A Healthcare Provider’s Guide To Chronic Traumatic Encephalopathy (CTE):
Diagnosis, pharmacologic management, non-pharmacologic management, and other considerations
Tolerable Risks? Physicians and Youth Tackle Football
At least 11 U.S. high-school athletes died playing football during the fall 2015 season. Their deaths attracted widespread media attention and provided fodder for ongoing debates over the safety of youth tackle football. In October 2015, the American Academy of Pediatrics (AAP) issued its first policy statement directly addressing tackling in football. The organization’s Council on Sports Medicine and Fitness conducted a review of the literature on tackling and football-related injuries and evaluated the potential effects of limiting or delaying tackling on injury risk. It found that concussions and catastrophic injuries are particularly associated with tackling and that eliminating tackling from football would probably reduce the incidence of concussions, severe injuries, catastrophic injuries, and overall injuries.1
But rather than recommend that tackling be eliminated in youth football, the AAP committee primarily proposed enhancing adult supervision of the sport. It recommended that officials enforce the rules of the game, that coaches teach young players proper tackling techniques, that physical therapists and other specialists help players strengthen their neck muscles to prevent concussions, and that games and practices be supervised by certified athletic trainers. There is no systematic evidence that tackling techniques believed to be safer, such as the “heads-up” approach promoted by USA Football (amateur football’s national governing body), reduce the incidence of concussions in young athletes. Consequently, the AAP statement acknowledged the need for further study of these approaches. The policy statement also encouraged the expansion of nontackling leagues as another option for young players.
The AAP committee shied away from endorsing the elimination of tackling in youth football, because doing so would fundamentally change the way the game is played. Yet evidence indicates that tackle football in its current form is inconsistent with the AAP mission “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults.” Repetitive brain trauma can have serious short- and long-term consequences, including cognitive and attention deficits, headaches, mood disorders, sleep disturbances, and behavioral problems. To significantly reduce the incidence of brain trauma in young people, I believe that physicians should consider endorsing strategies that alter the way football is played.
In the 1950s, the AAP took a much stronger stand against tackle football for children. The focus then was primarily on orthopedic injuries. Representing the AAP at a 1953 conference on planning programs of games and sports for young children, Dr. George Maksim argued that in football and several other contact sports, “the risk of permanent bone and joint injuries is just too great.”2 The 44 conference delegates, who represented medical, educational, and recreational organizations, recommended excluding body-contact sports, including tackle football, from programs for children 12 years of age or younger. In 1957, the AAP Committee on School Health issued a policy statement on competitive athletics for children in that age group, similarly concluding that “body-contact sports, particularly tackle football and boxing, are considered to have no place in programs for children of this age.”3
Yet as youth football grew in popularity, such medical objections were largely overshadowed by broader cultural trends favoring the expansion of competitive collision sports for children. The belief that careful supervision by coaches, athletic trainers, and doctors on the sidelines was the key to making youth tackle football safer increasingly predominated over the ensuing decades.
In addition, long-standing beliefs about the social value of youth football strongly shaped medical advice. For example, in 1956, Allan Ryan, chair of the American Medical Association’s Committee on Sports Injuries, wrote that the association was working with educators and coaches to highlight “the character-building advantages of football” while minimizing the risks.4Ryan portrayed football as a healthy sport that helped build boys’ bodies and promote teamwork but one that could be dangerous, even “a killer and a maimer,” without medical supervision. He advocated regular physical examinations of players conducted by physicians, properly fitting uniforms, and pre-play warm-ups as effective means of preserving the benefits of the “wholesome and valuable” sport.
The investment of coaches and team physicians in football, including in its perceived personal and social benefits, influenced their beliefs about the sport’s risks and the solutions they promoted to address safety concerns. Coaches and doctors have typically recommended the involvement of more coaches and doctors to minimize the risks associated with tackling while fostering the benefits of football as a recreational sport. The apparent need for supervision, in turn, helped justify the expansion of adult-organized youth leagues.
Several historians and philosophers have proposed that a “technological imperative” — a focus on technological approaches to medical problems — tends to prevail in medicine, particularly in the United States. The technological imperative is exemplified by efforts to improve helmet design as a predominant approach to preventing football injuries. In youth football, there also seems to be a “supervisory imperative” — a belief that adult supervision is necessary and even sufficient to ensure player safety.
Yet the long-standing emphasis on medical supervision, which is evident in the AAP’s recent policy statement, doesn’t address the risks inherent in youth football. Players in excellent physical health, enjoying the best medical supervision available, can be catastrophically injured or killed when they are involved in full-on collisions. Far more often, young athletes sustain less obvious but potentially cumulative damage to their brains from repeated hits.
Contemporary medical concerns about collision sports are concentrated on brain trauma, rather than on the bone and joint injuries that were the focus of mid–20th-century objections to football. Litigation and safety concerns related to head injuries have recently induced changes in youth sports beyond football. Notably, in November 2015, the U.S. Soccer Federation announced new policies to prohibit players 10 years of age or younger from heading the ball and to reduce the numbers of headers in practice for athletes 11 to 13 years of age.5 Today, both the short-term and long-term consequences of concussions are more troubling than ligament tears or broken bones. Brain injuries are also more difficult to treat, even with prompt medical attention. Consequently, confronting tackle football’s risks is even more urgent now than it was when the 1957 AAP committee recommended against children’s participation in the sport.
Perhaps most important, the AAP’s latest statement concludes that it is up to participants to decide whether the risks of tackle football “are outweighed by the recreational benefits associated with proper tackling.” Yet in the case of children, who are not fully autonomous and who are unable to fully weigh the long-term risks and benefits of playing football, physicians should not leave it up to participants to make such decisions. I believe it would have been more effective for the AAP, after clearly laying out the relevant evidence, to encourage a broader conversation among communities, parents, and school boards about whether it is acceptable to expose children to the risks of potentially severe head injuries associated with tackling.
It is understandable that the AAP has promulgated policy recommendations that seek to minimize the harm of tackle football as it is currently played, given the cultural prominence of football in the United States. But physicians also have a role to play in shifting the culture when it results in harm to children’s long-term health. Recommendations that prioritize children’s health should extend beyond supervision of risky activities to include counseling against them. Stronger recommendations against tackling would deepen public appreciation of the severity of the risks associated with repetitive brain trauma and would promote broader discussion about whether these are tolerable risks for children to undertake.
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