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Jul, 2018

Youth Football and Safety: Perspective of a Father, Physician and Former Player

By Donald Haas, MD, MPH

Three seasons ago, I was asked to volunteer as president for our local youth football program in West Windsor-Plainsboro.  At that time, some parents questioned why I would support football as a physician.  Their concern was understandable, given the usually negative coverage in the press surrounding football.  Up until then, I had a casual interest in the football safety narrative since I played football from the age of 8 until my sophomore year in college.  When my son came of age to play tackle football, however, I began to investigate football and head injuries in published medical literature more closely
.  

Mostly, I have found the data reported in medical journals regarding youth football reassuring.  This comes as a surprise to many, given the torrent of negative publicity in the media.  Unfortunately, the television networks and newspapers rarely cover studies that portray football in a positive light—but they exist.  That said, if football is to be played safely, it is imperative that the game is taught and learned under responsible adult supervision

As I enter my fourth and final year as president of our league, I would like to share my personal opinions on why I continue to support youth football as a physician, former player, coach, and—most importantly—loving father of a  youth football player.

Concussions. 

We cannot eliminate all risk from our children’s lives.  However, risk can be managed and minimized.   Therefore, two important questions to ask regarding concussions and sports are as follows: (1) can protocols be introduced so that the risk of concussion is at or below an acceptable rate  and (2) how is a concussion handled if one should occur?


Regarding the first question, there are many studies in the medical literature regarding this topic.  Research now demonstrates that limiting contact during practice, combined with teaching safer blocking and tackling techniques, lowers the concussion risk in youth football for a season to slightly less than one percent per season .  Of course there is risk of concussion in football and it will never be eliminated.   However, I find a 1% per season risk of concussion to be acceptably low .  Youth football has been shown to have a concussion rate of  0.6 per 1000 athletic events , where an athletic event is defined as a game or practice.   Therefore, the 1% statistic may be misleadingly high since it fails to account for the degree of exposure per athlete.     Concussions occur in nearly every sporting activity, and there are many activities and sports my son participates in that also place him at similar risk for concussion.  The rates of concussion for youth football and soccer (boys and girls) are roughly comparable.  Generally, these activities do not receive the same amount of negative press coverage as youth football . 


The second question, however, may be more important since research highlights the tremendous risk of letting a concussed athlete back into sports before they have healed.  One positive effect of the media scrutiny on football has been the heightened awareness regarding concussions among football programs.  Coaches and players are specifically trained in concussion recognition and management protocols in many football programs across the country.  I have 3 daughters, all older than my son, and between all four I have watched countless hours of nearly every youth sport.  I have found no sport as mindful of concussions and head injuries as football, even though many activities carry equivalent risk. 


Football is very different from the way it was taught and played twenty – even five – years ago; safety awareness now plays a prominent role in football culture.  Unfortunately, more work is needed in this area, for football and all sports, since research demonstrates persistent reluctance among some athletes to seek attention for potential concussion symptoms.  What matters most is identifying the concussed player and following extremely conservative protocols to ensure they do not return to play too soon.  The vast majority of youth players go through a football season without a concussion, so vigilance for such an unlikely event is crucial.  Coaches cannot see everything and will never know an athlete as well as their parent or guardian.  Therefore, parents and guardians are the front line against concussions, both for concussion[CY8]  recognition and education of their children to report potential symptoms.  Parents should never hesitate to bring any concern to any coach’s attention, and if the concerns are dismissed, report the coach and find another team for your child.  

Recently, some states (including New Jersey) have proposed legislation to ban tackle football under the age of 12 years.  The American Academy of Pediatrics assembled a task force in 2015 addressing youth tackle football and concluded there was insufficient scientific evidence to ban youth football. I do not believe youth tackle football needs to be banned.  Rather than ban the game, the measures that have been proven to make the game safer need to be strictly enforced, with consequences for those adults who fail to follow them.

There has also been a push to replace youth tackle football with flag football.  I find this problematic for two reasons.   First, because the concussion risk is low in youth tackle football (about 1% of participants per season), flag and tackle football have a similar concussion risk at the youth level (actually, in one study, flag football had a slighter higher concussion risk compared to tackle football).  Second, I believe teaching safe techniques at an early age will help ensure safer play at the high school level, where the kinetic energy of collisions is higher.  At the youth level, we mostly teach fundamentals of blocking and tackling.  We do not spend time on complicated offensive and defensive schemes because young kids cannot execute them, so we focus on safe blocking and tackling.  I believe this makes for better and safer high school players.  Click here for further reading: Concussion specialist discusses if we should we ban youth football

Chronic Traumatic Encephalopathy (CTE). 

Despite the tremendous media coverage, the risk of developing
CTE is, in fact, unknown.  Most of what is reported in the press is anecdotal or based on highly selected or  “convenience”  samples – this means that most of the patients whose brains were sent for autopsy were believed to have CTE before they died.  Such studies are important to link symptoms in life with autopsy findings after death (in fact, this was how the Alzheimer’s disease evolved), but one cannot determine the risk of developing a disease based on such studies.  Last July, there was tremendous coverage of a report that found CTE in 111 of 112 brains of former NFL players.   These players (or their families) thought they had CTE before they died and agreed to send their brains for autopsy, seeking confirmation of the diagnosis of CTE.  It does not mean, however, that the risk of a NFL player developing CTE is 111/112 = 99%, because the sample was referred.  To make a true determination of the risk of developing CTE among former NFL players, a large, unselected sample of former NFL players would need to be studied, whether nor not they had any symptoms of CTE before death.  Such data has not yet been published.

The CTE autopsy pattern has been described in deceased players of many sports, in veterans, and in individuals with just one head injury; it has also been described in people without a history of head injury.  Moreover, CTE is a diagnosis made by microscopic examination of brain tissue, but the extent to which the microscopic abnormalities of CTE correlate with clinical symptoms is unknown, and it is probable that there are former athletes with microscopic abnormalities but no symptoms.  That the brain can appear abnormal under a microscope but not correlate with symptoms before death is not unique – approximately 15% of brains on autopsy will have findings consistent with Alzheimers but with no history of dementia in life.  Furthermore, the symptoms of CTE – depression, memory impairment, mood disturbance – are widely prevalent in the US (among athletes and non-athletes).  Because the symptoms of CTE are nonspecific, the diagnosis can be challenging to make, and these symptoms alone in a former athlete do constitute a diagnosis of CTE, though frequently there is postulation that CTE exists because of prior exposure to football. 


More recently, reports have emerged suggesting that subconcussive head impacts can lead to CTE. It is crucial to bear in mind that few, if any, of these studies adequately control for the number of concussions an athlete sustained during their career, much less the severity of the concussion or how it was managed…and this is crucial.  Often, the researchers in these studies determine concussion exposure by asking family members of the deceased player whether he sustained a concussion during his career.  Yet the Concussion Legacy Foundation notes that only 1 in 6 concussions are diagnosed (to their credit, they are working hard to improve this).   Unfortunately, interviewing a family member to determine whether a player sustained a concussion during their career is likely inaccurate.  


To be clear, I believe CTE is a real entity and concern, especially for professional athletes—but there is much to be learned, particularly among non-professional athletes.  Importantly, it should be noted that many (but not all) of the players described with CTE today played in a by-gone era, and most played professionally.    Not only are the rules of the game different, but practices, the amount of contact in practice, and the awareness of head safety are vastly different now than they were even 5 years ago.    These changes are thankfully due, in part, to the work of physicians at Boston University who have stressed the importance of repetitive head blows.  CTE is a real entity but it is very complex, and we are just starting to learn about it. Click here for more on CTE : I'm a brain scientist and let my son play football.


I find it reassuring that two separate studies of former high school football players found no increased risk for cognitive disease (compared to those that did not play football) as these men aged into their 60s and beyond[CY11] .  These studies are important, because they are unselected.  In addition, they investigated men at ages when cognitive diseases are typically diagnosed.  Notably, these men played football when there were virtually no concerns for concussions or head safety.  A separate study of Division III athletes found that those playing collision sports did not differ from non-contact athletes with respect to neurocognitive testing after their college careers were completed.  There have been well over 1 million high school football players every year since 2000, far more than any other high school sport in the United States; there are an estimated 3 million youth football players.  The vast majority of amateur football players do not appear to be suffering an epidemic of cognitive disease.


Media bias?

Football commentator Danny Kanell was ridiculed when he suggested there was a bias in the media against football, but I believe his claim has some merit.  Rarely are research studies that portray football in a positive light covered widely by the non-medical publications.  The media’s reporting on issues related to football safety can be one-sided, if not misrepresentative. For example, CBS Sunday Morning ran a segment on head injuries in football and chose to profile a youth team from the Texas Youth Football Association (profiled in Friday Night Tykes).  This league has been widely criticized (as the segment points out), but CBS failed to describe the tremendous safety initiatives—which are yielding results—among football programs in Pop Warner Football, the largest sponsor of youth football in America.  


I am unaware of any major news outlet that has highlighted the studies that have demonstrated a 1% per season concussion rate in youth football[2], nor have they highlighted the aforementioned long-term studies of men who played football only through high school and had no higher rate of cognitive disease.  


Often, newspaper headlines sensationalize or overstate the scientific significance of a study, even when the scientists who authored the paper caution the interpretation of their data.  For example, recently scientists described poorer performance in certain elements of psychological questionnaires among mostly professional football players if they started playing before the age of 12 years[3].  The study had significant limitations, and the authors appropriately stated, literally, “Findings from the current study should not be used to inform safety and/or policy decisions in regards to youth football”.  What followed was a flood of calls to ban youth football, and politicians picked up on it.


Bennett Omalu, made famous by the movie Concussion, and who equates football to child abuse, wrote an Op Ed in the New York Times in 2015 calling for a ban on football.  In it, he referenced the American Academy of Pediatrics for publishing a position paper recommending that children should no longer be allowed to engage in high-impact contact sports, exemplified by boxing.  What Dr. Omalu failed to mention was that just a few months earlier, the American Academy of Pediatrics published the findings of their study group dedicated to youth tackle football, and found insufficient evidence for banning the sport. In fact, Dr Omalu’s mentor and co-author on the paper that described CTE, Dr. Julian Bailes, allowed his sons to play youth tackle football. 


Many other sports (men’s and women’s) are dealing with similar head injury issues that are less well reported, perhaps at a disservice to the athletes participating in those sports.  This is unfortunate because a balance of studies published in the medical literature should be presented to parents and students contemplating football.  Perhaps this bias exists because taking down football, America’s most popular sport, leads to sensational headlines.  Also, the NFL is generally criticized for how it initially handled the issues of concussions and CTE.  But youth and high school football are not the NFL, and that must be kept in mind when studies of NFL players are published.  Professional players have had much longer careers at a much higher level and have historically failed to report their concussions, or have them treated.  There are about 1700 active NFL players during the season compared to about 1.1 million high school football players—the chances of a high school player making it to the NFL are much less than 1%.  Research findings of professional players cannot be extrapolated to amateurs because a sample consisting of professional football players is not indicative of the total football playing population.   


Football is special 

We live in the video-game era with its attendant increasing rates of youth obesity and diabetes.  Nowadays, team sports are often a child’s primary source of exercise.   For kids who aren’t terribly athletic, football offers the opportunity to meaningfully participate and even excel on a team sport.  Unlike other sports, many football positions do not require hand eye coordination or the ability to run fast.  Strength, along with agility and quickness (which are different from speed), can always be improved upon and these are the core elements needed to play football.  Some of the most valuable life lessons learned in football stem from the fact that for many players, the difference between getting on the field or not depends on the amount of effort put in during the offseason, rather than inherent athletic ability.  Generally, if a player works hard and is tough, they will get onto the field and succeed, regardless of raw athletic talent

Football fosters toughness and perseverance—not just physically, but mentally.  It takes courage to line up against someone a foot away from you and compete for four quarters.  We tell our players they should be “tough below the neck”.  We expect any and all head or neck concerns to be reported immediately, but we also expect players to play through bumps and bruises.  Mental and physical toughness are valuable life skills and these are only developed though challenge.     


Football is truly unique among team sports, arguably the ultimate team sport.  Teams are comparatively large, and often diverse.   It is essential that the entire team (coaches included) prepare for a common opponent for a week.  The team is singularly focused on implementing an integrated game plan that requires all team members to execute effectively.  This intense preparation and dependence on team members creates special friendships.  Former players speak of the brotherhood of football with good reason.  


Conclusion.  Playing football was an overwhelmingly positive influence on my life, and I hope my son will have the same experience.   There are risks, but I know I cannot protect my son from everything in life.  Moreover, I believe the data demonstrates that when appropriate safety precautions are taken, football’s risks can be minimized to an acceptable level[CY15]  and which is comparable to the level of other sports.   I also let him ride a bike, climb trees, swim in the ocean, and ski –I don’t think that makes me a bad parent.   I credit youth football programs (which seem to be ahead of other youth sports) for their efforts to educate coaches, parents, and players regarding concussions which is crucial for all athletics.  I will continue to follow football safety closely in the medical literature rather than the media.  I will be the first to prohibit my son from football if the risks are unacceptable.  At this point, the data, in my view, does not support keeping him from a game that has been a positive influence on boys and young men for decades.


[1] Disclosure – I am neither a neurologist nor neuroscientist.  My specialty is advanced heart failure and transplant cardiology.  However, I have a Masters in Public Health with a concentration in epidemiology and can usually determine the merit and generalizability of a medical study.  I have no financial or research conflicts of interest as it pertains to football.   All activity related to our youth organization is voluntary.

[2] Actually, the New York Times criticized the study that demonstrated a 1% concussion rate.  The study compared cohorts practicing Heads Up Football techniques (HUF), Pop Warner rules for restricting contact (PW), both HUF & PW, or neither.  The most important element in achieving a 1% concussion rate appears to be PW.  The Times criticized the authors because they had published an earlier, preliminary paper that touted HUF. 

[3] Different authors were unable to replicate these findings.


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