Do you think tackle football can be reformed to make it safe for children?
No, tackle football cannot be reformed to make it safe for children. The fundamental problem with youth tackle football is that the act of tackling and blocking a moving person will always create accidental, but repeated, head impacts.
Does "Heads Up Football" training make youth football safe enough?
No, “Heads Up Football” does not make youth football safe enough. A game with blocking and tackling, no matter the form used, will cause repetitive head impacts.
In 2013 the NFL committed $45 million to create Heads Up Football, which purports to teach “proper tackling techniques” to improve player safety. While training form in tackling and blocking has a place in high school, college, and professional football, it is ethically inappropriate as the primary injury prevention strategy for children.
Children are not capable of executing “proper technique” 100% of the time, nor are their motor skills refined enough to consistently make the split-second movements required to put their head in the “proper” position when making a tackle. These are the same reasons why we don’t let children drive cars. Giving 6-year-olds driver education would lead to a safer form of 6-year-olds driving, but we still don't allow children that young to drive because it’s still not safe enough, no matter the technique we are teaching them.
Can helmets make youth tackle football safe enough?
No, helmets cannot make youth tackle football safe enough. Helmets primarily protect players from a skull fracture, but they are limited in how much they can protect the brain. The brain is the consistency of custard, and when the head is impacted, the brain moves, twists, and stretches within the skull, causing damage to the delicate cells and their trillions of fragile connections.
There is not much hope that helmets can be radically improved. When asked how much better football helmets can get, expert Dr. Stefan Duma of Virginia Tech University said, “I think we are at 90 percent of where we are going to be. About as good as we can get."
Can minimizing hitting in practice make youth tackle football safe enough?
Minimizing hitting in youth tackle football does not fully solve the repetitive head impact problem. We strongly encourage high school, college, and professional teams to limit hitting in practice. However, for young children, hundreds of head impacts are never appropriate. It is analogous to asking whether children should smoke two packs of cigarettes a day or limit their smoking to one pack of cigarettes a day. The only appropriate goal for a child is no cigarettes.
I have heard the CTE research sample is biased. Is that true?
People who say that CTE research is biased as a way of minimizing the results may not understand the research. There are many types of bias in scientific research, and all deserve scrutiny. In this study, the bias does not refer to the scientists conducting the research being biased, or the diagnoses or conclusions being biased.
A Brain Bank sample always has the bias that people are more likely to donate a brain if they are worried a love one showed signs of the disease. Therefore, a Brain Bank is not an accurate way to predict the prevalence of a disease. In this study, there is a bias only if this study is being used to predict how many football players are living with CTE, also known as the prevalence. The scientists conducting this research understand this potential bias, and therefore are careful to say this sample is not indicative of the general population.
However, that does not mean that Brain Bank data is meaningless. When the scientists at the VA-BU-CLF Brain Bank report that 177 of 202 football players studied have had CTE, consider the following:
- Not every family that donated believed their loved one had CTE.
- Even if they did donate because they believed their loved one had CTE, there are no clinical criteria for diagnosing CTE in a living person, so families should not be very good at diagnosing a loved one.
Therefore, the finding of 177 cases of CTE among the first 202 football players studied is greatly concerning, and is why we believe it is worth pausing hitting children in the head hundreds of times a season until we know more.
Isn't it safer for children to learn to tackle or block before they get big and strong?
No, there is no research that supports the argument that learning to tackle or block when small and slow makes football safer when a child is bigger and faster. It was originally a surprise to find smaller, slower youth players still suffer head impacts almost as severe as college football players. However, now that we understand the “Bobblehead Effect,” it makes sense that tackling as a young person appears to be at least as dangerous for the brain as tackling at any other age.
It is also worth considering the other major difference between the bodies of children and adults in football: upper body strength. Adults block and take on blocks very differently from children because they are able to use their upper body strength to push other players and create a buffer zone to prevent their head from being impacted. Children not only have larger heads relative to the length of their arms, they also cannot build significant upper body strength before puberty, making it very difficult for them to use technique with their arms to prevent head impacts.
Didn't a study show high school players from the '50s are healthy?
Yes, a study of members of the high school class of 1957 in Wisconsin found that high school football players did not have an increased risk of cognitive and emotional problems later in life. Two other much smaller studies from the Mayo clinic have had similar results studying boys who played high school football between 1946 and 1970. While the Wisconsin study authors noted, “Our findings may not generalize to current high school football players, as football has changed dramatically since the 1950s,” we look at this study as supportive of Flag Football Under 14.
Youth football was not widespread until the 1970s, so while the study did not know if subjects played youth tackle football, it is safe to assume few, if any, did.
Flag Football Under 14 would recreate the experience of this cohort, who played only four years of tackle football or fewer, and with hopefully the same results.
How can we make a recommendation without knowing genetic risks yet?
It is inappropriate to say our lack of understanding of CTE genetics prevents us from making policy recommendations to protect children. With 110 of 111 former NFL players diagnosed with CTE, it is very unlikely there exists a gene that is 100% protective against CTE. If that is the case, then we are required to protect all children equally from an environmental exposure.
How we have addressed genetic risk factors for smoking and lung cancer provides guidance for how to handle genetics and CTE. In the last few decades, science has made tremendous strides in understanding who is at greater risk for lung cancer if they smoke. However, that information is never part of a conversation between a doctor and their patient on whether or not they should smoke. The doctor still advises their patient not to smoke, whether their risk lung cancer is 10 times or one tenth the risk of the average person. Genetic risk has no place in CTE discussions for children either.
I heard flag football was more dangerous than tackle. Can that be true?
No, flag football is not more dangerous for the brain than tackle football. Youth tackle football advocates have been citing a poorly designed study out of Iowa (Peterson et al. Orthopaedic Journal of Sports Medicine) that required coaches to voluntarily report injuries. The study claimed that among 3,525 tackle players, 30 concussions were diagnosed (<1% of players), and among 269 flag players, 3 concussions were diagnosed (>1%).
First and most importantly, repeated head impacts are the problem unique to tackle football, not concussions. A 2019 study (Lynall et al. Journal of Neurotrauma) tracked head impacts amongst a cohort of 25 youth tackle football players and 25 youth flag football players over the course of a season. The tackle group experienced 11 times as many impacts overall (1,908 vs 169) and 6 times as many per session.
Second, the Iowa study was conducted without athletic trainers on the sideline to diagnose concussions. Independent studies show that sports programs with athletic trainers present diagnose more concussions than those without, as the medical professionals are better able to recognize signs of the brain injury and assess the athlete. Athletic trainers are rarely, if ever, provided at youth tackle football events due to cost. The only study of youth tackle football concussion rates using athletic trainers on the sideline to make the diagnosis (Chrisman S et al. Journal of Pediatrics, 2018) found 5% of children suffer concussions each season. With this knowledge in hand, the best use of the Iowa study may be in showing us how many concussions are missed when there is no athletic trainer on the sideline. If they found a less than 1% concussion rate in a youth tackle football program, that may mean over 80% of concussions are going undiagnosed, and the children are at great danger.
Will the national youth football companies adopt an age minimum for tackle?
We have designed this campaign as an educational campaign for parents because we believe that the national youth football organizations cannot set an age minimum without disrupting their business. At a 2012 Aspen Institute panel discussion on the future of football, Pop Warner executive director Jon Butler said that if Pop Warner only offered flag football, “90 to 95 percent of our members would drop out” and play for independent teams “because whether it be kids or parents, they want to play tackle football.”
If Pop Warner said no tackle until age 8, it would create a void to offer tackle for 7-year-olds that would be filled by a competitor, and the players would remain with the competitor, killing the Pop Warner business. To protect children, we have to focus on changing the demand for tackle football by educating parents, rather than focus on the supply of tackle football.
Do youth tackle football promoters care about the health of players?
Youth tackle football promoters absolutely care about the health of players. Consider that USA Football recommends waiting to lift weights until high school, because “Beginning any type of weight training before a body is ready puts too much strain on young muscles, tendons and growth plates. By 13, a child’s nervous system and muscles typically begins to develop into maturity.”
The brain is the central part of a child’s nervous system. We wish football organizations prioritized prevention of trauma to the brain as much as they prioritize prevention of trauma to “young muscles, tendons, and growth plates,” but currently that is not the case.
But what about the thousands of former football players who are fine?
The good news is that the majority of former football players likely don’t have CTE. It is also true that the majority of smokers don’t develop lung cancer; but that doesn’t mean that smoking is safe for children.
I've heard people say "football is as safe as it's ever been." Is that true?
Here is another way to look at it: now that more than 200 cases of CTE have been diagnosed in football in the last decade, we have never known football to be more dangerous.
Thanks to advocates for safer football, football may be safer than it’s ever been, but that doesn’t mean we should stop continuing to make it safer. Flag Football Under 14 is the best way to make football players safer in the future.
I heard no youth tackle football player has been diagnosed with CTE. Why ban it then?
A youth tackle football player, Kyle Raarup, never played any sport after 8th grade and was diagnosed with Stage I CTE when he died at age 20 from suicide. There is no scientific or medical reason to believe children might somehow be immune to CTE. In a study funded by the CDC, the median youth tackle football player was exposed to 378 head impacts per season.
Current evidence suggests a year of youth tackle football is just as risky as a year of tackle football at another level. Even the medical director of Pop Warner has said about CTE, “The NFL has sort of taken the brunt of the bad PR for this but we don’t know if it’s at the college or HS level when they’re adolescents or even at the youth level.”
Another way to approach the question is through our experience with smoking and lung cancer. Have you ever heard of a 12-year-old dying of lung cancer? No, but we still trust that smoking is bad for children when we look at all the research together, and that’s why it’s now banned for children.