The American Academy of Pediatrics (AAP) recently issued new recommendations for making football safer for children and teens: Officials and coaches should have “zero tolerance” for illegal head-on hits, skilled athletic trainers should be on the sidelines during every game, and nontackling leagues should be expanded.
“Parents and players will need to decide whether the health risks associated with tackling are outweighed by the recreational benefits of the game,” one of the authors of the new recommendations said in a released statement. “The AAP encourages athletes to continue playing organized sports, while supporting coaches and officials in their work to reduce these injuries.”
Two University of Minnesota physicians — Dr. Steven Miles, a professor of medicine and bioethics, and Dr. Shailendra Prasad, an associate professor of family medicine and community health — believe the AAP does not go far enough.
In a commentary that will appear in the January issue of the American Journal of Bioethics (but is already posted online), they say the AAP and other health professionals should be calling for an end to tackle football — at least, in publicly funded schools.
We agree with the AAP that the rare deaths (seven through October 2015) or catastrophic neck injuries do not, of themselves, tip the balance against school football. Tragedies occur in other sports and activities that young people pursue. Youth football also brings high risks of sprains, strains, ligamentous tears and fractures but these risks are roughly comparable to other sports.
Public schools should end their football programs because of the high prevalence of concussions. Five to twenty percent of students experience at least one concussion in a season of play. Nine to twelve year old players experience an average of 240 head impacts per season; high school players average 650 head impacts per season. An initial football concussion increases the risk of a subsequent concussion three or four fold not simply for the balance of that season but for the following season as well. Catastrophic brain injuries, though rare, are far more common in high school and college players who have experienced a previous non-catastrophic concussion.
The brains of children are more susceptible to long-term damage from concussion than adults. Although the frequency of concussion in football is about the same as in hockey, fifty times as many students play football than hockey; football causes far more brain injuries. The brain is an irreplaceable organ, the health of which is foundational for the ability to learn, socialize and for fully realizing life’s physical and vocational opportunities.
In the short term, football-related concussions — even mild or moderate ones — can lead to “impaired school academic performance, memory disturbances, headaches and absenteeism,” Miles and Prasad write.
But, as the two physicians also point out, concussions pose serious long-term risks for young people, too. The cognitive problems can become permanent, particularly if the trauma to the head is repeated.
Informed consent and dual loyalties
In its recommendations, the AAP suggests that parents be given an informed consent form to sign before their child plays football, so that all the risks associated with the game are known to them.
But, as Miles and Prasad note, “existing consent forms are deeply flawed. They do not quantify risk or they minimize it with misleadingly contextualization (e.g., “There is a degree of risk in all daily activities.) The consent forms do not rebut the ungrounded hope of 26% of parents, especially those with economic and educational disadvantages, that their child will turn school participation in to a professional athletic career. Even when parents have been educated by the team and signed consent, many student players do not understand the symptoms or potential consequences of concussion.”
School football programs are also rife with dual loyalties, which, as the two physicians explain,
can affect a team physician or coach’s assessment and counseling of an aspiring football player. Risks may be minimized as students sign up to play. The potential for training, equipment, rules and refereeing to reduce concussions may be overstated. Injured players may be prematurely permitted or encouraged to ‘choose’ to return to play. Such issues affect the authenticity of choices of students who are also influenced by appeals to ‘school spirit,’ the mirage of a pro career, or peer pressure especially in smaller communities that have few candidates to fill a team roster.
Dual loyalty conflicts also work at an institutional level. School football is big business and a large part of popular culture. It is fiercely protected as is evident in the words of a judge who dismisses an injured player’s lawsuit for fear it might “harm” the sport.”
The authors of the AAP’s new recommendations, say Miles and Prasad, also appear to fear “harming” the sport:
The report inexplicably omits discussing the effects of concussion on academic performance (the reason for going to school). It argues for respecting the ‘choice’ to play without noting how that schools, parents, coaches or the unrealistic aspirations for a pro career may pressure ‘choice’. It fails to offer an evidence-based template for informed consent, essentially preserving the current model of consent as a liability waiver. The report is optimistically speculative as when it suggests that neck strengthening might decrease the catastrophic neck injuries or cautions that that raising the age at which tackling is allowed might increase injuries. Throughout, the report upholds the tradition of youth tackle football against “fundamental change” even though scientific evidence is clearly trending in the opposite direction.
Time to take a stand
Miles and Prasad conclude their commentary by proposing that all health professionals take a stand against football in public schools:
By this option, health professionals would oppose public support for bonds to build stadiums or athletic facilities for junior or senior high school football. They would oppose public school programs granting academic credit for playing football or leave of absences for practice or games. Such a proposal would not ban youth football. Private play and private leagues, like the Pop Warner program, would continue. Young people choosing such programs would play purely for the game and not be lured by ‘school spirit.’ Health professionals would continue to promote life long exercise programs and school physical education programs. However, under this proposal, the medical community could help students, schools and society leave a sport on which the sun is setting.