Chronic traumatic encephalopathy (“CTE”) is a degenerative disease that is theoretically linked to repeat mild traumatic brain injuries (“TBI”). Since its discovery in 2002, CTE has been studied extensively, especially in regard to its prevalence in participants of certain sports. In recent years, football has been front and center of the discussion, as many former players were diagnosed with CTE posthumously. In light of recent findings, state lawmakers have begun proposing bans on youth tackle football, citing the recent CTE research that asserts the longer a player engages in tackle football, the more likely they are to develop the degenerative brain disease. This series is a deep dive into the issue, providing a foundation about traumatic brain injury and CTE, its effects on adults and children, notable cases and research findings regarding football players diagnosed with CTE, and the positions on the ban of youth tackle football.
The series concludes with a novel conclusion: blame the treatment, not the tackle. As the saying goes, “there isn’t smoke without fire.” Recently, with the prevalence of CTE in the news, popular culture, and the like, many began thinking “there isn’t CTE without the tackle.” This couldn’t be more off base. We really should be thinking of it as “there isn’t CTE without improper treatment.” Simply, the risk of brain degeneration due to improper treatment is far greater than the risk of injury from the hit itself.
Part 1 of the series focuses on defining and discussing traumatic brain injury and CTE, but in adults and children;
Part 2 of the series focuses on notable cases of CTE, as well as recent research into the disease;
Part 3 of the series discusses the proposals to ban youth tackle football; and
Part 4 of the series considers the truth about the research behind CTE and its limited scope in light of the spotlight it has received in pop culture and social media. The significant importance of proper protocol and treatment following head injuries is discussed, suggesting the possibility that CTE is not precipitated by the tackle itself, but rather poor treatment of the hit. Furthermore, it is not only the treatment, but the management of the treatment that needs serious attention. This is particularly true where treatment management can be addressed here and now and the possibility of CTE, although a valid concern, will never be definite until postmortem diagnosis, when it is too late to take direct action.
Taking Steps in Response to Recent TBI Studies: Banning Youth Tackle Football
Many state lawmakers have introduced bills to ban children from playing tackle football. Most of these states have focused on the age of the children and cite research that traumatic brain injury to children under the age of twelve can cause damage to the formation of the brain. Further, a study released by the Boston University School of Medicine found that the longer a person plays tackle football, the more likely they are to feel the effects of a neurodegenerative disease, such as CTE. Christopher Nowinski, co-founder of The Concussion Legacy Foundation stated, “the research has discovered that the single best factor that best drove whether or not [players] developed CTE is how many years they played tackle football.”
Looking back to those who suffered, namely, Webster, Hernandez, Stabler, Waters, Duerson, Seau, and Gifford, one thing is certain: they suffered for years and played through the concerning symptoms. Looking at those who are presently recognizing how prolonged careers in the NFL will threaten long-term health, such as Johnson, Willis, Gronkowski, Luck, and Kuechly, one thing is certain: players are attuned to the research and are drawing links to prolonged time in the game and the increased likelihood of degenerative brain disease. What is not certain is what exactly the CTE research suggests. Does it suggest that the best factor that drove whether or not players developed CTE is how many years they played football because of the amount of hits sustained or how the hits were subsequently treated?
Massachusetts lawmakers are the latest to propose a ban on tackle football for children before the eighth grade. Under the bill, any league or school caught playing tackle football could be fined up to $10,000 if a child was seriously hurt. Concussion experts from Boston University came to testify in support of the bill at a public hearing before the Joint Public Health Committee. Experts noted that their research found that kids who started playing football at age five are ten times more likely to develop CTE than kids who wait until age fourteen.
Angela Campigotto-Harrison lost her father to CTE in 2016. He was diagnosed as stage 4 after playing football for several years. She testified in support of the bill, stating, “It is something that I have to do as someone who had a family member that was a victim of this disease. It was a nightmare,” On the other side are football executives from Pop Warner and USA Football. They testified that if kids do not learn tackle early, they are more likely to get hurt later. They said they support measures to enhance the safety of the game, but they feel a ban would miss the mark.
If the bill were to pass, Massachusetts would become the first state with a ban on tackle football for a specified age group.
So why then, has there been such a reluctance to ban youth tackle football? California lawmakers proposed the “Safe Youth Football Act” which would ban tackle football before high school, but was later altered to ban tackle football for children under the age of twelve. One of the sponsors, Assemblyman Kevin McCarty, noted that non-contact youth football has produced a number of NFL superstars including Jerry Rice, Walter Payton, Lawrence Taylor, Jim Brown, and Tom Brady. However, the bill was pulled when it became clear there would not be enough votes for it to pass. Further, the Save California Football Coalition was formed and over 150 parents and kids rallied in opposition of the bill.
Delegate Terri Hill of Maryland filed a “public health” bill that sought to ban tackle football, heading in soccer, and checking in lacrosse below the high school level. As soon as it was filed, youth coaches across Maryland voiced their opposition on social media and radio. One youth football administrator accumulated more than 7,000 signatures to stop the bill. Despite the rapid negative response to the bill, Hill said she thinks this is a “conversation we have to have and . . . the conversation is not over.” Hill, a surgeon, noted that, “it’s difficult to appreciate that something we really enjoy, with clear benefits to our kids, may be hurting them without our knowledge.”
State Representative Carol Sente filed the “Dave Duerson Act to Prevent CTE” in Illinois. The act proposed banning tackle football for kids under the age of twelve and is named after the Bears defensive back diagnosed with CTE after his suicide. Duerson shot himself in the chest rather than the head, presumably so that his brain could be examined for degenerative disease. The proposal was immediately met with criticism and youth football coaches argued they had been making strides to make the game safer. They also argued that players are ill prepared to play tackle football when they are older, making them more susceptible to injury in the long run. The proposal died; Pop Warner spokesperson Brian Heffrom stated that the organization “can’t imagine elected officials mandating to parents which sports their children can play.”
Assemblywoman Valerie Vainieri Huttle sponsored a bill in New Jersey that would prohibit children under age twelve from participating in tackle football. Almost immediately, State Senate President Stephen Sweeny commented on the bill, stating, “That’s not happening.” He noted, “They’re teaching kids how to tackle properly. All you’re gonna do is get kids starting later, when it’s easier to teach kids early.”
State assembly member Michael Benedetto filed a bill in New York that would ban youth tackle football for children under twelve years old. First introduced in 2013, the executive director of Pop Warner called it “disturbing.” Benedetto filed the bill again in January 2018, naming it the “John Mackey Youth Football Prevention Act,” named after the Colts tight end who developed dementia and passed away in 2011. Benedetto compared the proposal to reducing risks for children by requiring use of car seats and bicycle helmets.
Opponents of Proposed Legislation: Why Banning Youth Tackle Football Is Not the Answer
At the heart of the criticism of the proposed legislation is the desire for parents to own the decision to consider what programs their kids will participate in. Steve Alic, director of communications for USA Football stated, “We converse with parents often, and they clearly do not want government telling them when and how their kids should play sports. They want to make informed decision for themselves.”
Regardless of this criticism, the US Soccer Foundation has banned heading in soccer for players under ten-years-old while body checks in ice hockey are prohibited for players under thirteen-years-old. At this point, sports associations themselves are taking steps to reduce the risk of injury from contact in younger players. Does this take the decision out of the hands of the parents? Does this not address the issue fully enough that states believe legislation must be enacted?
Opponents of proposed legislation note that tackle football is not as dangerous as the media has made it out to be. An often-cited statistic is gathered from data from the Consumer Product Safety Commission that shows that just 21% of all traumatic brain injuries among American children and adolescents are caused by sports and recreational activities and the first culprit is cycling with 40,272 incidents, with football coming in second with 21,878 incidents reported. This statistic is reported in an article authored by Gavin Newsham, who also notes that in light of these statistics, “and yet no one is calling for a ban on bikes.”
Arguably, no one is calling for a ban on football either. Just as we have legislation that requires children to wear bike helmets, current proposals are not calling for a ban on football, but a modification (like a helmet) where children under twelve do not tackle during games. Newsham further advances his point by noting that youth football may be the safest it has ever been. In 2016, Pop Warner introduced a new rule preventing kids under ten-years-old from using the traditional hand-on-the-ground squat before the snap to minimize the risk of head clashes. With safer equipment, better-qualified coaches, and a greater awareness of the risks involved with football, one can argue the concern is not great enough to place an entire ban on tackle football for youth players, as such may even lead to more injuries, as older kids will not be trained properly to participate in tackle football.
Proponents of Proposed Legislation: Why Banning Youth Tackle Football Will Minimize Degenerative Brain Diseases
On the other side of the aisle, proponents of proposed legislation liken recent studies on CTE to early studies that linked lung cancer to cigarette smoking and pointed out how it took decades to pass regulations on the tobacco industry. The most recent Boston University study found 223 out of 266 former football players had CTE, which has been linked to depression and other cognitive disorders. A player’s risk for developing the disease increased by 30% for each year they played the sport.
New York State Assemblyman Benedetto says for young kids, the recent revelations about the dangers tackle football can pose give him pause, and he’s been at the forefront of an effort to ban tackle football for kids under the age of twelve. He states, “when you get older and your brain is more developed, then go into the full tackle football,” Benedetto points to medical data showing the onset of traumatic brain diseases like CTE in people who play tackle football, resulting from the rough hits they can receive on the field. Rick Knizek, the athletic trainer and concussion management coordinator for the Shenendehowa Central School District in New York stated, “The concern about concussions long term, a lot of those are turning out to be concussions sustained at a much younger age. Unfortunately, there’s a lot of inherent risk in football. Kids are bigger, faster, stronger than they were a decade ago.” Knizek says the sport is continually evolving, and the state and the school district have taken steps in the past few years to prevent traumatic brain injuries if a player takes a serious hit.
Meeting in the Middle
Not all youth football coaches wholeheartedly oppose the ban on youth tackle football. Stephen George, a former high school football player, youth football coach, modified football head coach, and elementary physical education teacher from New York supports the proposed legislation to ban children under twelve from participating in youth tackle football, with a caveat. When asked his opinion on the proposed legislation and whether such legislation would lead to players being unprepared to play tackle football in the future he stated, “Tackle football should be banned until the age of twelve, in non-competitive leagues. When kids are younger than twelve, the game of football is about the fundamentals such as throwing, catching, and blocking. Coaches can still teach tackling and the proper fundamentals using tackling bags or tackling dummies.”
A discussion with Barry S. Willer, PhD, professor of psychiatry at the University at Buffalo School of Medicine and Biomedical Sciences bolstered a similar idea offered by George, exposing the possibility of focusing on limiting tackling in non-competitive contexts. Realistically, many “house” teams are formed for fun and the participants play recreationally. For these types of children’s teams, tackling is not a necessary aspect of the game and it is possible the participants would benefit from avoiding unnecessary hits. On the other hand, there are some teams formed to develop young children into competitive players with a chance to apply their talent and skills in a professional arena. In these instances, Willer suggests introducing tackling gradually. This way, players would develop the necessary skills over time in a controlled environment. Additionally, Willer explains the hits resulting in the most damage are those that are unexpected (i.e. running a route and inadvertently colliding with a player who wasn’t paying attention) than the expected tackle during a practiced play. Given this observation, it seems it is important to teach those wishing to play at a high caliber competitive level how to prepare themselves to be tackled as much as how to tackle.
A Model State: California’s Compromise
Although we should be cautioned by the stories of Webster, Hernandez, Stabler, Waters, Duerson, Seau, and Gifford, Dr. Robert Stern cautioned that CTE could not explain all of a player’s actions. He advises, “When it comes to suicide and chronic traumatic encephalopathy, it is possible that in some individuals the combination of CTE-related symptoms of poor impulse control, depression, and cognitive impairment may indeed lead to suicide. However, we can never clearly point to any cause-and-effect relationship in any one case.” Echoing this sentiment, Leszek Christowski, the Hillsborough County medical examiner told ESPN “scientifically, there is no [cause-and-effect] connection. Could it play a role? Yes. But the statistical studies do not show a clear-cut connection between concussion and depression.” Given this sentiment along with the intense opposition to legislation that bans tackling altogether, is a compromise possible?
The answer: maybe. In California, although the “Safe Youth Football Act” failed, the “Youth Football Act” was enacted, which regulates the game without banning youth tackle football. The bill will go into effect January 1, 2021. The act prohibits a youth tackle football team from conducting more than two full-contact practices per week during the preseason and regular season. It also prohibits a youth tackle football team from holding a full-contact practice during the offseason. It limits the full-contact portion of a youth football team practice from exceeding thirty minutes in any single day. Furthermore, the bill requires youth football team coaches to annually receive a tackling and blocking certification from a nationally recognized program that emphasizes shoulder tackling, safe contact, and blocking drills. Under the bill, parents or guardians of a youth tackle football player must receive concussion and head injury information and each football helmet must be reconditioned and re-certified every other year.
The bill requires a minimum of one state-licensed EMT, paramedic or higher-level licensed medical professional to be present during all preseason, regular season and postseason games. It requires the medical professional to have the authority to evaluate and remove any participant from the game who exhibits an injury, including, but not necessarily limited to, symptoms of a concussion or other head injury.
The bill also requires at least one independent non-rostered individual, appointed by the youth sports organization, to be present at all practice locations. The individual must hold current and active certification in first aid, CPR, the use of an automated external defibrillator and concussion protocols. The individual will have the authority to evaluate and remove any youth tackle football player from practice who exhibits an injury, including, but not limited to, symptoms of concussion or other head injury.
Conclusion: To Ban or Not To Ban?
At the end of the day, knowledge is power. Less than twenty years ago, CTE did not even exist in our minds. Football players were suffering concussions, returning to the sideline for a minute or two, and were right back in the game. Symptoms such as erratic behavior, headaches, and memory loss were simply “personality traits” and the effects of “getting older.” Although there is much to still discover about CTE, we are no longer completely ignorant of the effects of repetitive traumatic brain injury. Whether the knowledge we have gained will lead to a ban on youth tackle football or stringent rule changes to make the game safer, one thing is certain: parents, players, coaches, and the football community are more careful than ever. The more we keep the conversation alive, the less players will suffer in vain.