.3)   No 7.5
  18 years 2,380 (13.9)   Yes 19.2
Sex  Academic performance 22.40 (p < .001)
  Female 8,627 (50.2)   Neither A’s nor B’s 16.4
  Male 8,548 (49.8)    Mostly A’s or B’s 13.4
Sexual identity
  Heterosexual 14,693 (85.5)
   Gay or lesbian 379 (2.2) SPACs. About 15.4% of males compared to about 12.8% of
  Bisexual 1,418 (8.3)
  Not sure 685 (4.0) females had SPACs (χ2(1)=24.65, p<.001). About one in five
Race/ethnicity adolescents who played on a sports team (19.2%) compared
  Non-Hispanic White 9,172 (53.4) to 7.5% of adolescents who did not play on a sports team
  Black/African American 1,842 (10.7)
  Hispanic 4,351 (25.3) had SPACs (χ2(1)=472.34, p<.001). A little over 13% of
  Other 1,810 (10.6) adolescents who described their grades as mostly A’s or B’s
Played on a sports team compared to 16.4% of adolescents who described their
  No 7,495 (43.6)
  Yes 9,680 (56.4) grades as neither A’s nor B’s had SPACs (χ 2(1)=22.40,
 Academic performance p<.001). Age, sexual identity, and race/ethnicity were not
  Neither A’s nor B’s 4,061 (23.6) significantly associated with SPACs.
   Mostly A’s or B’s 13,114 (76.4)

and about one in five (19.3%) used marijuana 30 days pre-
ceding the survey date. About one in seven (14.1%) ado-
lescents had SPACs during the past year. About one in three
adolescents (33.5%) reported feeling sad or hopeless almost
every day for two weeks or more in a row such that they
had to stop doing some usual activities. About 18% of the
adolescents experienced suicidal ideation during the past
year. More than half (56.4%) of the adolescents played on
a sports team during the past 12 months, and a little over
three out of four (76.4%) adolescents described their grades
as mostly As or Bs.
3.2. Bivariate association between SPACs and
sample characteristics
Table 2 shows the bivariate association between SPACs,
playing on a sports team, academic performance, and the
demographic factors. Only sex, playing on a sports team,
and academic performance were significantly associated with
3.3. Multivariable binary logistic regression
Table 3 shows the multivariable logistic regression results
examining the association between SPACs and binge drink-
ing. Controlling for demographic factors and playing on a
sports team in Model 1, adolescents who had SPACs had
1.84 times higher odds of engaging in binge drinking
(AOR = 1.84, p<.001, 95% CI = 1.56–2.18) and 1.52 times
higher odds of using marijuana (AOR = 1.52, p<.001, 95%
CI = 1.32–1.74) when compared to their counterparts who
did not have SPACs. This significant effect was partially
attenuated with the addition of symptoms of depression and
suicidal ideation in Model 2. Upon controlling for the effect
of other factors in Model 2, adolescents who had SPACs
had 1.74 times higher odds of engaging in binge drinking
(AOR = 1.74, p<.001, 95% CI = 1.47–2.06) and 1.42 times
higher odds of using marijuana (AOR = 1.42, p<.001, 95%
CI = 1.24–1.62) than those who did not have SPACs.
Controlling for other factors in Model 2, adolescents who
had symptoms of depression had 1.69 times higher odds of
 Substance Use & Misuse 509

Table 3. Association between sports- or physical activity-related concussions and binge drinking and marijuana use (N = 17,175).
Binge drinking Marijuana use
Variables Model 1 Model 2 Model 1 Model 2
Age in years 1.46 (1.37–1.56)*** 1.47 (1.37–1.58)*** 1.33 (1.27–1.39)*** 1.33 (1.27–1.39)***
Sex (Female)
Male 0.81 (0.70–0.92)** 0.91 (0.80–1.04) 1.01 (0.90–1.14) 1.20 (1.07–1.36)**
Sexual identity (Heterosexual)
Gay or lesbian 1.04 (0.66–1.65) 0.80 (0.51–1.25) 1.89 (1.43–2.49)*** 1.41 (1.09–1.81)**
 Bisexual 1.25 (1.02–1.53)* 0.93 (0.75–1.16) 1.74 (1.45–2.06)*** 1.23 (1.02–1.49)*
 Not sure 0.72 (0.50–1.04) 0.62 (0.43–0.89)* 0.88 (0.64–1.21) 0.73 (0.53–1.01)
Race/ethnicity (non-Hispanic White)
 Black/African American 0.27 (0.20–0.37)*** 0.28 (0.21–0.38)*** 1.16 (0.98–1.37) 1.26 (1.07–1.50)**
Hispanic 0.76 (0.65–0.89)** 0.77 (0.66–0.91)** 1.10 (0.94–1.28) 1.13 (0.96–1.33)
Other 0.61 (0.49–0.77)*** 0.59 (0.46–0.75)*** 0.87 (0.73–1.04) 0.84 (0.70–1.00)
Played on a sports team (No)
Yes 1.27 (1.08–1.49)** 1.35 (1.14–1.59)** 1.02 (0.92–1.14) 1.09 (0.97–1.23)
Academic performance (Neither A’s nor B’s)
Mostly A’s or B’s 0.63 (0.56–0.71)*** 0.68 (0.61–0.77)*** 0.47 (0.42–0.53)*** 0.51 (0.46–0.58)***
Had a sports- or physical activity- related concussion (No)
Yes 1.84 (1.56–2.18)*** 1.74 (1.47–2.06)*** 1.52 (1.32–1.74)*** 1.42 (1.24–1.62)***
Has symptoms of depression (No)
Yes 1.69 (1.46–1.96)*** 1.86 (1.60–2.15)***
Past year suicidal ideation (No)
Yes 1.49 (1.30–1.71)*** 1.71 (1.48–1.98)***
NB: Reference category is indicated in parenthesis.
*
p < .05;
**
p < .01;
***
p < .001.

engaging in binge drinking (AOR = 1.69, p<.001, 95% CI = We calculated the explained fraction and found that
1.46–1.96) and 1.86 times higher odds of using marijuana symptoms of depression and suicidal ideation accounted for
(AOR = 1.86, p< .001, 95% CI = 1.60–2.15) when compared 12% of the association between SPACs and binge drinking,
to those with no symptoms of depression. Similarly, ado- and 19% of the association between SPACs and marijuana
lescents who experienced suicidal ideation had 1.49 times use. In the fully adjusted model, we observed that the asso-
higher odds of engaging in binge drinking (AOR = 1.49, ciation between SPACs and binge drinking and marijuana
p<.001, 95% CI = 1.30–1.71) and 1.71 times higher odds use remains significant, albeit the odds ratios were somewhat
using marijuana (AOR = 1.71, p<.001, 95% CI = 1.48–1.98) smaller. That is to say, symptoms of depression and suicidal
when compared to their counterparts who did not experi- ideation only partially mediate the association between
ence suicidal ideation. SPACs and binge drinking and marijuana use.
Upon controlling for other factors in Model 2, each To examine whether the effect of SPACs on binge drink-
additional increase in age increased the odds of binge ing and marijuana use is dependent on sex, we conducted
drinking by 47% (AOR = 1.47, p<.001, 95% CI = 1.37–1.58) a two-way interaction between SPACs and sex. Based on
and marijuana use by 33% (AOR = 1.33, p<.001, 95% CI = Figure 1, we found that there was a significant two-way
1.27–1.39). Whereas Black/African American (AOR = 0.28, interaction between SPACs and sex such that adolescent
p<.001, 95% CI = 0.21–0.38) and Hispanic (AOR = 0.77, males who had SPACs had 1.29 times higher odds of engag-
p<.01, 95% CI = 0.66–0.91) adolescents were less likely to ing in binge drinking (AOR = 1.29, p<.05, 95% CI =
engage in binge drinking compared to their non-Hispanic
White counterparts, we found that for marijuana use, the
odds were positive for non-Hispanic Black/African
American adolescents (AOR = 1.26, p<.01, 95% CI = 1.07–
1.50). Playing on a sports team was significantly associated
with binge drinking, but not marijuana use. Upon con-
trolling for the effect of other factors in Model 2, adoles-
cents who played on a sports team had 1.35 times higher
odds of engaging in binge drinking when compared to
their counterparts who did not play on a sports team
(AOR = 1.35, p<.01, 95% CI = 1.14–1.59). There was an
inverse association between academic performance and
binge drinking and marijuana use. Controlling for other
factors in Model 2, adolescents who described their grades
as mostly A’s or B’s had 32% lower odds of engaging in
binge drinking (AOR = 0.68, p<.001, 95% CI = 0.61–0.77)
and 49% lower odds of using marijuana (AOR = 0.51,
p<.001, 95% CI = 0.46–0.58). Figure 1. Current binge drinking.
510 P. BAIDEN ET AL.
Figure 2. Current use of marijuana.
1.02–1.64). Similarly, results in Figure 2 shows that adoles-
cent males who had SPACs had 1.44 times higher odds of
using marijuana (AOR = 1.44, p<.01, 95% CI = 1.14–1.82).
4. Discussion
This study examined the association between SPACs and
binge drinking and marijuana use among adolescents,
including an investigation into the mediating role of depres-
sion and suicidal ideation. We found that 14% of adolescents
in our sample had reported SPACs within the last year and,
congruent with our first hypothesis, that SPACs was signifi-
cantly associated with both binge drinking and marijuana
use. Moreover, this effect was robust to a host of demo-
graphic control variables and potential mediators. Similar
studies have found that TBI among high school youth and
young adults is associated with greater odds of cigarette
smoking, binge drinking, and other illegal drug use (e.g.,
cannabis, methamphetamines, opioids) as well as increased
substance use-related lifestyle problems (Allen et al., 2016;
Caplan et al., 2015). However, it is also important to rec-
ognize that the impact of SPACs on substance use and
analogous criminal behaviors may be conditioned by the
severity of the TBI, the age at which it is incurred, and the
presence of individual characteristics such as low self-control
(Corrigan et al., 2012; Kort-Butler, 2017; McKinlay et al.,
2014). Given that research on head injuries is often
cross-sectional in nature, it remains difficult to discern
whether an impulsive, risk-taking temperament precedes
incidents of substance use and SPACs. For instance, among
juvenile offenders, SPACs has been linked to a host of det-
rimental mental health and antisocial outcomes (Moore
et al., 2014), yet when it comes to specific misconduct,
recent longitudinal research suggests that head injuries are
a likely causal factor only for specific types of aggressive
or violent offending (Schwartz, 2021; Williams et al., 2018).
Nevertheless, the co-occurrence of SPACs and substance
use, particularly among adolescents, warrants further
investigation since prospective findings tend to show that
TBI increases alcohol misuse and may simultaneously impair
recovery over the long-term (Beaulieu-Bonneau et al., 2018;
Corrigan et al., 2020), thereby posing a rehabilitative chal-
lenge for clinicians (Taylor et al., 2003).
Our second hypothesis, informed by SMT (Khantzian,
1985, 1997), was supported by the partial attenuation of
SPACs through depression and suicidal ideation. The SMT
posits that the decision to use a particular substance is not
happenstance; rather, it is chosen based on its pharmaco-
logical potency and efficacy in relieving feelings or symp-
toms of distress that accompany certain traumatic events
(Khantzian, 1985). Applying the SMT to the present study,
binge drinking and marijuana use may be viewed as a
response to the trauma arising from the SPACs. More
importantly, SPACs is related to symptoms of depression
(Chrisman & Richardson, 2014; Irwin et al., 2020; Sarmiento
et al., 2020) and suicidal behaviors (Knell et al., 2020;
Mantey et al., 2020, 2021; Wangnoo et al., 2020; Yang et al.,
2019), and research shows that adolescents with these mental
health problems turn to alcohol and marijuana to
self-medicate (Kaasbøll et al., 2018; Park & Wu, 2017;
Stewart et al., 2013; Zullig et al., 2015). Future research
would benefit from the ability to disentangle the associations
between SPACs, emotional regulation, and executive func-
tioning, as they are likely to play a substantial role—directly
or indirectly—in substance use among adolescents (Baiden
& Tadeo, 2019).
Moreover, it is worth noting that with the legalization
of marijuana across several U.S. states, coupled with the
increasing shift toward its recreational and medicinal pur-
poses, it is possible that marijuana might not be a drug of
choice to turn to in response to severe injuries in compar-
ison to other illicit drugs. However, in the U.S., marijuana
remains the most commonly used illicit psychoactive sub-
stance among adolescents despite being prohibited among
individuals under the age of 21 years (Hammond et al.,
2020; Sharma et al., 2018; Substance Abuse & Mental Health
Services Administration, 2019; Wadsworth & Hammond,
2019). Additional research on the impact of regulated mar-
kets, youth consumption of marijuana, and the abuse of
alternative substances like opiates or prescription drugs for
SPACs are thus worth investigating.
Lastly, an interaction term between SPACs and sex
revealed that males who experienced SPACs were signifi-
cantly more likely than females to report binge drinking
and marijuana use, supporting our third hypothesis.
Contemporary research on SPACs in student athletes has
generally focused on examining post-concussion quality of
life, neuropsychological functioning, and reentry into the
school setting. For example, one study of high schoolers
found that while health-related symptom severity was
increased in the days directly after an injury—and slightly
more so for female athletes—following a median 14-day
recovery period, there were no detectable concussion symp-
toms from that point onward across a 12-month follow-up
for either males or females (McGuine et al., 2019). On the
other hand, systematic reviews have reported that while

children may appear to be fully recovered from SPACs,
subtle deficits can still persist in other domains such as
attention, working memory, and planning (Semrud-Clikeman
& Klipfel, 2016). Specifically, these lingering issues tend to
manifest as externalizing problem behaviors in males and
visual memory or internalizing difficulties in females (Brown
et al., 2015; Merritt et al., 2019).
More broadly, sex differences in substance use as it relates
to SPACs have received relatively less attention in the liter-
ature, underscoring the need for additional multivariate
examinations as demonstrated in the current study.
Exploratory research suggests that while males are more
likely to have substance abuse disorders and to suffer SPACs,
females are at a greater risk of progressing from casual use
to addiction more quickly (Oliverio et al., 2020). Similarly,
females with substance abuse disorders have been found to
have an increased relative risk of TBI which may be comor-
bid with other psychopathological problems (Chang et al.,
2019; Felde et al., 2006), but further research will be nec-
essary to unpack the importance of the associations between
these various outcomes. Our findings also revealed that
higher academic achievement is associated with reduced
substance use; nonetheless, research indicates that concus-
sions themselves may impair academic and cognitive func-
tioning among youth, particularly among males who have
sustained multiple SPACs (Lowry et al., 2019).
Taken together, the findings of this study suggest that
SPACs could have a deleterious impact on mental health.
Recognizing this, an expert panel was recently convened
to review nearly 40 years of literature on SPACs and issue
a consensus statement in regard to youth sports (Rivara
et al., 2020). Notably, they encouraged educating parents,
participants, and coaches on the risks of concussions and
suggested that attempts to limit unnecessary contact and
collisions in sports should be considered. Their recommen-
dations also called for further research on the contribution
of age, sex, and mental health conditions to SPACs as well
as the neuropsychological outcomes of repetitive head
injury. Our study serves to fulfill this latter request, offering
cautionary evidence that closer attention should be paid to
the role of SPACs in adolescents as it relates to mental
health and the development of substance use disorders. To
that end, recent CDC guidelines on the management of
mild TBI in children recommend that return-to-school pro-
tocols should consist of a “collaboration among medical,
school, and family systems to gradually adjust interventions
and return the child to full participation” (Lumba-Brown
et al., 2018, p. e7). Consequently, such rehabilitative efforts
could potentially benefit from modifications to monitor
children for poor mental health outcomes, substance use
problems, and other psychosocial factors in order to min-
imize the risk of academic failure following a concussion.
4.1. Limitations
As with any study, there are limitations to our analyses that
could be improved to enhance future research. First, data
used for this study were cross-sectional and, as a result, we
Substance Use & Misuse 511
are unable to determine when the SPACs occurred in relation
to other variables in our models, its intensity, or how long
symptoms may have persisted. Likewise, our binary measure
of SPACs did not permit us to capture its frequency or sever-
ity (i.e., the classification level of the TBI). A longitudinal
study that followed adolescents over time might help us
understand the temporal order between SPACs and substance
use. Second, it is possible that some adolescents may under-
report or overreport whether they experienced SPACs, which
may be especially pertinent to those who had experienced
SPACs in the years prior to the survey. Third, the use of
self-reported behaviors, mental health problems, and suicidal
ideation may be susceptible to social desirability and recall
biases. However, the possibility of recall bias or false reporting
was addressed in the YRBS by screening the data for responses
that conflict in logical terms and the measures in the YRBS
have been found to have strong psychometric properties
(Brener et al., 2013). Future studies should consider utilizing
a more clinical approach such as reviewing medical records
to assess these self-reported behaviors. Fourth, the use of
secondary data limits our analysis to variables present in the
dataset. We were unable to control for pain-related measures
found to influence substance use (Baiden & Tadeo, 2019).
More importantly, we were unable to ascertain the type of
sports team adolescents played on or the type of physical
activity they engaged in. Given the importance of socialization
processes in the development and emergence of adolescent
delinquency, studies incorporating peer networks and mea-
sures of individual self-control are warranted (Hoeben et al.,
2016). Indeed, there is evidence that participation in youth
sports can escalate one’s association with risky peers, leading
to increased binge drinking (Drane et al., 2017), though this
effect may be reversed for tobacco and illicit drug use (Lisha
& Sussman, 2010). Finally, the sample is generalizable only
to high school students and therefore excludes youth that are
more likely to have dropped out, been incarcerated, or who
are otherwise at a greater risk for substance misuse (Townsend
et al., 2007).
4.2. Conclusion
The findings from this study indicate an association between
SPACs and binge drinking and marijuana use, with symp-
toms of depression and suicidal ideation partially attenuating
this association. Moreover, the effects of SPACs on substance
use were found to be significantly higher among males.
Although participation in youth sports and physical activity
provides numerous benefits for adolescents, it should be
noted that SPACs could have a deleterious impact on mental
health. Future studies should consider rehabilitative measures
aimed at preventing the onset of poor mental health out-
comes and subsequent substance use following the occur-
rence of SPACs.
Acknowledgements
This article is based on publicly available data from the 2017 and
2019 Youth Risk Behavior Survey (YRBS) collected by the Centers for
512 P. BAIDEN ET AL.
Disease Control and Prevention (CDC). The views and opinions
expressed in this article are those of the authors and do not necessarily
represent the views of CDC or that of its partners. Dr. Baiden had
full access to the data and takes responsibility for the integrity of the
data and the accuracy of the data analysis.
Declaration of interest
The authors declare that they have no conflicts of interests with respect
to the authorship and/or the publication of this paper.
Funding
The author(s) reported there is no funding associated with the work
featured in this article.
ORCID
Philip Baiden http://orcid.org/0000-0003-3877-2594
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