Column: The Reclassification of Football Part II
Editor’s Note: This is the second installment of the three-part series by Dr. Andrew Blecher on the state of football, and the all-important issue of concussion. The series is also being published in Concussion Litigation Reporter. For more details on how to subscribe, click here.
The High School and Youth Game of Football
by Andrew M. Blecher MD
In Part I we recognized that professional tackle football is a truly unsafe sport. Even though we enjoy it, in our hearts and minds we know that the NFL is just as brutal as boxing and MMA. It’s bloodsport. But if grown men want to risk bodily harm for money, fame, the love of the game or whatever other reason they choose, then so be it. Adults choose lots of risky or unhealthy behavior all of the time. But these are adults. Now let’s talk about kids. I remember trying tackle football for the first time when I was eight years old and I remember trying it again when I was eighteen. What a tremendous difference. The eight year old thinks that the game is fun and occasionally you might get hurt. The eight year old also has no clue what the words “possibility of permanent long-term cognitive dysfunction” even mean. The eighteen year old on the other hand knows that the game is fun and also knows that you are likely to get hurt. The eighteen year old does know the terms “permanent long-term cognitive dysfunction”, but he also thinks he is invincible so it won’t happen to him. But in the end, the eighteen year old is making a choice to play football. Is the eight year old also making a choice?
In the medical world a child cannot consent to being a participant in a research study. Why? According to the National Institutes of Health Protecting Human Research Participants:
“Children may not have full capacity to make decisions in their own best interests; and therefore: “Persons who have not attained the legal age for consent to treatments or procedures involved in the research, under the applicable law of the jurisdiction in which the research will be conducted.”
- Children are considered a vulnerable population, and
- Children are unable to provide “legally effective informed consent”
A legally-effective, voluntary agreement that is given by a prospective research participant following comprehension and consideration of all relevant information pertinent to the decision to participate in a study.
Because children cannot provide informed consent, children provide assent to participate in research, to the extent that they are able, and parents/guardians give permission for a child to participate in research.”
So can a child consent to playing tackle football? Well maybe they can in their backyard but not in any sanctioned league. A parent or legal guardian must sign a release form to allow them to play. But this is true of any interscholastic or organized youth sport. So why am I making a big deal out of this? Because parents can feel confident that participating in interscholastic or youth sports are likely to be beneficial for their children and have an extremely low likelihood of posing any long-term health risks to their child. But is this true about tackle football as well? Honestly, I believe the medical and scientific community is starting to question it. We hear about the unfortunate second impact syndromes in high school football players that result in death or permanent disability. This year already there have been five fatalities of high school football players due to trauma and the season has just barely begun. We also worry that all of the concussions and repetitive sub-concussive blows at such an early age may contribute to developing CTE later in life. So the truth is that we really can’t yet quantify how tackle football poses health risks to our children and we are still doing research to figure it out. So essentially, playing youth tackle football is research.
Let’s design a research study that recruits adult males to undergo baseline testing to evaluate their cognitive brain function. Let’s divide them into two groups. One group will have to go out into their driveway naked and run full speed into their garage doors. They will have to lower their heads just before impact so that they hit the door head first at full speed. We won’t re-evaluate them after the impact. Instead we will give them about 24 seconds to recover but then they will have to run into their garage door again. They will have to repeat this about one hundred times before they can call it a day. We won’t re-evaluate them at the end of the day either, but we will have them repeat this once a week for 16 weeks. Then they will have to repeat this every year for about 10 years. Then the subjects will be re-evaluated. Their scores will be compared to the other group that never had to run into their garage doors. The study will be designed to see if repetitive running into your garage door causes any long term brain damage. How many volunteers are we going to get for this study? It sounds ridiculous, right? We could never perform a study like this. It would never pass a review board. Well now let’s repeat the study but give them pads and a helmet. Does that change anything? We already know that the helmet doesn’t protect the brain inside. This would still never pass a review board. But instead of a study let’s call it a game and pay the volunteers a lot of money. Ok I admit I might sound a little cynical here but is it really that far off? Football is research. We don’t have the answers. As unethical as the above study might sound, it’s even worse if it were conducted in children. Not only are they a vulnerable population that cannot provide informed consent to a study, but they may even be more at risk in the study itself. We know that the human brain continues to develop until at least age 18 so a child’s developing brain may be more susceptible to trauma than an adult’s. Perhaps that is why second impact syndrome almost always occurs in teenagers. Perhaps that is also why the incidence of concussion is almost twice as high in high school as it is in college. Whether we blame the smaller relative neck sizes or the poor tackling technique or whatever other reason you choose, it certainly seems that children are not only a vulnerable population by study standards, but their brains are more vulnerable by any standard.
So if children are by definition a vulnerable population that are unable to consent to a sport that has a higher incidence of brain injury and a potentially worse outcome than their adult counterparts, should they really be participating in it? Is the risk vs. reward balance still in their favor especially since there is no fame and fortune to be had in youth football? Should they be playing tackle football at all? Some say no. Some say tackle football should be eliminated for kids under the age of 14 or maybe even age 18. I don’t know that it necessarily needs to be eliminated, but it does certainly need to evolve. Let’s look at boxing and martial arts again. These sports do exist on the youth level, but the youth versions are far safer than the adult professional versions of the sport. We don’t see the professional versions in our schools because there is too much liability and it is generally considered unsafe. Every parent knows this at a gut level. So why can’t we see a safer and more diluted version of tackle football in our schools? The NFL talks about evolution but it is evolving at a glacier’s pace. Youth football on the other hand needs a major evolution. It needs to separate itself from the professional game. After all, we have reclassified professional football as a brutal sport. We cannot let our children play a brutal sport. The youth and high school version of football also needs to be “reclassified” and become significantly different from that of the NFL. Of course the NFL will resist this change because they don’t want to lose their “feeder system”. But one of the NFL’s defenses in the lawsuit against them is that any causal link between football and CTE might be due to the thousands of hits and head trauma that occurred in youth, high school and collegiate football while the brain was still developing. Therefore how can the NFL be held responsible if the damage was already done even before the players entered the NFL. Well, NFL, you can’t have it both ways. If the NFL is not to be blamed and youth football is, then it is youth football that must be changed. Now that doesn’t mean that I’m in favor of reducing the game to two-hand touch or flag football. It does however, mean that youth football can evolve into a less brutal contact or even collision sport. It must be a sport that has absolutely no repetitive or purposeful head contact at all. Sure we can’t completely eliminate head injury from any contact sport but we can significantly reduce it. Tackling and collisions can continue to exist, but any head contact or leading with the head on any play, be it tackling or blocking, offense or defense, must be completely eliminated from the game. We will need to have major changes in football rules, equipment, education and culture in order to get this done. The way the game is played, coached and taught will need to evolve. Intentional head contact of any kind must lead to immediate ejection. Tackling and blocking techniques must be completely changed to eliminate all head contact. The helmet must be redesigned so that it cannot be used as a weapon. The helmet’s sole purpose is to prevent skull fractures. Unfortunately its design has developed such that it is now the players hardest shell on his body and thus his best tool to tackle or block another player. It is used as a weapon because of its design. This is simple instinct. This must be eliminated. It cannot be simply “coached away” with a heads up tackling campaign. Helmet redesign must go along with the rule and coaching changes. The facemask must also be redesigned so as not to encourage leading or blocking with the face. The athlete must have absolutely no incentive to use the head to initiate contact. In fact, the helmet /facemask unit must be redesigned to create a disincentive to use it to initiate contact. Instead of making helmets that are “more comfortable to hit with”, we need to do the opposite. These changes may be costly and they may be unpopular but this evolution needs to happen until such time that we can prove that tackle football is safe and is no longer a research study on long term head trauma.
Because these changes will be unpopular, they will certainly be resisted by players, coaches, parents and fans. So how can we enforce these unpopular changes? As suggested in part I, if one were so inclined, we could force the changes in the NOCSAE standards so that their football helmet certification matches what the helmets are truly being tested for. Football helmets would therefore only be certified for a single day of use. Without any certified helmets for repetitive use beyond one day, tackle football would only be able to continue if new helmets were issued for every single day of practice and for every single game. This would become so cost prohibitive that schools and youth programs would be forced to make a choice to either abandon tackle football, or to accept a change in the rules and a change in the equipment. In addition, if a sport is going to be played with such a high risk of head injury, then it should be mandated that a representative with experience in diagnosing and managing head injuries (such as a certified athletic trainer) would need to be in attendance for every practice and every game, just like the coaching staff. This needs to be the case not only for varsity football, but for every single level of tackle football in every single school and every single youth program. In order to play organized tackle football there must be equipment, coaches AND an athletic trainer. If the program cannot afford an athletic trainer, then it cannot afford tackle football. Period. This may mean that due to economic constraints, not every child may have an opportunity to participate in tackle football. Some may argue that it will not be fair to inner city children. Well not every child has the opportunity to participate in boxing or karate either. Not every child has the opportunity to participate in skiing, or skating, or fencing, or horseback riding or many other sports for that matter. But either we need to make every effort for our children to participate in these sports safely, or they should not be participating in them at all. I think tackle football is a great sport and I have decided that I want my child to be able to participate in it. But I also don’t want to regret that decision forty years from now. Only time will tell just how dangerous tackle football really is to the developing human brain. But when it comes to a generation of our children, can we really afford to be on the wrong side of history on this one? The only solution is that tackle football for minors must evolve and it must evolve now. There is no time to wait.
Stay tuned for the most complicated part of the story with Part III of: “The Reclassification of Football: The Collegiate Game”
Leave a Reply
You must be logged in to post a comment.