Editor’s note: This commentary is by Jack Mayer, MD, MPH, of Middlebury, a Vermont primary care pediatrician and the author of “Life in a Jar: The Irena Sendler Project” and “Before the Court of Heaven.”
“Dr. Jack, should I let my kid play football?”
Most of my patients are adolescent males, and lately, I’ve heard this question more and more.
Concussions are only the visible tip of the iceberg of brain injury associated with tackle football. There is rising concern about football and brain damage, CTE (chronic traumatic encephalopathy), from repetitive sub-concussive impacts and their long-term consequences. We cannot see this pathology in a living individual. There are, as yet, no biomarkers of damage, no blood test, no brain scan, so we must rely on evidence from autopsied National Football League players. As Dr. Ann McKee and colleagues at Boston University and the VA Boston have demonstrated, virtually all autopsied NFL brains (110 of 111 brains studied) show evidence of CTE.
These players’ pre-morbid histories are rife with depression, dementia, anxiety, impulsivity and, sometimes, domestic violence. Many have chosen to end their lives. Can we extrapolate from the NFL experience to risks for children and adolescent football players whose developing brains are more susceptible to injury than adults?
We know from multiple studies that young rapidly growing brains are uniquely susceptible to trauma and toxins, such as environmental toxins, drugs and alcohol. As a pediatrician, I worry about concussions and their lasting effects. But what about the much more frequent repetitive sub-concussive injuries sustained in practice and during games? Football is a game of multiple collisions between players, collisions that cause the brain to accelerate and decelerate in the bony confines of a rigid cranium causing microscopic injury.
A recent multi-center, peer-reviewed study (“Age of first exposure to American football and long-term neuropsychiatric and cognitive outcomes” by Robert Stern, et al: Translational Psychiatry, 2017) found that adults who began playing tackle football before the age of 12 suffered more behavioral, emotional and cognitive problems later in life than those players who started tackle football after the age of 12. (A doubling of problems with self-control, judgment, problem solving and three times as likely to suffer depression.) This study is not proof of causation, but the findings are biologically plausible and constitute a concerning association – a warning.
Youth football – Pop Warner (ages 5-16) and high school, are popular venues for children and adolescents. Football and boxing are the two sports where normal play involves repetitive jarring injury to the brain, directly in boxing, indirectly in football by multiple high-impact collisions in games and practice. How much? To what consequence? Is there a linear dose-response relationship between trauma and brain damage, so that even minimal, but repetitive trauma causes some damage?
For several years in my pediatric career I was a National Cancer Institute Fellow studying environmental toxins and cancer at Columbia University. Children have unique susceptibilities to toxins for multiple reasons. Risk evaluation must include age, genetics, physiology, biochemistry, metabolism and developmental stage. In considering risk from toxic exposures, we often invoke the “precautionary principle,” that the suggestion of harm from environmental toxins should lead us to limit exposure, and to be especially mindful of the heightened susceptibility of the fetus, infant, child and adolescent – periods of rapid growth and development. How do we apply the precautionary principle to youth football, where risk and susceptibility are intertwined?
Risks must always be balanced by benefits, and I want to acknowledge the unique benefits of sports participation for the development of mind, body and character. I have always counseled parents to participate in the decision about which sport to allow their child to play by maximizing the benefits and minimizing the risks. Ultimately, parents decide, and fortunately there are many sports to choose from. Professional athletes are adults who also weigh the risks and benefits. Children cannot be expected to make these decisions that will affect their entire future.
My advice to my patients is this: “Know the risks and weigh the benefits.” When I consider difficult clinical decisions I am often guided by the question: “What would I do if this were my child?” And I say to my patients, “I would not let my son play football.”
