Last month, the American Academy of Pediatrics (AAP) endorsed efforts to limit contact practices in youth football, but declined to make a clear recommendation in favor of delaying the age at which tackling is introduced. The AAP likewise refused to support those calling for an outright ban on tackling in football for athletes below age 18, unwilling to recommend at this time such a fundamental change in the way the game is played.

Writing for the AAP's Council on Sports Medicine and Fitness, William Meehan, M.D., Director of The Micheli Center for Sports Injury Prevention at Boston Children's Hospital, MomsTEAM concussion expert emeritus, and an expert featured in our PBS documentary, The Smartest Team: Making High School Football Safer, along with co-author, Gregory Landry, M.D., a professor of pediatric and adolescent primary care sports medicine at the University of Wisconsin School of Medicine and Public Health, recognized that head and neck injuries in football have been a topic of "intense interest recently in both the public media and the medical literature."

They acknowledged that safety concerns -- especially about the risk of concussions and catastrophic injuries -- have led to a drop in football participation, and likewise recognized that the potential for adverse long-term health consequences from multiple concussions and repetitive head impacts (RHI) had not only prompted calls for limits on the number of full-contact practices and a delay in the age in which tackling is introduced, but for an outright ban on tackling in football.

Noting that the effect of RHI on long-term cognitive function, the incidence of chronic traumatic encephalopathy (CTE), and other health outcomes remains "unclear," and that further research was needed, the group nevertheless endorsed efforts to reduce the number of impacts to the head in football because, "Repetitive trauma to the head is of no clear benefit to the game of football or the health of football players."

The AAP saw in a delay in the age at which tackling is introduced both benefits (a likely decrease in risk of injury) and potential risks (once tackling was introduced, athletes lacking tackling experience might be exposed to an increased risk of injury). The group therefore decided that no "informed recommendation" could be made until further investigation into the effects of delaying the introduction of tackling until a certain age could be made.

Despite recognizing that an outright ban on tackling would likely lead to fewer injuries of every kind (e.g. overall injuries, severe injuries, catastrophic injuries, and concussions), the AAP decided against recommending a complete ban on tackle football, largely because removing tackling from the game would lead to a "fundamental change in the way the game is played." The group thus left it to "participants" to "decide whether the potential health risks of sustaining these injuries are outweighed by the recreational benefits associated with proper tackling."

Step in right direction

As someone who has been working for 15 years to make youth football safer, I was glad to see the nation's largest and most prestigious pediatrics group support so many of the evidence- and expert consensus-based recommendations MomsTEAM and I have been making to improve the safety of the game, and which were featured in our 2013 PBS documentary.

Like the AAP, MomsTEAM has long supported limits on full-contact practices as a way not only to reduce concussion risk but RHI, which likely plays a role in the development of neurodegenerative diseases such as CTE.

Research presented at the AAP's meeting in Washington, D.C. last month shows that such limits actually work to reduce concussion rates at the high school level (where an increasing number of states have followed the 2014 recommendation of the National Federation of State High School Associations in imposing limits), just as an earlier study showed that such limits (adopted by Pop Warner in 2012) -- along with teaching USA Football's Heads Up tackling -- are working to reduce concussion risk in youth football.

That the AAP decided not to join those calling for delaying the age at which tackling is introduced in youth football was not surprising. As one who has been following the debate on this issue for a number of years, and based on my experience working with youth football programs around the country the past two seasons as part of our SmartTeams program, I think there are good arguments on both sides, and that the AAP was right not to call for such a delay in the absence of more research.

Likewise, the AAP's refusal to recommend an outright ban on tackle football at the youth, middle and high school because it would fundamentally change the way the game is played was not in the least surprising. Like the AAP, I have long held the view that the decision about whether a child should play tackle football, and at what age to start, should be left up to parents, in consultation with their child's pediatrician, based on an honest assessment of the risks associated with the sport versus the benefits of participation.

Recent research shows that teaching proper tackling and limits on full-contact practices, along with other safety measures, such as making sure helmets fit properly, and immediately removing players showing any signs or reporting any symptoms of concussion and not allowing them to return until cleared by a medical professional with concussion expertise (all of which are part of the evidence-based Six Pillars approach to concussion risk management featured in The Smartest Team) has made and continues to make the game of football safer.

Still work to do

But there is still a lot we can and should do. Despite the fact that helmet-first tackling was banned in 1976, the sad truth is that the rule is still not adequately enforced. Perhaps adding the AAP's voice to the chorus of those calling for stricter rules enforcement (the NFHS, for one, has strengthened its rules against "targeting" defenseless players, and "spearing") will finally result in concrete action to do just that.

Likewise, working to put athletic trainers on the sidelines at all tackle football games and practices is a goal almost universally shared by the sports safety community. The challenge, as I have found from my experience working the last two years with youth football leagues around the country, is that not all programs can afford the cost of an athletic trainer; even if they could, finding one to provide coverage on weekends (when most are busy staffing high school football games) can be difficult. Simply put, there aren't enough ATs to go around, with access to ATs in rural communities -- where football is almost a way of life -- presenting a particular challenge).

Thus, while a certified athletic trainer at every youth football game and practice is the gold standard which I have long supported, and we have made significant progress in recent years towards the goal of giving every high school athlete access to an AT (a 2015 study published in the Journal of Athletic Training pegs the percentage at around 70%), I believe, from a practical standpoint, that programs for younger football players (those ages 7 to 12), forced to choose between hiring an AT and shutting down the program, can probably get by with game day coverage from volunteer paramedics, RNs and LPNs, or medical doctors (as long as they have received training in the recognition of concussion), and even from parents and coaches who have completed the CDC's Heads Up program (as parents and coaches in our Grand Prairie, TX SmartTeams pilot program are taking, along with a Red Cross first aid, CPR, and AED course).

If an athletic trainer or health care professional with concussion training is not present, however, experts say that there are two essential ground rules which must be followed: first, if a concussion is suspected (in other words if an athlete exhibits any signs of possible concussion (balance problems, confusion, vomiting, dazed look) or reports experiencing any symptoms (e.g. headache, dizziness, memory problems etc.), the player needs to be removed from play, their helmet taken away, and barred from returning to play under any circumstances; and, second, if a concussion is suspected, the athlete must be referred for a full evaluation by a clinician; no layperson is qualified to determine that it is safe for an athlete to return to play, no matter what the results of a sideline test may say, even one marketed for supposed use by non-medical personnel.

The under-reporting of concussions by athletes, as Bill Meehan and fellow MomsTEAM Institute board member, Jim MacDonald, reported at the AAP conference in D.C. in October, continues to defy efforts to persuade more athletes to honestly self-report through education. That culture of resistance, and the win-at-all-costs attitude that is deeply entrenched in our sports culture, represents significant challenges to improving the safety of contact and collision sports. Change is not going to happen overnight.

But efforts, including by MomsTEAM under a NCAA-Department of Defense Mind Matters Challenge grant, are being made to move the culture of sports towards safety by working with the key influencers of an athlete's attitudes and behavior -- parents, teammates, and, above all, coaches -- to create an environment in which athletes feel safe in self-reporting and are confident that they won't be penalized for reporting by a loss of playing time or being viewed as weak.

A multi-pronged approach to football safety, such as advocated by the AAP in its Policy Statement, and by the experts with whom I work on daily basis, is working. We just have to keep not just talking the talk, but walking the walk.

---

Brooke de Lench is Executive Director of the non-profit MomsTEAM Institute, founder and publisher of MomsTEAM.com, producer of The Smartest Team: Making High School Football Safer (PBS), and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins). You can follow Brooke on Twitter @brookedelench and reach her by email at delench@momsteam.com.

Originally published on October 28, 2015 on Huffington Post.com  

 

n/a

Now that the concussion lawsuit filed by retired National Football League players has apparently been settled (remember: the judge still has to give her approval), it's time to focus on the upcoming football season, and working to make the sport safer at every level of the game.

Sincerest form of flattery

We could sit back and wait for the N.F.L., National Federation of High School Associations (NFHS), USA Football and Pop Warner to lead the way on football safety.

From personal experience over the years, I believe that waiting for national organizations to act and adopting a complete top-down approach would be mistake.

In 2002, after USA Football was formed, I wrote to the organization encouraging it to put safety first by requiring, among other things, that all its coaches have appropriate safety training, and by adopting a concussion policy. I was met by silence.

Seven years later, USA Football finally got back to me, asking me to put together a proposal on ways that MomsTEAM could help the organization make the sport safer. I again recommended that USA Football do more than it was doing on concussion safety, such as by training coaches to teach youth football players Coach Bobby Hosea's "Heads Up" tackling and doing more concussion education of coaches, parents, and players.

Finally, in late 2011, USA Football began adopting some of what we had been recommending for ten years.

I had a similar experience in trying to work with the N.F.L. During my 2008 keynote speech at the National Sports Concussion Symposium, I gave the league a long list it could use to help make the sport safer at the youth level (a list I have been constantly updating; for the most recent checklist, click here). I remember being chided for having the temerity to suggest that the N.F.L. was not doing all it could be doing to improve football safety.

Yet it wasn't too long after that I saw that the league implementing some of my suggestions (such as my recommendation that they join with MomsTeam in sponsoring public service announcements about the dangers of concussions in sports, although the PSAs that ultimately aired were, of course, sponsored solely by the league).

In the fall of 2012, the N.F.L. invited me to its New York City headquarters to present a proposal to the league on ways that I thought MomsTEAM could help them preserve and strengthen the sport of youth football, in part by educating parents, and especially safety-conscious moms, about the dangers of concussions and ways in which the risk of concussion could be reduced.

Like USA Football, the N.F.L. went ahead on its own to implement some of our recommendations (witness N.F.L. Commissioner Roger Goodell's recent visit to Columbus, Ohio, where he co-hosted, with Ohio State football coach Urban Meyer, a safety clinic for 600 mothers of youth football players).

This past June I was invited to a press event at the NFL headquarters, where representatives from a group of national governing bodies for team sports talked about their safety initiatives, which showed just how far behind the NFL and its youth football arm, USA Football, had been until recently. To their credit, they pulled together this meeting to learn from the other national organizations whom I have been advising since 2002 such as US Lacrosse, which has been a leader in making its sport safer.

I say until recently, because I believe that, over the past two years, the NFL, USA Football and Pop Warner have done yeoman's work to catch up on the safety front, to the point where they are now making strides in their safety outreach efforts. The additional $10 million earmarked in the concussion litigation settlement for research is a step in the right direction, albeit a fraction of the money that will be needed to be devoted to concussion research to make the sport safer.

Wanted: Pro-Active Parents

But, as far as the N.F.L., NFHS, USA Football and Pop Warner have come in recent years in their efforts to improve football safety, I still believe, in the final analysis, that football safety is largely up to parents, working in their local communities with all those with a stake in making football safer, including independent football organizations, school boards, school superintendents, athletic directors, coaches, school nurses and psychologists, and other health care providers, and networking with other parents, coaches, administrators and medical professionals at the local, state, regional and national levels to share ideas on what works and what doesn't.

It is up to parents to make sure that football programs adopt best practices based on the latest medical research and technological advances in the identification and treatment of concussions;

It is up to parents to insist that coaches be part of the concussion solution, not continue to be part of the concussion problem. Recent qualitative and quantitative studies have confirmed MomsTEAM's longstanding belief that, more than education about concussion signs and symptoms, it is changing the negative attitude of too many coaches towards reporting and creating a safe concussion-reporting environment that may be the best ways to improve the low rates of self-reporting found in study after study.

It is up to parents to do whatever they can to make sure that their child's coach does not continue to convey the message to athletes that there will be negative consequences to concussion reporting by removing them from a starting position, reducing future playing time, or inferring that reporting concussive symptoms made them "weak", but, instead, creates an environment in which athletes feel safe in honestly self-reporting experiencing concussion symptoms or reporting that a teammate is displaying signs of concussion (and reinforcing that message at home)

It is up to parents to be advocates in their community for creating a culture of safety at all levels of the game, instilling in kids when they first start playing sports positive attitudes about sports safety and concussion that they can carry with them throughout their lives.

It is up to parents, whether it be individually or as members of a booster club, "Friends of Football," or PTA, to raise money to (a) fund the hiring of a certified athletic trainer (who, as we always say, should be the first hire after the head football coach); (b) consider equipping players with impact sensors (whether in or on helmets, in mouth guards, skullcaps, earbuds, or chinstraps); (c) purchase concussion education videos (which a new study shows players want and which they remember better); (d) to bring in speakers, including former athletes, to speak about concussion (another effective way to impress on young athletes the dangers of concussion); and (e) to pay for instructors to teach about proper tackling and neck strengthening;

It is up to parents to make sure that the helmet their child wears fits properly, maintains that fit over the course of a season, and has been properly reconditioned, and, if the football program does not buy impact sensors for the whole team, to consider buying one on their own, weighing the benefits of knowing the magnitude and frequency of the hits that their child is taking to the head against the risk that adding a two-ounce piece of plastic to the inside or outside of their helmet may void the manufacturer's warranty and NOCSAE certification or increase the risk that the protection the helmet's polycarbonate shell provides against skull fractures will be compromised;

It is up to parents to decide for their family whether to allow their child to start, or continue, playing football, not some present or former player, journalist or scientist who takes the position that football is either too dangerous to be played by anyone or safe enough to be played by all (October 25, 2015 update: this is exactly the position adopted by the American Academy of Pediatrics in its 2015 Policy Statement on Tackling in Youth Football in which it leaves parents - presumably in consultation with their child's pediatrician - to "decide whether the potential health risks of sustaining ... injuries [in tackle football] are outweighed by the recreational benefits associated with proper tackling"); and

It is up to parents, when a child sustains a concussion playing the sport, to know what to do to help the child recover, including the need for cognitive and physical rest in the first few days after concussion, when it is safe to return to school and everyday social and home activity, whether their child's school day should be modified to take into account cognitive difficulties experienced after concussion and, in consultation with their child's health care providers, including the athletic trainer, if there is one, to sports.

Call to action

Finally, it is up to football parents like you, if you value MomsTEAM as a trusted source of youth sports parenting, nutrition, hydration, and safety information, to help us spread the word about MomsTEAM, about our PBS documentary, The Smartest Team: Making High School Football Safer, and about our newSmartTeams initiative

You can help in three ways:

First, you can help make football safer by sending a note to the programming director at your local PBS station encouraging them to find a slot in their fall schedule to air THE SMARTEST TEAM. If they are skeptical about the value of airing yet another concussion documentary, tell them that this one is different: it starts where other concussion documentaries like "Head Games" and "United States of Football" leave off: not just scaring or documenting the concussion problem but showing ways the sport can be made safer right now.

Second, you can help make football safer in your community by suggesting to your school or its PTA that it purchase a DVD of the documentary from our educational distributor, Films For The Humanities (most schools are subscribers already, or it can be purchased a la carte).  Why not Invite some former athletes and concussion experts from your community to lead a discussion about concussions after the film.

Third, you can help make football safer by sharing links to MomsTEAM concussion articles with other football parents, coaches, athletic trainers, and PTA presidents, or by distributing copies of key articles, some of which are listed here:

1. Concussion Safety Checklist for Parents: 12 ways parents can help protect their kids in contact/collision sport
2. Concussions: Parents Are Critical Participants in Recognition, Treatment, Recovery
3. Gradual Return to Play After Concussions Recommended
4. Coaches: Improve Concussion Safety By Creating Safe Environment For Athlete Self-Reporting
5. Honest Self-Reporting Of Concussion Symptoms Critical

I am as convinced as ever that, together, we can preserve and strengthen that uniquely American game: the game of football. It will take work, it will take commitment, it will take dedication, but it CAN and MUST be done.

---

Brooke de Lench is the producer/director of THE SMARTEST TEAM: MAKING HIGH SCHOOL FOOTBALL SAFER, Founder and Publisher of MomsTEAM.com, and the author of "Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins).

 

Recently, I received the following letter from a mother who had attended one of my talks to a group of sports moms.

"My daughter has just signed up for a 3rd grade travel soccer team after having never played soccer before.  But last week, she told me that her teammates were teasing and bullying her (telling her she's not a good soccer player) and telling secrets about her. I have stayed and watched all her practices and all her games except one. She is completely devoted in her practices, and seems to work at least as hard if not harder than the other girls. She pays attention and does what the coach (or trainer) says. She seems to be one of the more mature girls on the team, and has made amazing progress from the first practice, to now (practice #5). I am not sure she fully understands the game, nor the nuances of each position, but she is definitely participating in earnest.

My question really is what I should expect out of the coach in this regard? I have already sent him an email telling him about the behavior of the other girls, and I borrowed some language from your handout to say that I expected the girls to show respect to each other (i.e. no teasing or bullying). Should I really expect this situation to change? Should I pull her out in the middle of the season? She is telling me now that she never wants to play soccer again. I think that, other than the behavior of the other girls, she enjoys it. I have told her she needs to finish out the season. Help!"

Bullying is violent behavior

The subject of bullying in sports is one that is near and dear to me.  According to an about-to-be- released book from the United Nations titled Violence Against Children In Sport - The Right To Play Safe (a book to which I was honored to contribute) and Article 1 of the UN Convention on the Rights of the Child, what her daughter's teammates were doing to her daughter actually constituted emotional abuse/violence.

It is sad, but true, that some kids think that one way to keep moving up the sports pyramid is to eliminate the competition and drive kids to quit, especially if they perceive them as competitive threats, through bullying or teasing that makes them so unhappy they see quitting as a better alternative than being abused.  In extreme cases, teasing in youth sports can even lead to tragic results, such as the teasing that led a thirteen-year-old California boy to beat a fifteen-year-old boy to death in April 2005.

Common problem

A recent study revealed that there is a high probability on most teams that one or more of the lesser skilled players will be bullied or teased by a more skilled teammate.  Good coaches are alert to the possibility of bullying and proactively seek ways to reduce it.

If the coach allows the bullying to go unchecked, the player being bullied may end up deciding that quitting the team is the only way to get the abuse to stop. I remember when my son, Taylor, was on a youth basketball team.  He had just gone through a big growth spurt and towered above the other boys on his team.  He was still trying to get used to his new body, but showed real potential as a basketball player, especially given his height (he is now close to 6 feet 6 inches tall).  One of the players on the team, who actually happened to be one of his closest friends, decided that the best way to eliminate Taylor as his competition was to tease him and so he did did everything he could to undermine his self-confidence by teasing him about his skills, especially at the offensive end of the court where, despite Taylor's height, he had trouble scoring over smaller opponents.  Unfortunately, because the coach did nothing to stop the bullying, the strategy worked: Taylor finished the season but decided not to sign up again.  There is no way of knowing how good Taylor could have been as a basketball player (he was definitely a late bloomer), but I would like to think that he would grown into his body and been pretty good.

Given my experience with my own son and thousands of emails on this subject spanning the tens years I have been running MomsTeam, I thought there was a pretty good chance that the daughter of the mother who wrote me was  being bullied because, despite having just started off in soccer, she was already showing real potential and was therefore viewed by her teammates as a competitive threat.  I wondered whether the coach's child was one of the bullies and when/where was the bullying actually taking place.

The bottom line, I told her, was that the her daughter's coach should have a zero tolerance for bullying and needed to do whatever it took to get it to stop. Easier said than done, though.

Here is what I suggest to parents who find their child is being bullied by his teammates:

1. Find articles and information on bullying on MomsTeam, especially in sports, such as Quitting Sports: A Difficult Decision and Good Youth Sports Coaches Teach, Model and Demand Sportsmanship, Fairness and Respectful Behavior ;
2. Print the articles and when handing them to the coach demand that he or she put an end to the bullying and teasing, because it is a violent activity, because teaching respect for teammates, officials and opponents is critical part of a coach's job, and because bullying is damaging to team spirit; and
3. Teach their child to look directly at the kids who are teasing or bullying her and in a loud, assertive voice say something like, "I have had enough of your bullying. I just want to have fun. Stop it now!" (Repeat as necessary to get it to stop).
4. Ask your child's coach to make a quick announcement prior to each practice or game along the lines of  "There will be NO bullying or hazing or teasing and anyone on the team who does will sit on the bench! This was something I did before each practice when I was coaching and there were no problems-ever!

November 4, 2013 update: As the sad story of alleged bullying of Miami Dolphin offensive tackle Jonathan Martin by teammate Richie Incognito, which led Martin to take an indefinite leave of absence and to the indefinite suspension of Incognito while the NFL investigates, bullying can happen on teams at every level of sports.   

Has your child ever been bullied? Please add your comments below--I am very interested in what worked to eliminate the bullying of your child. 

---

Brooke de Lench is Executive Director of the 501(c)(3) non-profit MomsTEAM Institute of Youth Sports Safety, author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (Harper Collins), founder of MomsTeam.com, and producer/editor of the PBS documentary, The Smartest Team: Making High School Football Safer. You can contact Brooke at delench@momsteam.com

One of my biggest gripes about the media in the age of Twitter and ever-shorter attention spans is that it doesn't lend itself well to an examination of issues in the depth they deserve.  

Recently, I was asked a series of questions by a newspaper journalist for a story on a concussed athlete who had decided to quit football despite being cleared by the team doctor to return to play.

Even though I knew that 95% of what I said in my emailed response would never make it into the story, I nevertheless spent the time formulating thoughtful responses, hoping that at least some of what I offered would avoid the cutting room floor.

I was wrong.

Here, for those of you out there who are interested in the full responses (with links for further reading) are the questions I was asked and the answers I gave: 

Question:  The player I'm writing about made the decision to quit football (even though a team doctor said he could still be cleared to return) due largely to the emotional and mental effects (rather than the physical ones) the concussion had on him. He found himself dealing with depression and struggling with his studies. How common is it for concussion sufferers to deal with such issues? Is this a part of concussion treatment that often goes overlooked in sports?

Answer: Depression is common after concussion, especially when the symptoms of concussion linger, but clinicians say it is often difficult to determine whether such depression is pathological or psychological. A 2013 study by researchers at the University of Washington also found that a history of concussion in teens was linked with a 3-fold increase in risk of depression. I'm not a psychologist, of course, so I'm not in a position to say how depression in a concussed athlete should be treated, but I do note that some experts criticize the symptom scales currently in use because some of the symptoms attributed to concussion, such as depression, can be the result of non-brain related conditions that were present before the athlete suffered his/her concussion. A 2014 study in the journal Pediatrics, for instance, found that some children and adolescents who continue to report symptoms weeks and months after suffering a concussion may be exaggerating or feigning symptoms in order to get out of schoolwork or sports, or for other reasons unrelated to their injury (a phenomenon called "secondary gain"), including underlying depression.  As Dr. Rosemarie Moser points out in that article, neuropsychologists "know that whenever symptoms do not improve and the recovery period is longer than expected, the possibility of emotional/psychological factors affecting symptoms should be considered."

Question: What role can or should a coach play in assisting a player in dealing with concussions -- both from a mental/psychological and physical standpoint?

Answer: Like the athlete's parents, treating physician, and athletic trainer, a coach should make sure the athlete understands that he or she should not try to rush back to play before they are symptom-free, and that he or she has not only completed the program of gradually increased exercise experts recommend without symptoms returning, but is psychologically ready. Coaches need create an environment in which athletes feel safe, not only in reporting concussion symptoms so that they can be removed from play to minimize the risk of further, potentially catastrophic injury but of a longer recovery, but in which athletes feel safe in telling the coach that they aren't ready to return, either because they are still experiencing physical symptoms or because they aren't ready from a psychological standpoint. In practical terms that means that the coach should never question a player's toughness, masculinity, competitiveness, or attitude, either directly or indirectly because doing so contributes to the prevailing "culture of resistance" to honest concussion symptom reporting by athletes that makes early identification of concussed athletes so difficult. Unfortunately, at least two studies has shown that athletes are not very good at assessing their own readiness to return to play after a concussion. A growing body of evidence suggests that psychological factors play an important role in determining whether an athlete makes a successful return to sport following injury. Clinicians, not the coach, need to take such considerations into account during injury rehabilitation and the period before an athlete returns to competition.  But even if a doctor or athletic trainer has cleared an athlete to return to play, if a coach has any doubt about the athlete's psychological or physical readiness to return to play, he or she should not let him play.

Question: Despite his situation, the player in question has no regrets and said he would encourage his own future children to play football. What kind of advice or counsel do you provide to parents whose children want to play football?

Answer: There is no simple answer to that question, but the most important thing a parent can do in deciding whether to allow their child to play football or any contact or collision sport is become educated: about the risk factors (including whether their child may be at greater risk of injury because of pre-existing neurological conditions, such as ADHD or a history of migraines, about what the program is doing, or not doing, to minimize the risk of concussion or repetitive brain trauma, to identify concussed athletes as quickly as possible, and to make sure they do not return to play before their brains are fully healed. A child may want to play football, but, ultimately, it is up to his or her parents to be ... well ... parents, weighing the individualized risks of participation versus the benefits and deciding whether football, when all of the pluses and minuses are added up, is right for their child.

Question: There's a perception in some places that concussions can only happen at the highest levels of football (NFL, college, competitive high school), and that young children can't hit each other hard enough to cause concussions or other injuries (an NFL QB made a fairly passionate speech to me making this very argument a year ago). Is there truth to that? What risk of concussions is there for children, and contact at a young age have a cumulative effect that could contribute to a player dealing with continued and chronic issues into adulthood? It is a myth that children can't and don't suffer concussions playing youth football or can't and don't hit each other hard enough to cause concussions.

Answer: A pair of studies by researchers at Virginia Tech, one in 2012, the second in 2013, found that young kids playing tackle football do indeed sustain hits just as heavy as high school, college and pro football players, although not as frequently, and that they do get concussed. One recent study of former NFL players found that those who started playing football before age 12 were more cognitively impaired later in life than players who started later, but the scientific literature on the cumulative effect of repetitive brain trauma, and whether children, because their brains are still developing, are at much greater risk, is in its infancy and there is still a lot we simply don't know. The evidence does seem to be clearly pointing in the direction of establishing that cognitive difficulties later in life are dose-related; in other words, that the more hits a player sustains over time, the greater the risk that he or she will suffer some form of early cognitive impairment or, worse, a degenerative neurological condition such as chronic traumatic encephalopathy (CTE). But there are many, many factors, including genetics, use of alcohol, recreational or performance-enhancing drugs, the number of concussions, the way in which they were managed, even playing position, that may affect that risk. Science is a long way from determining if there is a so-called hit count or threshold above which continuing to play a contact or collision sport such as football puts an athlete at substantially increased risk. Until then, caution, not panic, should be the byword.

---

Brooke de Lench is Executive Director of the MomsTEAM Youth Sports Safety Institute, a 501(c)(3) tax-exempt non-profit youth sports safety education and watchdog organization, Founder and Publisher of MomsTEAM.com (now in its 15th year as a leading source of youth sports health and safety information for parents, coaches, and sports medicine professionals), producer of The Smartest Team: Making High School Football Safer (PBS), and author of Home Team Advantage: The Critical Role of Mothers in Youth Sports (HarperCollins). You can follow Brooke on Twitter @brookedelench.