Three years after an American Academy of Pediatrics (AAP) policy statement recommended against banning youth tackle football, an Aspen Institute white paper is essentially calling for such a ban.
Released this week, the report encourages youth football organizations to "shift to a standard of flag football before age 14" and requests the medical community support that and its other recommendations.
"To be effective, these recommendations need full, interlocking support from both the football and medical communities," co-authors Tom Farrey and Jon Solomon of the Institute's wrote.
Besides shifting youth football to a flag model, also recommended:
- Youth football organizations should begin teaching fundamental blocking, tackling, and hitting techniques at age 12 in practice, so kids are prepared to hit and tackle if they play tackle football in high school. Coaches should instruct in "a controlled, safe-as-possible manner that does not involve player-to-player and helmet-to-helmet hitting and contact"
- High school and college coaches should follow a practice model adopted by Dartmouth College coaches designed to minimize tackling and other collisions outside of games
- The number of flag football leagues and other options should be expanded for players ages 14 and older who don't want to play tackle football, including college-age students
Focus on Youth Level
Most of the report focused on the youth level. "We suspect that flag football could prepare children for the world ahead no less readily than tackle football, and other sports, especially if delivered by coaches trained to work with youth," the authors wrote. "There's a developmentally appropriate time for everything. Life lessons are best taught when youth have the mental maturity and perspective to process them; before they reach adolescence and perhaps high school, it's more about creating experiences where kids can have fun with their friends and develop , or all-around athleticism that lays the groundwork for them to be active for life."
Solomon told ľֱ that practitioners can help simply by "being wise and understanding of what data is out there, what the health risks are." Some practitioners, therefore, refuse to sign tackle football participation waivers, for example.
The paper stems from a panel discussion in January, as well as a post-panel survey including open-ended questions, news, and other reports published after the panel, and Institute research. The panel included Robert Cantu, MD, a neurosurgeon with and the , and Andrew Peterson, MD, a sports medicine specialist at the University of Iowa who represented the AAP. The survey yielded 62 responses.
Calls for More Evidence
The medical community has been divided regarding the youth tackle football debate, but few dispute that not enough evidence exists to support either side. "It is unclear exactly how risky youth football participation is, or how many hits to the head over the course of a football career is likely to be too many," found the authors; they also noted that, while many former youth and high school players have suffered serious brain injury, many others "appear not to have suffered lasting or clinically significant brain injury." In addition: "Both the short- and long-term clinical significance of brain changes observed via imaging studies of youth and high school football players is unclear."
"There's no evidence to suggest that youth tackle participation is a necessary precondition for high school, college, and professional success," the authors added, "nor any showing that exposure to tackle football prior to high school reduces the risk of injury."
But some research casts doubt on the safety of tackle football for younger kids, who are more susceptible to sustaining brain injuries with long-term consequences -- especially because of the so-called "subconcussive" blows many players sustain nearly every play during collisions. "All of our studies are pointing towards subconcussive impacts causing a change in the brain," said Elizabeth Davenport, PhD, of the University of Texas Southwestern Medical Center, who has used imaging technology to study the brains of youth and high school players. "Everything we've seen has shown that just a normal football season will cause changes in the brain."
Said Cantu, "Multiple papers we've been a part of have shown that if you play tackle football under the age of 12, you have a higher chance later in life to have cognitive behavioral and mood problems than if you started at a later age." The Aspen Institute report indicated long-term data were largely non-existent: it cited decades-long prospective studies of men who played tackle football in high school, which found no greater risks of neurodegenerative disease or dementia than in non-playing peers. But those studies had no data on participation in tackle football before high school.
Other researchers, such as Peterson, firmly supported youth tackle football. Peterson told the Institute that "the health benefits of playing tackle football simply outweigh the risks," echoing the AAP statement. "You know, the rates of injuries are very low here," he said. "I think having a few years of exposure to contact sports as a young person is a fairly safe thing to do."
Farrey and Solomon concluded, "Physical inactivity and obesity are greater threats to [youths'] health and vitality, and to our society, than the risk of getting injured playing football or other sports. We also recognize that football can offer psychosocial benefits."
Other experts also cited the public health costs of preventing kids from playing tackle football (or any sport) -- particularly obese and other heavy children who often play on the offensive or defensive line. Just over one-third of boys get the recommended 1 hour of daily physical activity, according to the report (which cites the CDC), and only one-quarter of all did in 2012. This is "a factor that deserves consideration given the healthcare costs tied to obesity-related illnesses," the authors wrote.
But "it's hard to quantify the value that tackle football brings" to reducing medical costs and lost economic productivity, the authors wrote, noting the relatively small percentage of kids who play. "Further, it's unclear how early participation in tackle football impacts a person's desire or ability to be active for life. If a child suffers a knee or spinal cord injury that limits their mobility into adulthood, or a brain injury that affects emotional or cognitive function, what are the downstream costs on the individual and public health at large, including taxpayer burden?"
Citing the , Solomon argued that the possibility of tackle football being a huge public health boon "shouldn't necessarily be used as reason to postpone preventative measures ... and to protect kids. There's a lot of evidence and suggestions showing this [flag] is the right approach."
Flag Participation Up
More kids ages 6-12 played flag than tackle football on a regular basis last year (3.3% versus 2.9%), according to the , with flag participation up 38.9% over the past 3 years. Earlier this year a few states introduced (but have not passed) bills calling for minimum age requirements to play tackle football. found that 81% of its members want to limit or eliminate tackling from practices, and 77% would not let their son play tackle football. (Respondents were limited to members of the Section of Bioethics, Council on Injury, Violence, and Poison Prevention; and the Council on Sports Medicine and Fitness.)
"This report is just following where the public already is," Solomon said. "We ask this question: 'Should flag become the standard?' In some ways it's already becoming that."
In the report, said Solomon, "we say age 14" as the earliest age to begin tackle football, regardless of physical maturity. That's largely based on Cantu's work and similar recommendations that set the age at 13. "It's a recommendation," Solomon added. "It's not necessarily a hard and fast rule."
The AAP issued its youth tackle football recommendations during its 2015 annual meeting, with its Council on Sports Medicine and Fitness concluding that coaches should focus on reducing contact outside of games and teach proper techniques -- instead of banning tackling, which "fundamentally changes" the game. Greg Landry, MD, of the University of Wisconsin Madison, and William Meehan, MD, of Boston Children's Hospital, co-authored the statement.
Farrey and Solomon are former journalists who covered football for years; Farrey directs the Sports & Society Program. Besides health issues, the report addressed the likely impacts on high school, college, and professional football from ending tackle football in middle school.