Brain Health in Contact Sports: Putting It All on the Line

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For more than 50 years, the AAP's stance on youth tackle football was that this high-risk sport had no place in programs for children 12 and younger.
For more than 50 years, the AAP's stance on youth tackle football was that this high-risk sport had no place in programs for children 12 and younger.

As we approach another fall season, my practice sees a significant increase in the number of physical exams for school and pre-participation physical exams for sports. Well-child exams and adolescent physicals tend to be a nice, comfortable spot on the schedule as children and adolescents usually tend to be healthy. While the visit may be prompted by a school form or immunization requirement, they do help get the children into the office each year — and this provides an excellent opportunity to focus on safety, including high-risk behaviors. 

Recently, while completing a form with a parent, I was discussing their child's intended activity and found myself becoming uneasy, particularly because this small early adolescent was joining the "varsity" football team. 

My concern was underscored by a report published just a week or so prior in a JAMA report revealing that 110 out of 111 deceased professional football players' brains on autopsy showed chronic traumatic encephalopathy (CTE).1 Brains subjected to repeated trauma or concussion have been found to have increased Tau protein deposition, which is associated with brain cell degeneration. Changes in the brain can begin months, years, or even decades after prior brain trauma. This degeneration is commonly associated with symptoms such as memory loss, confusion, impaired judgment, impulse control issues, aggression, depression, increased suicidality, Parkinsonism, and progressive dementia.

This prompted me to look into the American Academy of Pediatrics' (AAP) positions on a few of the contact sports, which are reassessed every 5 years and updated. For more than 50 years the AAP's stance on youth tackle football was that this high-risk sport had no place in programs for children 12 and younger. While a clear stance for ice hockey and boxing has been taken by the AAP, their position on youth tackle football does not seem consistent with the other two sports. Their opinion on boxing is that “there is no place in programs for children.” The policy on ice hockey is that "body checking should not be allowed for children ages 15 years or younger." They even recommended an expansion of non-checking programs for boys and older.

But back to football. AAP's position here is a little more ambiguous: "Removing tackling from football altogether would likely lead to a decrease in the incidence of overall injuries, severe injuries, catastrophic injuries, and concussions. The AAP recognizes, however, that the removal of tackling from football would lead to a fundamental change in the way the game is played. Participants in football must decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling."

This position essentially leaves it up to the parents and their children to decide whether they think that the risks outweigh the benefits. While I support and admire the AAP for empowering families, I believe it is hard for parents to make a well-informed decision in this situation. I have had parents tell me that football can be safe if children are taught to tackle the "proper way." The problem with that is that children and adolescents are impulsive, and even with excellent education and coaching, during a game they may have a hard time controlling themselves, as do adults sometimes.

The AAP will update their position on football in 2020. It will be interesting to see the stance they take based on the most recent information. It may take many years, but I am sure that at some point in the future the rules for youth, and probably even professional, contact sports are going to have to change.

At this point, I don't endorse parents having their children play tackle football. I recommended to one family that they consider an alternative sport with significantly less risk for impact injury. My recommendation, however, went unheeded as the desire to play the sport was much stronger.

As a former ice hockey player myself, I know this game, too, needs to change in order to protect the brains of our current and future generations.

References

Mez J, Daneshvar DH, Kiernan PT, Abdolmohammadi B, Alvarez VE, Huber BR, et al. Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football. JAMA. 2017;318(4): 360–370.

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