Dr Keith Parry co-authors this article about new research which questions whether it is right for children to be involved in high impact sports that risk injury to the brain…
Children’s high-impact sports can be abuse – experts explain why
Chronic traumatic encephalopathy (CTE) is a brain disorder likely caused by repeated head injuries. It was first described as dementia pugilistica and punch drunk syndrome almost 100 years ago. CTE continues to be a serious risk associated with high impact sports, such as boxing, American football and rugby.
Although the risks of traumatic brain injuries, such as concussion, and longer-term brain degeneration from repetitive hits in impact sports have been known for decades, some sport governing bodies continue to try and cast doubt onto the relationship between impact sports and CTE. However, media attention has begun to change people’s minds.
This growing awareness is accelerated by the many lawsuits against organising bodies in relation to brain trauma. Former professional and amateur players in sports such as American football, Australian rules football and rugby say their governing bodies failed to prevent harm during their playing careers.
These are not only issues for elite players. Studies into the brains of former players have found CTE in those who only played as amateurs. CTE has also been found in the brains of players under the age of 30 and even those as young as 17.
Each additional year of playing impact sports raises the risk of CTE, by as much as 30% in American football.
The dangers of high-impact sport aren’t contentious. Academic evidence and medical professionals now agree that sport-induced brain trauma leads to degenerative brain disease.
Not suitable for under-18s
Given this context, our recent paper written with Jack Hardwicke, a senior lecturer in the sociology of sport at Nottingham Trent University, has questioned whether it is right for children to participate in sports that intentionally feature impact, particularly involving the head. We argue that allowing under-18s to take part in high impact sports should be viewed as a form of child abuse – we use the term “child brain abuse” – and that these impact sports should be legally prohibited.
We are not calling for adult versions of impact sports to be banned and our argument does not apply to sports or activities where brain trauma might occur by accident. But in sports where impact is a structured part of the game, like boxing – or sports that create rapid brain movements, as in rugby tackling – collisions are not accidents, they are an inherent part of the sport.
The risk of CTE is far higher in sports such as American football and rugby. The odds of developing degenerative brain diseases are increased in former players of impact sports than are found in sports without deliberate impacts or the general population.
But these benefits can still be gained from non-impact versions of sports, such as touch rugby, which can help teach discipline and teamwork without the harm from brain trauma.
There are no health benefits of tackling – and there are no health benefits of being struck in the head. The health benefits of impact rugby or boxing are instead gained from the body’s overall movement.
Tag rugby tends to be faster moving than the sport’s full contact version so is better for improving cardiovascular health. Research has shown that incidents of contact during children’s rugby are the cause of cause of 87% of known injuries. Tackling, in particular, is responsible for 52% of all injuries – with concussion being the most common injury type. Tagging, rather than tackling, saves children’s brains from harm.
Inability to consent
Our research shows that impact sports should be treated equally with other prohibited activities for children, such as smoking. Children are unable to make informed decisions about the long-term risks of these activities. Parental provision for these activities is also socially stigmatised or criminalised.
Our research draws on a number of legal positions that support our argument that neither children nor parents on their behalf can consent to sports that require brain trauma as a necessary component of the sport.
For example, Article 19 of the United Nations Convention on the Rights of the Child (UNCRC), to which 195 countries are signatories, covers protection from violence, abuse and neglect. It states that:
Governments must do all they can to ensure that children are protected from all forms of violence, abuse, neglect and bad treatment by their parents or anyone else who looks after them.
Some commentators have agreed that while high-impact sports are dangerous, using the term child abuse is a step too far.
However, the NSPCC, the UK’s leading children’s charity, say that physical neglect is a form of abuse that occurs if a child is not kept safe. Allowing children to participate in impact sports while being aware of the harm they can cause is, our research shows, a failure keep children safe.
There is no justifiable health reason for a child to play impact sport over non-impact versions. We are asking that ministers privilege children’s brains over corporate sporting bodies.
Rugby has a higher rate of injury than most other sports frequently played in schools in the UK. It is a collision sport where players purposefully tackle each other, which can result in serious injury, such as to the head and neck.
The risks of injury, and particularly brain injuries, from playing rugby are now widely recognised. And yet it remains a compulsory sport in many schools.
Tackle rugby should not be compulsory in any school, for any age of children. Where rugby is compulsory, it should be non-contact.
What’s more, schools should provide children and their parents with information on the dangers involved with playing sports like rugby at school.
School rugby
Research with 825 teenage school rugby players over one season found that more than one in three of the children suffered an injury from playing full-contact rugby. Almost half of these injuries were serious enough that the child could not return to play rugby for 28 or more days.
These injury concerns are also recognised by teachers. Our research has found that 67% of teachers in charge of school PE believe rugby union is the sport that puts children at the greatest risk of harm.
Despite the high risks involved with playing rugby, our research also shows that it is one of the most common sports in schools. We surveyed 288 state-funded secondary schools in England and found that rugby union was played in 81% of these schools. It is more common for boys to play rugby, but over half of the schools offered rugby for girls.
What is more worrying is that rugby is compulsory in the majority of the secondary schools we surveyed. Where schools offered rugby for boys, in 91% of cases it was compulsory. And 54% of schools that taught rugby to girls made it compulsory.
The risks of playing
In elite sport, understanding of the risks of playing rugby is growing. Concussion is the most common injury suffered by elite-level rugby players according to the Rugby Football Union (RFU), the governing body of rugby in England. Professional rugby union players are more likely than not to have suffered a concussion after playing just 25 matches.
This rate of injuries is growing. Some attempts to improve safety in the wider sport have been made. In community rugby, for example, the permitted tackle-height has been lowered.
But research has found that lowering the tackle height might not reduce the number of concussions suffered by players.
28th September 2019. Marcus Watson of Wasps Rugby Football Team is tackled during a Premiership Rugby Cup game between Northampton Saints and Wasps, September 28 2019. atsportphoto/Shutterstock
Repetitive head impacts, such as those that happen in rugby, can also cause neurodegenerative diseases such as chronic traumatic encephalopathy and dementia.
Nearly 200 former players are suing the governing bodies of rugby. These players are suffering from neurological impairments and claim that World Rugby, the RFU and the Welsh Rugby Union did not protect players enough from permanent injuries.
Current England player Courtney Lawes has recently said that he would have reservations about his children playing professional rugby, because the financial benefits are not worth the injuries that come from playing the sport.
The risks remain at amateur levels. Amateur rugby players are also taking legal action against the same governing bodies who, they say, did not protect them from brain injuries during their playing careers.
Rugby, particularly at school level, does not need to include tackling. Safer versions of the sport, such as tag rugby, already exist.
Rugby can be played without tackling and still provide a wide range of physical and mental health benefits that help children stay physically active and maintain psychological wellbeing. School rugby must change to keep children safe.
BU’s Dr Keith Parry contributes to this article from The Conversation, sharing the experiences of family members of those with brain injuries as a result of sport…
Sport-induced traumatic brain injury: families reveal the ‘hell’ of living with the condition
San Francisco 49ers running back Jeff Wilson Jr (centre) in action against Los Angeles Rams linebacker Leonard Floyd (left) and Los Angeles Rams defensive tackle Aaron Donald (right) an NFL game in California in 2022. EPA-EFE/JOHN G. MABANGLO
This article is part of the Insights Uncharted Brain series.
Jill* looked drained as we sat down to speak about her late husband. It had been a long day. It was February 2020, and we had been conducting interviews at the Concussion Legacy Foundation family huddle.
Despite being tired, Jill, 47, was keen to be interviewed. She wanted to share what she had gone through and hoped her story might help others. We sat down in a quiet corner of the foyer of the Rosen Centre hotel in Orlando, Florida, and I listened to her speak for over 90 minutes.
You can listen to more articles from The Conversation, narrated by Noa, here.
She told me all about her husband, Michael, a larger-than-life character who was the “life and soul of the party”. She spoke about how he had played many sports and had experienced multiple diagnosed concussions playing American Football and lacrosse – but this never dimmed his enthusiasm for sports.
Jill described how his behaviour gradually changed. How he forgot simple tasks. How he became aggressive. How his behaviour had become so erratic, she didn’t feel they were welcome at social events anymore. She said:
You’re just watching somebody you love disappear before your eyes and it’s hell.
Then one day she was on the phone to her husband while he was at work and the call went quiet. Jill rushed to his office, only to find that he had taken his own life.
Jill was one of the 23 interviews we conducted with family members over the three days our research team spent at the Concussion Legacy Foundation event. Our conversations provided an insight into what it was like living with a former athlete with chronic traumatic encephalopathy (CTE), a neurodegenerative disease similar to Alzheimer’s that has been caused by repetitive head impacts in contexts like sport and the military.
This story is part of Conversation Insights
The Insights team generates long-form journalism and is working with academics from different backgrounds who have been engaged in projects to tackle societal and scientific challenges.
The people we spoke to had been through so much. The confusion, hurt and despair of seeing the mind of someone they love gradually deteriorate seemed overwhelming. But we also saw some positive signs, such as how they wanted to share their stories to help others, and how there appeared to be a shared determination to change things for the better and to make sport safer so other families wouldn’t have to go through what they’d experienced.
Head injuries in sport
Chronic traumatic brain injury associated with boxing has been known about for around 100 years. In 1928, Harrison Martland first described chronic traumatic encephalopathy in retired boxers. It was first referred to as “punch-drunk syndrome” or “dementia pugilistica” and sometimes develops in boxers as a result of long-term sub-clinical concussions (not detectable by the usual clinical tests).
In 2002, neuropathologist Bennet Omalu examined the brain of Mike Webster, a former National Football League (NFL) player who died from a heart attack after his physical and mental health had rapidly deteriorated. Subsequently, former NFL players sued the league, claiming that they had received head trauma or injuries during their football careers, which caused them long-term neurological problems.
The VA-BU-CLF UNITE Brain Bank at Boston University is the largest tissue repository in the world focused on traumatic brain injury (TBI). In a 2017 study into the first 202 donated brains, high rates of CTE were found, with 177 diagnosed with CTE, including 110 of 111 from the NFL players (99%). The brain bank now has over 1,000 brains from donors as young as 14 who have been exposed to brain traumas, primarily from playing sport. Studying these brains is crucial, not only for preventing, diagnosing and treating CTE, but also understanding the long-term consequences of concussion and traumatic brain injury.
Subsequent research from Boston University’s CTE Center in 2019 found that every year of playing full tackle American football increases the risk of developing CTE by 30%. So for every 2.6 years of playing, the risk of developing CTE doubles.
But the problem is not isolated to American sports. Compared with most other sports, rugby union has a relatively high injury rate, including at school level in the UK where it is often a compulsory sport. In addition, it has been reported that there is about one brain injury per match in international rugby.
Demise of England’s ‘lions’
In football, concussion often results from accidental head impacts (like head-to-head collisions or collisions with the goalposts). But a growing number of studies have shown that detrimental sub-concussive impacts (a bump, blow or jolt to the head that does not cause symptoms) may result from repeatedly heading the ball. And there have been an increasing number of high-profile examples in recent years who have been raising awareness of this issue.
In late 2020, three incidents shifted attitudes on the dangers of football. First, Norbert “Nobby” Stiles, a member of England’s 1966 Fifa World Cup winning team, died. Stiles had been diagnosed with dementia and the cause of this disease was linked to repeated heading of the ball in his career.
Then, it was announced that Sir Bobby Charlton, another World Cup winning hero, had also been diagnosed with dementia. He was the second member of his family to suffer with this disease as his brother, Jack (who played in the same winning team) had died earlier in the year after his own battle with dementia.
Bobby Charlton was thus the fifth of the 11 starting players in the 1966 final to have been diagnosed with neurological diseases. Media reports have linked all of these cases to the repeated heading of footballs during their playing careers.
But the first case that drew attention to the link between football and traumatic brain injury was that of Jeff Astle. Following his death in 2002, the coroner’s verdict at the inquest into his death at the age of 59 recorded a verdict of “death by industrial disease”, linked to heading heavy, often rain-sodden, leather footballs. Astle’s health had deteriorated – he had struggled with an eating disorder and was unable to recognise his children.
Astle’s daughter, Dawn, has become a leading figure in the campaign to protect footballers. She presented evidence to the 2020 DCMS committee on concussion and brain injury in sport. Her submission to the committee included the following comment:
My dad choked to death in front of me, my mum and my sisters. Please think about that for one minute. He choked to death because his brain had been destroyed. Destroyed because he was a footballer. I don’t want any other family to go through what my family went through, and continue to go through every day. Please don’t let my dad’s death and all the other footballers deaths be in vain. My dad was my hero and my best friend. His death will haunt me forever.
Families speak out
In February 2020, our team of five researchers were invited by Chris Nowinski, the CEO of the Concussion Legacy Foundation, to Orlando. The CLF is an international non-profit organisation that aims to support athletes affected by head injury, and to assist patients and families by providing personalised help to those struggling with the outcomes of brain injury.
Our interviews were conducted at their “family huddle”, which was a support event for family members to allow them to share stories and connect with others who have had similar experiences.
We were given the opportunity to talk to family members, and build trust and rapport. This gave us a greater insight and understanding of their world. We conducted interviews with the partners, parents, siblings and the children of the deceased athletes.
Our research, published in The Qualitative Report, was presented as an ethnodrama (playscript) to best allow the stories of the family members to be heard. This also showed the distinct temporal phases that these family members went through, and by sharing these stories we hope this raises awareness of the powerful emotions they have experienced.
This article is accompanied by a podcast series called Uncharted Brain: Decoding Dementia which examines new research unlocking clues to the ongoing mystery of how dementia works in the brain. Listen to the full series via The Anthill podcast.
Disbelief and confusion
Many of the people we spoke to said the initial stage, when they started to see changes in the behaviour of their loved one, created very strong emotions because they couldn’t understand why this was happening. They had seen someone they loved decline in front of their eyes. Alice, 68, reflected on seeing this change in her husband: “He went from functioning perfectly, to struggling to remember or do anything he was so used to doing.”
People went on to recall specific instances when this behavioural decline became noticeable. For example, David told us this about his brother: “Once when he went to the airport to pick up my aunt. He proceeded to drive her around, and she finally said, ‘Where are we going?’” He replied that he didn’t know.
There was evidence of a mounting feeling of hopelessness that declines in neurological functioning were causing. Another striking, distressing example was this story Sophie told about her husband:
One weekend, I had 12 big black trash bags to go out to the garbage. And I told him when I got up and went to work on Monday morning, I said, ‘those are going out to the trash tomorrow’. I came home after work and he had unpacked every trash bag … I just sat there and cried … I’d worked a 12-hour day. I said, ‘why did you unpack all that trash?’ and he couldn’t tell me why. He just didn’t know.
Others reinforced other emotions at seeing this happening to their loved one. Emily explained how she felt: “I do think at the start you are in this sense of disbelief because the person you love is doing these things that are out of character.” And Evelyn reflected on the sadness of seeing such changes:
I was shocked, but also felt like the world had been turned upside down. We were so happy. I remember just sobbing.
Researchers have previously highlighted the emotional consequences that family members experience when they witness the decline of their loved one. For example, one 2019 study involving interviews with 20 wives of either current or retired professional American football players, revealed their serious concerns about the cognitive, emotional and behavioural decline of these players. Some wives identified behavioural changes that included rage, reduced positive social interactions and various erratic behaviour, like starting risky business ventures.
As we also found, deterioration in cognitive functioning meant that those affected by traumatic brain injury were no longer able to carry out simple household tasks and often struggled with language problems.
Anger, guilt and fear
Another study, which examined families who have experienced a severe traumatic brain injury outside of sport highlighted the difficulties caused by the uncertainty of the situation – both in terms of the progression of the illness and how to support and deal with the cognitive, physical and behavioural changes exhibited after the injury.
All of this presents huge challenges to families. Negotiating appropriate treatment is hard and the emotional and physical exhaustion of dealing with these difficulties just keeps mounting up for the people involved.
Our participants explained the toll it took on them as they saw first-hand the severe changes in behaviour as their loved one experienced further decline. For example, Katherine said she felt drained and responsible. “It’s hard because you don’t know what’s happening,” she said. “So you just blame yourself and think you are the reason. And that’s not good for your own wellbeing.”
Helen spoke about her intense feelings as her partner drank as a response to his condition:
I was so angry at him for making the same choices over and over with drinking though. Like, “you’ve drank so much that you fell down the stairs in front of me at home, are you kidding me?” And it hurt, you know, and left a lot on my plate, so I was really, really, angry. And that didn’t help things.
Changes in behaviour created further problems for family members, such as how their loved one was perceived in social situations. Elizabeth described one specific incident at a party:
We went to a catered event, and he would take the top of the [burger] bun off, take the meat out to eat, put the bun back, and then go to the next one. And someone caught him and was like, “what is he doing?” Of course, we never got invited back to any of those people’s homes. No one wanted to have anything to do with him because they couldn’t understand him.
Laura also spoke about the implications of a lack of understanding of this condition, highlighting how others would misinterpret her husband’s actions. This led to feelings of sadness as they became socially isolated from their friends. She said: “When we went to events, a lot of people thought he was an alcoholic, because he could have one cocktail and then he’d fall. They had no idea that the falling had nothing to do with that one drink that he had. And it became very sad because people didn’t want to have us around.”
Our participants also spoke of the burden as a result of effectively becoming their partner’s primary caregiver. Sophie spoke about the struggles she faced with supporting her husband with daily tasks. “I couldn’t physically handle him,” she said. “At that point he was unstable. He would shuffle, and fall, and he couldn’t get in and out of the shower. He was also incontinent, and I couldn’t handle him by myself. I felt so weak.”
Evelyn also spoke of these experiences, highlighting that the physical size of her partner caused significant strain. “The sheer problem with these guys was their physical size. As the disease progressed, he fell probably 10-15 times a day, and we’d have to figure out how to get him up. I was both physically and mentally exhausted,” Evelyn said.
Meanwhile, others spoke of the physical fear of danger they felt. Like Emily who told us:
I did become scared of him. I hate to say that, but I did. He made me sign some papers and I had no idea what they were. He was just escalating and escalating, and he was standing over me and I just knew if I didn’t sign that paper, I was in physical danger. Which was an awful thought to have about your own husband that you love.
Moving forward
Our interviews gave family members the chance to reflect on their time living with and caring for their loved one, and also, how they might approach the situation differently. Helen told us she wished she had taken more time for herself, and advised anybody going through a similar situation to “get into therapy, to help you process everything and to let you have an outlet”.
Katherine agreed, saying: “You’ve got to try and take some time for yourself. I remember I took a trip with a girlfriend once and I was scared to death the whole time I was gone, but I went, and we had a wonderful time, and I’m so glad I did it. You know, trying to keep some semblance of normalcy in your life for yourself, for your own good. Try to keep yourself healthy, eat healthily, work out. Keep yourself well because there really was nothing, I could do for him except be present. I couldn’t make him well.”
Other family members reflected on the dangers of certain sports. For example, Alice highlighted how her awareness had increased, giving her the knowledge and understanding to allow her to come to terms with her husband’s situation. She realised there were “significant pathologies” that he had no control over that affected his decision-making.
His brain was still functioning, and he was still able to make decisions, just the wrong parts of the brain were directing his decisions. That totally makes sense now, so that’s been a huge relief, that he wasn’t just an asshole in his own right, he really just couldn’t control it.
While our data contained accounts full of sadness, participants also reflected on different ways they were moving forwards in a positive way after experiencing the death of a loved one. Laura detailed the benefits of attending the huddle and being with people who had been through similar struggles: “Everyone here is in the same boat. It may not have looked exactly the same for us, but we don’t have to explain for once. And just the support I’ve got from the people here has been great.”
Others talked about how the support helped the grieving process and inspired them to get involved and help other families. For example, Evelyn spoke of the need to make changes at a junior sport level: “I’m just so concerned this horrible disease is hitting younger and younger people, yet no one knows about it … giving people the information to be able to make the correct decision is super important.”
The final word goes to Elizabeth, who had become involved in the support work of the CLF, and spoke of her new found purpose to help others. She said it helped make her loss “bearable” because “millions” might benefit and “hopefully not have to experience the kind of tragedy that affected our family”.
I feel like part of the reason this happened is for me to be part of raising more awareness and be a part of this movement towards new culture change. I can help families navigate … the difficult waters of dealing with this. And so, I feel like it speaks to sort of a calling … I have in life or part of my purpose.
Consequences
What is clear to us after concluding this research project is that greater recognition of the challenges faced by both those living with diseases of the brain, such as CTE, and their carers is needed.
We heard about the devastating losses and tragedies. But we were also privileged to highlight more positive stories that showed how people were able to move forwards and help others to create a constructive change in sport so others won’t have to suffer.
It also illustrates how neurodegenerative disease resulting from head trauma as a consequence of impact sports has far reaching effects – not only the athletes, but also those around them. This represents a growing public health concern and societal problem.
It shows that greater recognition of the challenges faced by both those living with diseases of the brain, such as CTE, and their carers, is needed.
We hope their stories will stimulate discussion and be used to support people who might be going through similar experiences. Our findings might be used to help practitioners, sporting governing bodies and charities such as the CLF, to understand more fully these negative emotional responses and, in turn, consider strategies that might be developed to support people. In turn, these organisations must also act to address the causes of head injuries to make sports safer.
All names in this article have been changed to protect the anonymity of those involved.
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Our BU briefing papers are designed to make our research outputs accessible and easily digestible so that our research findings can quickly be applied – whether to society, culture, public policy, services, the environment or to improve quality of life. They have been created to highlight research findings and their potential impact within their field.
Sports concussion has been the subject of much discourse in the scientific literature and mainstream media for many years. Major national and international sporting events are extensively covered by the media, with vast numbers of column inches and webpages dedicated to summarising these events. The frequency of concussion in some of the world’s biggest sports such as soccer, football, and rugby means that many of these concussive events which occur in high-profile competitions are also the focus of this reporting.
This paper analyses the descriptions of online sports concussion news on a global scale, using a search engine to retrieve news stories, and evaluates the media’s role in shaping public perception and misconception regarding concussion in sport. Further analysis sought to identify geographical patterns associated with different descriptions of sports concussion.
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