Two of the top experts on sports-related concussions disagree on whether children less than 14 years old can safely play collision sports such as football.
Dr. Robert Cantu of Boston University believes athletes under 14 should not play tackle football, ice hockey and lacrosse unless rules are altered to reduce the danger of concussions and the impact of repeated hits to the head. He also questions whether to allow children to head the ball in soccer.
Dr. Kevin Guskiewicz of the University of North Carolina believes it is important for young athletes to learn how to safely handle contact at an early age and develop those skills against competition that is the same size and age.
"Bob and I don't disagree on much, but we do on this," Guskiewicz said.
The question is whether the safety advantage gained by learning to perform athletic skills at an early age is offset by the risk of brain trauma caused by repeated blows.
Guskiewicz believes it is much safer for young players to learn how to safely play games when they are small, rather than wait until they enter high school.
"The youth league players generally are close to the same size and are about the same age," Guskiewicz said. "If you wait until the kids are freshmen in high school, you might have a 130-pound player competing with a 300-pound player. The forces can be tremendous. I believe it is safer for the players to learn at younger ages."
Cantu, who is co-director of the Center for the Study of Traumatic Encephalopathy at the Boston University School of Medicine, said after treating many young athletes with concussions, it is essential to find ways to avoid blows to the head.
"That's where Kevin and I differ," Cantu said. "I'm treating these children and I've seen them miss school for a week, a month, a semester, even a year because of post-concussion symptoms.
"It doesn't make sense to me to be subjecting young individuals to traumatic head injury. There's no head injury that's a good one, and you can't play collision sports without accumulating head injuries. To allow children to play with no informed consent of the dangers is inexcusable. To allow children to play in collision sports with the rules as they are written should not be allowed."
Experts on concussions
Cantu and Guskiewicz are among the world's pre-eminent authorities on sports-related concussions.
In addition to his medical practice, Cantu is co-director of the Neurologic Sports Injury Center at Brigham & Women's Hospital and co-founder of the Sports Legacy Institute, which, among other things, studies the post-mortem brains of athletes looking for the lingering effect of head trauma. He also is an adjunct professor at the University of North Carolina and works closely with Guskiewicz.
Guskiewicz is Kenan Distinguished Professor and chair of the department of exercise and sport science in UNC's College of Arts and Sciences. He also is co-director of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center and research director for the Center for the Study of Retired Athletes. He helped write concussion guidelines that are now recommended by the National Athletic Trainers Association and the American College of Sports Medicine and is on the NCAA's concussion committee and the NFL's head, neck and spine committee.
Questioning the rules
Cantu has become increasingly concerned in recent years as he found early signs of chronic traumatic encephalopathy (CTE) in athletes who were 17, 18 and 21 years old at the time of their deaths.
CTE is a progressive, degenerative brain disease found in individuals exposed to repetitive head trauma. CTE was most often identified in the past with boxers. Symptoms typically include memory loss, behavioral changes, confusion, and dementia. It can only be confirmed during autopsy.
The Boston University center has found evidence of CTE in 14 of 15 former professional football players and four of six former professional hockey players whose brains were studied after death, but finding signs of CTE in the young athletes was unexpected.
The deceased young athletes had not exhibited symptoms of CTE, but researchers believe they would have been symptomatic eventually.
Researchers believe that it doesn't take a tremendous blow to injure a child's brain. Damage can be from an accumulation of sub-concussive hits, blows which jar the brain but do not cause an immediate concussion. Children are more susceptible to concussions than adults. Their brains are still developing and their brains react differently to trauma. Children also are slower to recover from concussions than adults.
Cantu believes it is imperative that youth sports eliminate deliberate hits to the head. Football should consider playing flag football in its youngest youth leagues, he said. Hockey should eliminate all checks to the head and lacrosse should eliminate blows to the head.
"We have millions of youngsters putting their heads into collision sports right now and we don't really know how safe this is for them," Cantu said.
A high school football player may receive 650 sub-concussive hits in a season, more than 2,500 in a four-year career. Football collisions can generate more than 100 g- force (imagine a car hitting a concrete wall at 25 miles per hour). The greater the weight and speed, the higher the g-forces.
In North Carolina, players who have a concussion must stay out of games until receiving written clearance by a physician. The law, in effect since last year, covers high school and middle school athletes.
Cantu sees no advantage in beginning children in collision sports at an early age. "If one is ultimately going to be superior in a sport, it's their genes that are going to determine that, plus their work ethic. It's not going to be that they started the sport earlier. It's what they inherited from their mother and father," he said.
"Tom Brady (the New England Patriots quarterback) didn't play football until he was in the ninth grade."
Guskiewicz allows his three sons to play youth football. He wants them to be trained in the proper techniques for blocking and tackling before they are bigger and faster.
"Players can learn the proper techniques of blocking and tackling when they are 9, 10, 11," Guskiewicz said. "That skill development is crucial. I think it would be good for young players to have the opportunity to learn those skills against other players closer to their size and age.
"I'd rather have them learning in that environment instead of waiting until they are much bigger and faster and are playing against bigger and faster players."
'A safer game'
Anthony Horton, the commissioner of the Capital City Steelers youth football team, says the youth leagues provide an introduction to football. Players 5 and 6 years old play flag football and the 7-year-olds play with four coaches on the field.
"It is a very controlled environment," Horton said. "And as the children get older, we are still controlled by size and age."
He said the organization stresses concussion awareness, giving literature to players and parents, and abides by N.C. High School Athletic Association concussion management guidelines, even though the recent concussion-related legislation doesn't apply to youth leagues.
Charlie Slagle, the CEO of the 800-team Capital Area Soccer League, said the youth soccer league also follows the concussion protocols and has a certified athletic trainer available for practices and games at the WRAL Soccer Center.
"We take head injuries seriously and it is extremely important that players are taught the proper technique in heading," Slagle said. "But I have not heard of any national movement to take heading out of soccer."
Protecting his children
Rodney Farlow, a former high school head coach and the coach at Durant Middle School, said he sees he legitimacy in both views. He didn't let his oldest son play until he was in middle school. His second son played two years in youth leagues before middle school and his youngest son played three years of youth league ball before middle school.
"If children are taught properly and have the right equipment, I think getting started early and learning to play safely is better. But those are two big caveats," Farlow said. "The instruction needs to be very good."
Farlow said about 50 percent of his middle school teams have players who have never played before.
"We treat them all like they've never played," he said. "Middle school is the first time most of them have played without weight limits. It takes some adjustment."
Guskiewicz and Cantu each stressed they are in favor of children playing sports and being active.
"Neither of us is for eliminating football or changing the sport," Guskiewicz said. "I am a huge fan of football. It is my favorite sport.
"My research has been to create a safer game of football, not eliminate it."