Last week The Aspen Institute hosted a round table discussion on “Playing Safely: The Future of Youth Football” to address growing concern about the epidemic of concussions on our youth. It should be noted that professional athletes are both more mature (in size and brain development) and are adults who can make informed consent decisions. The issue this panel discussed was for the youth football.
The speaking list was both wide and deep including: DeMaurice Smith, NFLPA, Dr. Gerry Gioa, Chris Nowinski and Dr. Robert Cantu amongst others in attendance;
At the Aspen Ideas Festival in June, a panel featuring concussion experts and former NFL players considered the health safety risks of playing football. Since then, concerns have sharpened, with many parents of young boys saying that tackle football should not start before age 14. At the same time, football also plays a role in addressing the epidemic of physical inactivity. Our roundtable dives deep into the state of football at the youth/community level with a discussion on reforms — and implications on the game up to the professional level.
With awareness beginning to gain traction and definitive research in the area starting to bear fruit this round table took place at an opportune time. This topic of youth tackle football will be very hotly contested, mainly due to our traditionalist thinking and lack of full understanding of this injury.
PBS will televise an edited version of this event on November 20th, so check your local listings. In the mean time if you want to listen to the proceedings you can do so by clicking HERE.
I was able to get comment from one attendee or attendee by proxy, Michelle Trenum, who watched online. Her husband – and father of Austin Trenum – was able to go and get some insight as well. Michelle had the following thoughts (mind you all of her sons played football and she continues to be a fan of football);
What bothered me the most were the frequent comments by USA Football, Pop Warner, etc. that the reason they would not prohibit tackling under age 14 was that “the kids love it”, “the parents want their kids to look like what they see on Sunday”, “the kids and parents say tackling is fun”.What I thought was the most profound were the comments that all the precautions and demands (limited contact practice, independent medical people, extra trainer in sky box to look for concussions not spotted on the field, etc) that the NFL players unions have demanded (negotiated) from the leagues are not precautions we take with younger kids. Instead we have the little kids doing the same thing as the adults with NO athletic trainer, no medical people, no constraints on tackling practices, etc.
Michelle is exactly right with her last sentence, we have all the “bells and whistles” for the professional athlete, yet most if not a massive super majority of youth sports have nothing other than parents and coaches. The first line of defense at the professional level is a health care provider, the athletic trainer, and at the high school level only 42% of schools have this much-needed coverage.
If you have followed me long enough I have sort of “flip-flopped” on the 14 and under issue. I fully endorse exposure limits for all athletes at all ages. If we are limiting exposure for professional athletes (14 contact practices with 16 games in the NFL, 30 total days) why would we do LESS for younger individuals. Those same younger individuals that are skeletally immature, brain immature, don’t have the best/proper equipment, and don’t have the coverage at the highest level. That makes no sense. For example at the high school I am contracted at we have 32 contact days from early August until the end of October. Basically if HS and youth teams take the model of; five preseason days and two hit days per week along with nine regular season games, that group is being exposed to more hits than the professionals and all their “bells and whistles”.
If you break down the two (my HS and NFL) you can see a massive disparity in the way we limit exposure to the younger athlete. I may not agree with an arbitrary (as of now) age, but what I do believe in is cutting down on concussions; the only way to do that currently is limit exposure.
The Concussion Blog 
Not only from a selfish viewpoint did I find it “interesting” that no helmet makers were invited to this round table of the concussion fabulous. You’d think that such great minds would at least give lip service to the industry that is constantly being held accountable for the head injuries.
Agree with Glenn…
I saw the entire conference.
Kids need football blah blah. One party did kick in that the case for football is weak in tough economic times. Chris Mason, a retired NFL player, who volunteers coaching flag and tackle (5 teams/leagues in total) was bemused that the football community refuses to change. It is astonishing that someone who reached the highest level of the sport is not heeded by parents and coaches who could not hold the guy’s jock strap. If a parent who has decades of experience excelling at every level of game and gives his time to the community is ignored by nobodies, the sport’s demise is virtually guaranteed.
The NFL was honest and said it needed to indoctrinate kids early so they could cash in on them as adults (translation of NFL rep).
DeMaurice Smith bordered on comedy. He is a lawyer, and it showed. Lot’s of equivocal claptrap. Try’s to read everything. On the other hand, it is quite clear he does not understand the issue or is just disingenuous. It was inexplicable that the NFLPA did not send its President, Domonique Foxworth, or the head of the Mackey-White Committee as either man knows more about football than Smith will ever know. Sending a mouth piece who last played ball in high school (given his diminutive stature I gather it was JV only) was disappointing. Given Smith’s dismissive presentation, he must have had the taste slapped out his mouth in prep ball.
It was instructive that neither Mr. Smith’s daughter (basketball) nor son (Lacrosse) plays football (Commissioner Goodell’s daughters don’t play football either). Given the vast sums Smith and Goodell make and how important the sport is to forming a complete person, it would be nice if they practiced what they preached. You know, who needs to eat their own cooking. I guess their kids can be spared being pounded in the head; it will be some gullible parent who sacrifices their kids for their profit.
It was also disappointing not to see doctors representing the pediatric research hospitals. It would have been vastly more interesting. (It did not appear that any NFL docs showed either).
Helmet and equipment makers would have also added some flavor but it seemed more like a love in promoting tackle football based on the latest scientifically unsupported marketing materially from NFL HQ.
A smaller better focused panel would have been better.
Finally, I support Cantu’s 14 year cut off. Medical support, equipment, and coaching are simply too primitive to risk a child’s brain on a sport where the cast majority of children amount to nothing more than tackling dummies.
PS: Mom’s Team you need to put down the Kool-aid Roger handed you.
Some perspectives on potential / significant conflicts of interests (COIs) existing within ‘Expert panels’ such as Aspen or Zurich…:and other panels…
The below excerpts are taken form my 2004 Dissertation entitled:
A Preliminary Investigation of Active & Retired NFL Players’ Knowledge of Concussions (Brady, D., 2004)
1- Expert panels may be self-serving……
A concern pertaining to COIs being exhibited by members of expert panels and blue ribbon committees was recently voiced by a clinical professor of medicine at the SUNY Upstate Medical University Hospital located in Syracuse, NY – Dr. Anton Joachimpillai.
During 2004 Dr. Anton Joachimpillai, professed that
“from his clinical perspective derived from almost 50 years of practicing medicine, expert
panels and blue ribbon committee findings should be both cautiously accepted and
critically reviewed as he has frequently found that committee members promulgate self
serving, and thus biased interests (personal communication, March 9, 2004). ”
2- Multiple relationships…and resultant COIs… who is the clinician serving?
The concept of multiple relationships (Behnke, 2004) also adheres within potential COI situations, as when a health care provider is employed by a sports team to provide treatment to players. Thus, a core ethical question emerges from this possibly enmeshed relationship: May a health care provider objectively render adequate injury treatment and management while serving both: (a) an employer/owner who may have vested financial, power and prestige interests; and (b) an athlete who sustained and is recovering from an injury?
3- Funding research to purcha$e ‘desired’ result$….
Along similar lines, the potential for both sports-related clinician and researcher bias becomes quite evident when an investigation and assessment of adverse concussion consequences occurs by individuals involved in COI situations. The potential for bias will now be examined more closely.
Given the above perspectives regarding the potential for companies to demonstrate bias and thus influence research findings, it seems plausible that organizations that fund sports-related concussion research have a similar potential to bias and influence the research findings.
4- The need for full and complete disclosure of financial and all other secondary gains for
‘experts’ whom:
a- write policy,
b- publish research
c- serve on ‘expert’ committees
Thompson (1998) voiced concern about the possibility of the funding source influencing the choice of the specific research topics and related research questions for investigation.
Therefore, it seems imperative that full and complete disclosure of financial and all other secondary gains discussed above be provided in writing by each member of the various sports- related concussion research teams and expert panels.
Examples of specific research teams and committees include, but are not limited to, NFL- and NCAA-sponsored and funded research and expert committees, and designated concussion management committees such as the Colorado Medical Society, the 1997 Quality Standards Subcommittee of the American Academy of Neurology, and the Vienna Conference Concussion Committee.
A complete list of all members of the respective committees should also be included within the descriptive disclosure notice of financially and not-financially-related COIs.
The adoption of these disclosure guidelines by sports concussion clinicians and researchers could serve as a proactive model for fostering complete and open disclosure of the nonmedical factors which may directly influence professional health care decisions.
5- Detective Charlie Chan’s 1944 definition of expert:
Expert:
one who is quick to answer and occasionally correct…
Peace…
Love Charlie Chan’s definition.
Solid comments joe!
Joe, Send me your address and I will send you a screener of the final film we produced called THE SMARTEST TEAM: Making High School Football Safer which airs across the nation on PBS this fall. We ultimately reduced the rate of concussions by 75%. Funny thing about that Kool-aid, they love our work but we are very critical of much of what they are about. And for the record, we have never taken a dime from them. Brooke Lench, MomsTEAM
It’s time we protect a child’s brain! If we are protecting children, why are we letting this happen? Someday education regarding concussions and brain injury will pay off and rules will change.
Brain injury: You don’t get it, until you get it! Even experts don’t get it, until it happens to them! When parent’s live with someone with a brain injury, then they will get it!
Dustin,
I watched the entire event on the web and thought it was really interesting. Must say I agree with Michelle Trenum’s comments. I thought her husband did a great job addressing training in his school district (must be difficult for him to participate in those types of discussions at times).
Haven’t checked today, but as of a few days ago the event was still available for viewing on C-SPAN.
I am curious as to why you changed your mind regarding no tackle football under 14.
My thoughts are that perhaps if a program is run perfectly, with all proper steps taken to minimize risk, then there’s a chance that tackle football under 14 might be okay. However, after spending much of the past few years volunteering with various organizations my children have been involved with, I just don’t think it’s reasonable to expect most programs to be run perfectly.
We’ve got millions of children and teens playing a game with little to no real oversight, and the adults in charge may not even be receptive to the need for change. There is no governing body with any true regulatory or oversight capabilities to make sure the adults take necessary precautions either. And, just look at some of the problems that have been exposed this year — alledged bounties and other rule violations in California, coaches in Massachusetts using spread sheets to allow kids to engage in tackling drills for the maximum period of time allowed by Pop Warner rules, 5 concussions in one out of control game (again in Massachusetts), and gambling and other possible crimes in a youth league in Florida (I believe).
Schools and municipalities don’t want the responsibility of overseeing these programs, and they certainly don’t want to be exposed to any liability. Resources are limited, and some kids end up using outdated/ill fitted equipment. Additionally, medical care is often non-existent (who’s supposed to oversee RTP protocols – can tell you that in my son’s league no one seemed to do anything when one of the players returned from a concussion – the impression I got was that since the high school federation rules only apply to high school, everyone thought it wasn’t necessary to exercise the same level of care with the younger athletes, that it wasn’t needed or required).
The realist in me recognizes that kids will most likely continue to play tackle football, at least in the near future (suspect much depends on research findings). I don’t think we should try to continue to fool ourselves that they’re safe just because they’re smaller and slower, or that they don’t need ATCs because they don’t have ATCs in their backyards. Youth leagues should be encouraged to work with USA Football and certain minimum requirements should be set with respect to education/disclosure of risks, contact limitations, and some type of access to an ATC or equivalent medical professional. If the leagues can’t meet these minimum requirements, then they shouldn’t be allowed to operate.
Based on the articles and stories I’ve read this past year, think it’s past time for safety issues and minimum requirements to be re-addressed from the bottom up (pee wee, MS, HS and into college). I’m just a mom, don’t consider myself an expert and recognize I don’t have all the answers. But, it just seems obvious that the stakeholders (who should include some parents) need to have serious conversations, and they need to get real. I don’t want to take tackle football (or any other sport) away from anyone, but as things stand today, kids in some programs (including sports other than tackle football) are being exposed to unacceptable levels of risk, and some of the proposed solutions spouted by so called experts have sounded like magical or wishful thinking to me.
Aspen was a good start to the conversation, but it just seemed to scratch the surface. When a teen with a kidney laceration is driven to the ER by a coach’s wife, you know there’s a lot of work to be done.
Don’t rely on the so-called research findings because the research is being paid for by the NFL and that includes the CDC. The results will be made equivocal or positive.
The NFL has been cooking research for two decades and it is not going to stop now.
Thanks for the insight. I guess the real world is often less perfect than ideal.
I know you said no tackle football under 14, but younger kids are playing, and I suspect they’ll continue to play. What do you think we should do to make them safer? The high school level has more stringent requirements than youth leagues, and even there, I’ve come across some nasty stories where adequate care has not been provided (the teen with the lacerated kidney reportedly sat in the ER for 3 hours and wasn’t seen until he started vomiting – then he was sent to a trauma center).
Just the other day there was a release sent out about a study showing that some doctors aren’t up to speed on concussions, and right now the health and safety of children playing collision sports is being put into the hands of volunteer parents who at best may have spent some time watching a few educational videos. I would hope we, as a society, could at least set forth some basic minimum standards to help make youth sports safer. (I’ve read stories about kids’ lemonade stands being shut down by authorities, yet when it comes to youth sports, we’re somewhere between the dark ages and the wild west.)
I think I changed my stance because 14 is arbitrary… However, that does not mean I think full contact/collision football is ideal for kids… Certainly there should not be any tackle football for kids up to the age of 12 (yes also arbitrary)…
I am having trouble with the age thing, I flip and flop all the freaking time… I see kids at 13 or 14 that can handle the sport under proper coaching… I think my main concern is that the coaching and coverage for injuries are not suffice… I think that can happen at a middle/junior high school level…
The more and more I read/research/talk about concussions the more I feel we are not steering our attention to the proper place… Concussions are going to happen… If you ban football for under 14 why wouldn’t you then ban the biggest perpetrators of concussion: wheeled sports, snow skiing, trampolines and general recreational activities?
I don’t pretend anyone will understand what I am debating in my own head, I just know that repetitive brain trauma is not good for anyone… FWIW, I didn’t play football until HS, and I ended up with 11 of them, only one coming from football…
Am I protecting a sport? Don’t think so… Arghhhh…
We live in a rural area and there are kids who engage in what could be considered risky activities – such as, 4 wheelers, dirt bikes, horseback riding (including barrel racing, etc.), and driving/operating farm equipment. And, of course there are kids who ride bikes, scooters and skateboards. Oh, and one of my least favorites, because no one enforces any rules, are the backyard trampolines.
Anyway, it would be interesting to see how those activities compare to football per exposure (I don’t know, say hour of engaging in activity). I suspect football may have a higher rate of concussion per exposure, but since we don’t have good data, who knows for sure.
Now, one of the major differences in my mind, is that with the other activities, accidents are possible. A child may fall off their bike, bump heads with another jumper on a trampoline or even crash their dirt bike. I’ve actually heard of a couple of kids around here who’ve experienced some serious accidents. With football however, as it has traditionally been played and practiced, kids are subjected to a number of subconcussive and perhaps even concussive impacts during each practice and/or game.
When I think back to my son’s practices, I literally feel sick. I certainly wish I could go back in time and save him from sustaining a concussion at age 8. However, I also recognize that if he had been allowed to play in a program which emphasized hard hitting practices from age 8 through high school, he could have experienced even worse problems, problems which may not have become evident until years later (not all of the dots have been connected, but can’t help suspecting that having neurodegenerative diseases on both sides of the family could have put him at higher risk).
Kids certainly can and do injure themselves playing in their backyards, but at least with my kids, I’ve noticed that they tend to come in when they’re tired or when they’ve fallen and hurt themselves. When kids are under the supervision of a coach, they may be pressured to continue even if they’re tired or hurt, some coaches feel it’s their job to toughen kids up and whip them into shape. Some parents do too, others don’t feel confident enough to question coaches or pull their kid off the field (although that should change as more become educated).
I hear you, Dustin, for I feel much the same way, that a strict age limit on tackle football is tough to wrap around. If anything, from experts I consult or read in pertinent disciplines such as medicine, law, the best line of demarcation may be juvenile standing of 17-years and younger, with alarming findings/conclusions of pediatric neurology (which will only continue; no sound research is going to find ‘safe football’ anywhere) compounding upon festering questions of juvenile assumption of risk in a lethal activity such as football. Perhaps insurance companies will devise new models of risk-casualty for tackle football that determine no coverage until a certain age is feasible for business. Money will drive change, not morality, and I think the game is largely finished in the public sector for the near future, the way boxing has gone since the 1980s. Boxing isn’t “banned” in America, never has been, likely never will be, but government has largely cut off funding for it. Private, tightly regulated club football is the way ahead for amateur levels, just like boxing’s evolved, I think, and that could include all ages currently in participation.
Dustin,
14 is arbitrary, however, most middle schools don’t have an ATCs, Doctor, Nurse or anyone else looking out for the kids. If the coach was that former NFLer, Mason, I could see 12 year-olds given the kids are strong and mature. Someone like that has experienced stupid coaching and does not seemed inclined to continue on stupid. He seems like the type of coach that a child could learn lessons valuable off and on the field. On the other hand, some wannabe drilling kids like Mike Singletary because he did not make the scholarship cut does not wash for me.
I have one quibble with your debate. The wheeled sports, ski etc. argument is getting a bit tired. Head injuries in those sports tend to be episodic and incidental although often quite severe. Football has evolved even at the lowest level to using the head as a weapon. Head injuries are not incidental to football. It is a direct result of how the sport is practiced. It is a big difference that distinguishes it with most other sports.
Dustin,
Football, by its nature, is an agressively played contact / collison sport.
Comparing football to driving an auto, skateboarding, running, golf, crew, sledding and so on involves a SIGNIFICANT ILLOGICAL COMPARISON.
The primary purpose of driving an auto, skate boarding, running, crew, golf and so on is NOT to deliberately crash violently into another auto, skateboarder, boat, sled and so on !
Perhaps there is a more ‘global’ sport injury issue emerging that has been underaddressed and not mentioned in the above post?
The global issue follows: That the SPORT CULTURE in the U.S. often idealizes sport participation & therefore uncritically accepts various types of sport injuries as part of the game…whether the injury be a sprained ankle, broken leg or a damaged brain….and ignores all the significant inherent short term and long term risks of particpation.
As Dustin has stated many times, it’s not the injury, it’s the management of the injury. We do not see a significant problem with other activities because human nature removes us from activity until we feel better. Its only peer pressure, or coach’s pressure, that makes kids get back into an activity before they feel “normal”. This is a self preservation instinct that gets over ridden when kids are in organized sport.
The argument about an age limits is arbitrary and not scientifically backed, yet. I do not think we should be having the conversation about an age limit because we cannot offer adequate medical coverage to the younger age groups, so they should not be involved in contact sports, period. The conversation we should be having is making sure we have medical coverage (ATC’s) for all high schools and that we will not accept any contact sporting activity without an ATC present.
Jake,
Would you please restate what you are sharing in paragraph one? Am uncertain as to what you are discussing. Thanks..
Without re-hashing a lot of what has been said, what I was trying to convey is that concussions happen in all walks of life. And when you think about it, even if all contact sports were eliminated, we could not prevent all concussions.The vast majority of patients heal quickly with no long term effects. While complications do happen outside of organized sports, the risk for complication is much higher for people in organized sports. Why is this, I believe its because we naturally remove ourselves from things that make symptoms worse until we feel better (good management). People in organized sport often feel pressure, real or not, to return as early as possible, possibly too early (bad management), which increases the risk of complication.
Jake …thanks for clarifying
No doubt that concussions / brain injuries occur in numerous nonorganized activities.
It appears though that we have different perspectives…so we can agree to disagree.
I have personally witnessed occurrences that are contrary to your views.
1- Have seen numerous persons not involved in organized sports downplay a concussion:
…Some out of ignorance
…Some perhaps out of denial or minimizing…
…Some because they needed to work to earn a living to support themselves & family…missing work would mean loss of pay…
…Furthermore, some people will engage in risky behavior…that will result in concussions.These persons are not removing themselves from danger…but are choosing to enter into dangerous activities
Thus I do not believe people “ naturally remove themselves….”
2- Re the concept of “ Heal ”…am not sure how you define that term…I prefer to say “ functionally recover ” as I believe the brain has been permanently damaged …
The cumulative effects of concussions and being more prone to sustaining a stroke support the notion of a damaged brain… “good management’ will not repair, make whole or cure the damaged brain. “Good management” can assist in preventing further brain damage.
3- I suffered one concussion…and continue to have lingering effects…20 + years later.
4- An aside…but I think important one…I have clinically seen school age children mislabeled with ADD when in fact they had sustained a previously undiagnosed brain injury.
Thanks for the input everyone… Again another good reason the blog is here…
Dr. Benford hits on what I am struggling with… The culture of all sports is to hurry up and get back into action; with recreational activities we will use the human nature approach of avoidance until we feel better. As he stated its a natural instinct, hence the reason moms can detect when kids “are just not right” after a concussion (was that a stretch, its not in my weird mind).
I am and continue to be a FIRM believer regardless of age if you do not have an athletic trainer (wearing asbestos suits) you should not have collision sports.
Yep, great discussion among us, all the way back up to Mr. Beckmann. We need these more than the trendy, hokey ‘expert’ shows or panels clearly steered by Lord Football.
Dustin,
1- Perhaps the term ” organized ” should be added to sports…thus the culture of organized sports
This same sport culture has also ” normalized injuries ” to the point the injuries sustained are not often critically challenged… and thus historically allowing for concussions / brain injuries to be more readily accepted…as just another injury.
What seems to have become lost…
is the mantra for “playing ” sports…that is, ” sport participation supposively promotes physical health ”
If this assumption of ” promoting health ” is true…
then why do so many sport-related injuries occur ?
and why is there the growing need for athletic trainers and the other sport medicine clinicians to address and manage the multitude of injuries occuring in sports ?
2- When it comes to brain injury assessment and management knowledge…how much present info is truly “scientific’, COI driven, or mere speculation under the guise of “expert” opinion ?
Great points Don…
As the head coach of a 13 unlimited weight team (2012), poor tackling fundamentals, i.e, head down, was the #1 reason for head injuries.
It wasn’t all that long ago that I was knee high riding in the backseat of a car without a safety seat. I rode around the neighborhood on my bike without a helmet. The entire playground was metal and wood and I knocked my head more than once and had bumps and lumps and bruises over my body from just playing at the park and falling down etc. Over the years we’ve done things to provide our kids a level of safety that we never had growing up…but has it really been necessary? I really can’t say for certain.
I do feel that the issue of concussions in youth football is being sensationalized. There are plenty of sports where concussions are possible yet football is taking a considerable amount of heat. I have a tough time accepting statistics at face value yet I read a study where soccer is more dangerous than football for concussions…true or false? What about Lacrosse and Hockey? God forbid your son becomes interested in boxing or mixed martial arts. You’d think that every boxer that ever had a career in professional boxing would be suing the WBO or the IBF or another sanctioning body over brain injuries sustained while getting knocked out time and time again…but they aren’t.
With all of this said I think there are a couple of keys here. Coaching. If you’ve got John Doe “Daddy Coach” out on the field coaching the kids based on how he remembers being taught back when he played high school ball, that’s a problem. My HS coach played football professionally for the NFL and he was a great guy but a HORRIBLE coach. I never received any instruction on how to tackle or really even how to block or do anything. Everything that I was taught was X’s and O’s…which probably explains why we didn’t win many games. In any case, the youth coaches of today need to be taught so that they may teach. Coaches and equipment managers need to KNOW how to fit this equipment correctly. They also need to genuinely CARE about the kids where they aren’t going to put the kids’ safety at risk over a youth GAME. Also, I’m not a huge fan of turf fields. I’d be interested in seeing the correlation between concussions and the type of field that the game is being played on.
Thanks for the great comment…
In regards to your last question on field type, I do believe that current technology has made turf fields and improvement for all injuries, including head trauma. Studies are underway regarding concussions specifically, but previous research on general orthopedic injuries clearly shows that the modern synthetic surfaces allow for consistent play, and help diminish overuse trauma associated with field sports…