Until I became involved in CTE research, I never considered that most brain trauma in the industrialized world occurs in children playing sports. Since participation is voluntary, and the rules of recreational sports are malleable, it seems reasonable to make every effort to reform each individual sport, with the goal of reducing risk of concussions and CTE. As logical as that sounds, adoption of brain trauma limits and other protections for athletes has been remarkably slow. Based on what we know today, there are a number of steps we can take to lower the risk of concussion and CTE.
Historically, athletes have participated in sports with rules that ignored the risks. Until recently, ice hockey players were allowed to intentionally use their skating momentum to slam into any part of their opponent, including the head, with little concern for penalties, fines, or suspensions. When I played football, which wasn’t that long ago, coaches taught us to lead with our heads as the point of initiating contact for blocking or tackling. Athletes were encouraged to play through concussions if they were able.
New rules in both these sports have since been designed to lessen brain trauma, but with every new horror story that emerges on the sports pages, parents worry even more. What sports should I allow my child to play? What power do I have to protect my child on the field? To evaluate the risk, simply compare how that sport is played at the youth versus adult level, and consider the safeguards professionals are provided. Football is a prime example since, amazingly, 6-year-olds play by essentially the same rules as professionals. Right now we have a healthy national discussion about whether the NFL is too dangerous for adults, yet we pay lesser attention to the risks of youth leagues, despite the fact that football is far more dangerous for kids.
We need to consider the way the human brain develops and recognize that children are at an anatomical disadvantage compared with NFL players. A child’s axons, which connect brain cells to one another, are not fully myelinated (in other words, insulated), and his or her brain cells are more sensitive to the neuron-damaging shock of concussions, making each impact and concussion potentially more damaging to the brain.6
Children are also at a biomechanical disadvantage. A child’s head grows much faster than his or her body, so the head is nearly fully grown by the age of 4, a time when body mass is about 20 percent of full size. Even by age 12, when a child’s head is 95 percent of its eventual full size, his or her body is only half its eventual full mass.7
Combine the child’s mature head with a weak neck and torso, and a comparison might be made to a bobble-head doll. It doesn’t take much force to accelerate the head to dangerous levels, such that the brain pitches back and forth and twists within the skull, producing chemical, metabolic, and even structural injury to the brain. In fact, studies with sensors in helmets have revealed children take blows to the head of almost equal force as college players.8
When it comes to diagnosing concussions, children also face inadequate safeguards. There is no biomechanical or neuroanatomical reason to believe that children aren’t suffering as many concussions as adults, and yet they are rarely diagnosed with the injury. A few years ago sports leaders believed that children didn’t actually suffer concussions—they were somehow resilient. Now we know there are two major reasons children aren’t frequently diagnosed with concussions.
First, rarely is anyone on hand to diagnose the injury and, second, young players seldom report symptoms. Your average NFL team has multiple medical professionals at every game and practice. Your average youth football game or practice has no medical personnel on hand. A recent study found that high schools with athletic trainers diagnosed eight times as many concussions as high schools without medical staff.9
Another study found that medical doctors who aggressively evaluated hockey players displaying concussion symptoms diagnosed seven times as many concussions as teams that only had athletic trainers on the bench.10
Do the math: if we provided children with athletic trainers and doctors on the sideline, we’d diagnose about 56 times more concussions. By not providing these resources, a solid case can be made that we will continue to miss 55 of every 56 concussions.
If this statistic seems hard to believe, consider that most concussions are not diagnosed unless the player self-reports symptoms. Educational programs from the Centers for Disease Control and Prevention advise players, “It’s better to miss a game than the season,” an effective message for prompting high school and college athletes to consider their long-term futures and self-report their symptoms. Young athletes, however, are not likely to have the cognitive capacity to recognize their symptoms as being connected to trauma, nor to realize they should inform an adult. Moreover, such messaging is rarely provided to children. Because there is no validated educational program for child athletes, parents, coaches, and other adults must actively teach youngsters about concussions and also encourage them to report their own symptoms or those of a teammate.