Informing Decision Making in Youth Tackle Football — Lessons from AAP Policy Statement Criticism

The 2019 policy statement published by the American Academy of Pediatrics (AAP) may have ambiguity and inconsistency, preventing ethical and informed decision-making for participation in youth tackle football. Critics explain how this can be improved by defining essential terms, roles of different stakeholders involved, identifying an appropriate evidence-base, and ensuring consistency with other sports.

According to research evidence, 2 to 4 million youth under 19 play tackle football in the United States. Short- and long-term effects of concussions are a major concern. mTBI is a transient injury, but its neuropathophysiology may last from weeks to months or even longer. Subconcussions may lead to CTE. Individual players experience 100–1000 head impacts and about 53,000 to 178,000 school-age players sustain at least one concussion (data from 2011–2019).

The policy statement of AAP was published in 2015. In 2019, the implications of AAP Policy Statement on informed consent in youth tackle football were met with criticism. There have been several criticisms of AAP policy with regard to informed and ethical decision making in youth tackle football — participants being able to decide whether recreational benefits outweigh potential health risks of injury in tackle football. The prominent criticisms against the policy statement include:

Ensuring Information Disclosure and Guidance from Informed Provider is a Priority

Lerner and Fost (2019) stated the need for information disclosure along with written material and an opportunity to consult an informed provider. The AAP did not provide any guidance on the nature of adequate consent process or form. Children and parents must have access to relevant information and guidance on obtaining additional information to be able to make morally and legally meaningful decisions.

Including mTBI Education towards Ethically Meaningful Consent is Essential

Parents and children lack an understanding of mTBI in youth football. Ethically meaningful consent is informed, in the absence of which, a written or verbal agreement to participate in tackle football does not imply sufficient understanding that supports a conclusion or decision. Critics argue that AAP must state their stand on whether comprehension in this context is important.

Understanding that Teaching Tackling Early may Not Offset Lifetime Risk

AAP policy statement may be unclear or without sufficient scientific evidence to allow informed decision-making. Evidence-based literature is targeted at collegiate, professional, and high school football, but not young players. Further, while AAP suggests that teaching proper tackling to young children can reduce concussion burden, not enough data supports this claim, which may be misleading. To add to this, it must be noted that illegal tackles including targeting and spearing (improper tackling technique) may increase risk of catastrophic injury. Evidence does not prove that teaching the proper tackling technique reduces high baseline risk of mTBI in football. Furthermore, their claim about later introduction of tackling increasing concussion risk in young players is also not justified. In effect, no evidence supports the claim that teaching proper tackling when young offsets risk of total lifetime collisions. On the contrary, the success of several NFL players supports the notion that proper tackling can be learned later in life.

Explaining Involvement of Child Player in Decision-Making across Ages

AAP policy implies that children can assess risks and benefits, and make informed decisions. The roles of parents and players are not clearly defined for different age levels. This needs to be clarified as the involvement of child player varies across the age spectrum. Players belonging to different age groups tend to underreport concussion symptoms or not report at all. This behavior is explained in developmental neuroscience for preadolescent, high school players, and college athletes. Even if they are not able to provide ethically meaningful consent, children need to understand risks in an age-appropriate manner, why it is important to report injury signs and symptoms, and the potential consequences of brain injury that is left untreated.

Reevaluating the Definition of a “Concussion”

AAP statement does not define “concussion”, which is often linked to clinical signs of brain injury. However, players may sustain repeated brain damage without observable symptoms, which may lead to long-term consequences. It must be noted that players may have serious neuropathology such as CTE without a concussion history. Further, athletes may have prolonged disruption of brain function extending from days to years following acute brain damage. Athletes may suffer from a “second concussion”, concentration difficulties, light and noise sensitivity, difficulties with learning, emotional regulation, an memory. Critics suggest the use of the terms “brain injury or damage” and “mTBI” in place of “concussion” to clarify the nature of injury — i.e. acute symptoms are external signs of brain injury that may not necessarily be resolved and may have lasting effects.

Making a Proper Context-Specific Risk Assessment

AAP does not clearly define a model consent form, and even though they recommend that Pop Warner is the most influential youth football organization, it is difficult to understand risks of repetitive concussions and sub-concussions. The statement also trivializes the risk on the pretext of riding an automobile being a leading cause of death due to concussions in children and teenagers. However, it must be noted that football is an elective activity with multiple low-risk alternatives, unlike riding an automobile which is an essential activity. Comparing football head injury to biking is also flawed as data suggests a higher number of injuries in football (53,675 per year) versus 25,955 annually in biking. Besides, biking is linked to accidental trauma, whereas football is associated with unavoidable and repetitive trauma. Biking has benefits different from football, and bike safety is different from football safety.

Verifying Consistency of AAP Statement with Other Sport Policy Statements

AAP policy statement is not consistent with its statement on other sports such as hockey. While body-checking for under 13s is banned in hockey, AAP recommends body-checking for under 15s and encourages physician advocacy for expanding non-checking programs. Given that banning body-checking in hockey led to 50% overall injury reduction and 64% concussion reduction for 11–12-year age group, allowing blocking / tackling in football is not justified given body-checking in hockey being perceived as too dangerous.

Accounting for Inadequate Evidence on Risks and Benefits of Tackling

The AAP does not support its statement on benefits of tackle football outweighing risks. The benefits of regular exercise are not synonymous with football due to availability of limited evidence. Children who do not participate in organized athletics are able to live fulfilling lives and the benefits stated are not unique to tackle football. These benefits may be insufficient to outweigh the disproportionate risks of harm from head injuries.

Defining Involvement of Pediatrician in Decision-Making

The pediatrician is not included in the AAP policy statement unlike the policy statement on ice hockey. Authors do not explain whether pediatricians are to use “directive counseling” to advise parents and children in decision-making in playing tackle football. Further, there is uncertainty on responding to recommendations on tackle ban. Survey results indicate parental concerns on tackling (77% do not allow children to play tackle and 81% support age limits on tackling according to 2017 survey; 61% — 85% support age restrictions for tackling according to 2019 study). Critics say that it is important for AAP to reconcile differences between policy and opinion of primary stakeholders i.e. pediatricians and parents.

In effect, while informed decision making on whether to participate in youth tackle football may allow parents and players to make better choices, it may add to the attrition in participation and contribute towards closure of school-based football programs. This may have economic implications for the multi-billion-dollar football industry. Critics conclude that the policy statement definition of decision making for youth participation is problematic and the underlying issues may prevent it from being ethically meaningful. These arguments are presented towards a revision and review of the current statement.

Reference

Lerner, A., & Fost, N. (2019). Informed Consent for Youth Tackle Football: Implications of the AAP Policy Statement. Pediatrics, 144(5), e20191985. https://doi.org/10.1542/peds.2019-1985