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Is High School Football Safe?

January 20th, 2015 No comments

Henry David Abraham, M.D.

I was recovering from orthopedic surgery chatting with my hospital mate, Scott. I was in for skiing. He was in for football. Scott was the biggest person I had ever seen- a football lineman from a Div 1 school. His coach loved him. He came every night to boost his spirits. “Coach,” said Scott one time. “Do you think I could take up skiing?” “No, Scott,” said the coach solemnly. “Your winter sport is tobogganing.” “Huh?” said the student-athlete. “Yes, Scott. You go up a hill with six of your friends, and Scott, you’re the toboggan.”

No doubt that Scott would have made a great toboggan. He was already a great lineman. Seeing him in bed reminded me that playing football can hurt you, even though the commonest injuries are not lethal. Most are orthopedic, like knee sprains, hamstring injuries and contusions. But there are more worrisome ones. They involve the head. And of all the high school sports football has the greatest number. The chart below tells the story. Of 1219 kids with mild head injuries, football players had the most.

Mild traumatic brain injury (MTBI) is a newer way of saying concussion- head trauma that causes a change in mental status and/or unconsciousness. MTBI is always serious. In the course of a football season the chance of suffering one is about 5%. The risk is four times greater during a game than a practice. Astroturf raises the risk. Taking a hit to the top of the helmet doubles a kid’s chances for losing consciousness, but more concussions occur with front of the head impacts. High school running backs and line backers are more likely to be injured. Needless to say, the injury rates are higher in the NCAA, and still greater in the NFL.

The most disturbing observations come from studies of the brains of deceased NFL players. In selected cases the brain shows an Alzheimer’s-like condition correlating with the player’s previous mental decline. In the emerging alphabet soup of head injury, this new finding is chronic traumatic encephalopathy or CTE. But its existence is controversial because it’s extremely difficult to do controlled studies on this problem. The tragic suicide of Junior Seau, for example, does not prove that his years of football led to his death. Sadly, other people who never played football have committed suicide, too. The simple question is whether football players suicide more. They may not.

But not so fast, football fans. If you count how many times a player’s head gets hit during a season, you find the more hits, the more changes in the brain’s white matter. And after six months, the changes don’t go away. This is what a small controlled study of 15 players found. Would studying more players give the same result? We don’t know. But the average high school player in a season has between 175 and 1410 repeated head impacts. That can’t be good for you. But in this study, none of the 15 suffered an actual concussion. And even if they did, the overwhelming majority of kids who suffer MTBI have a complete recovery of mental function.

How can a parent calculate the risks and benefits to their child athletes? Some numbers can help. But apply common sense. The risks of playing in the NFL aren’t the same as those for high school kids. Take CTE, for example. The rate of high school students who appear to have developed this illness is less than seven in a million. What about other potentially lethal brain injuries? In the U.S. in 2013 there were 243 football related deaths in high school and college. Three were from brain injury. More were from heart disease. Let it be noted that the risks of death or brain injury from riding a bicycle, walking on the street, riding in a car, or swimming are greater.

There is little debate that a major head injury signals an end to playing for the year, and maybe for one’s career. One of my patients wisely called it quits after he tried out for the New England Patriots. On the first play suffered a helmet to helmet blow that knocked him out and caused a convulsion.

More difficult to answer is when and if a kid who suffered a mild concussion should be permitted to get back into the game. One expert in this field is Robert Cantu, a neurosurgeon who has also consulted with the NFL. Because recovery is the rule, so is returning to the season. The mildest cases of head trauma can return to the same game after a period of sideline examinations, once all signs and symptoms are gone at rest and during exertion. One concern is that once a kid suffers one concussion, the chances he or she will suffer a second one go up three to six times. This is a replicated finding. We don’t know why. Perhaps it reflects the child’s style of play, or a brain sensitized by prior trauma.

Numbers asides, the chance to play a sport in high school is unique. For every kid it’s a chance to pursue a dream of strength, grace, courage, and skill. Why else take the risk of skiing, skating, shooting hoops, or swinging perilously over a horizontal bar? Playing a sport is a dream of perfection. What’s so bad about that?

Categories: Opinion Editorials

Outwitting the Woolly Mammoth

June 27th, 2013 No comments

My mother was welcomed onto her bowling team with open arms. She won trophies, and wore her red satin bowling shirt with pride. On its back in gold stitching was the name of her team, the Philadelphia Armenians. My mother-in-law in the suburbs of New Jersey played bridge every month with the same seven friends for 25 years. They supported each other through births, marriages, careers and deaths. What do bowling and card playing have in common? In his landmark work, Bowling Alone, sociologist Robert Putnam calls them examples of “social capital,” the glue that holds us together as a community. Social capital is how the first hunters banded together to outwit the woolly mammoth. In the last half century we’ve had lots of examples of social glue. Watch It’s a Wonderful Life or Saving Private Ryan and you’ll be treated to large doses. But Putnam shows that many of the real ways we’ve bonded with one another are in decline. This is where you can make a difference in the lives of your kids, now and tomorrow.

When I took my kids bowling for the first time, the Big Lebowskis were gone, and by 2002 so were our lanes. Bowling isn’t the only social bond that has faltered. People are also losing interest in churches, scouting, fraternal organizations, and even playing cards with one other. Tom Kissell, membership director of the VFW, sadly noted, “Kids today just aren’t joiners.” Choirmaster Ian Watson bemoans, “People just don’t sing anymore.” Political life is suffering, too. In the recent US Senate race in Massachusetts only 27% of registered voters took the time to go to the polls. Putnam’s work bears out these observations. In one survey 77% of Americans surveyed said the nation was worse off because of “less involvement in community activities.” In 1992 three fourths of Americans felt that the “breakdown of community” was a serious problem. In Washington a paralyzed Congress is more than the result of one party trying to get advantage over another. It reflects a loss of our common vision as Americans.

In a number of ways this shift to a credo of “me, not we” is a byproduct of technology. Air conditioning and TV keep us cool and entertained, but off our front porches where we’d be at risk to talking with a neighbor. What about the Internet? The best of the Internet can energize our communities and spark political involvement. The ‘net can help build bonds between people who like the same stuff but are in distant parts of the world. It can create flash mobs and viral jokes. This is powerful stuff. But can the ‘net build real communities? Join a dating service, and you are connected to scores of potential partners. But if there is “like” at first click, there is no love at first sight, because the ‘net is removed from the world of faces and pheromones. And worse, the ‘net is easily hijacked, with voter manipulation, child abuse, hate mongering, and bomb building the result.

But for parents big changes are possible from many small acts. Every T-ball game you coach, every kids’ concert you attend, creates the long term dividend of human attachment. Churches, scouting, and volunteer fraternal organizations are not dead. If you connect with your community as adults, you create models for your kids to emulate. The Elks value “charity, justice, brotherly love & fidelity.” Got a problem with that? Take a look at the K of C. They’re into “churches, children of special need, and the community at large.” Not your cup of tea? Take a look at Habitat for Humanity, Jimmy Carter’s brainchild building housing for the needy. Pound some nails on a Habitat project. No religion is required, and you can take your teen along to learn a skill or two.

OK, you work 50 hours a week just to pay the mortgage, and the last thing you want to do is give up a day doing volunteer carpentry. So consider this. When I rake leaves I’m like the Invisible Man to anyone walking down the street until I put a Red Sox hat on. Then my neighbors, the oil man, the letter carrier, and dog walking strangers stop to make some baseball small talk. The hat bonds me to “the Red Sox Nation.” Yes, we love the Sox. What’s not to love about Ellsbury stealing third, or Big Papi launching one onto Lansdowne Street? But for town with a team, the team is bigger than baseball. Take your kids to Fenway, and take a look around at the sea of Red Sox hats and jerseys. And in the 8th inning, when people stand and sing Sweet Caroline, sing with them. People are sharing feelings of loyalty we historically have reserved for ethnic groups and nation-states.

After the Boston Marathon bombing, Bruins fans made news at the TD Garden when they rose as one and sang The Star Spangled Banner before the game. Singing is not what hockey fans are known for. But sing they did. In the days that followed, the city blossomed in every corner with people wearing the simple message, “Boston Strong.” We don’t have to wait for another tragedy to teach our kids that we are strong, and that there is value in working, playing, praying and singing together.

Categories: Opinion Editorials

“Energy Drinks”

April 15th, 2013 No comments

The story goes that coffee was discovered when a shepherd noticed his sheep dancing after they ate beans growing on a hillside. Humans have been using that bean ever since for alertness, inspiration, and energy. Caffeine is the world’s most popular drug. The US is the world’s greatest importer of coffee- nine pounds a year for each one of us. At birth caffeine is present in 75% of infants, and thanks to sodas and cocoa, in preschoolers, too. So when caffeinated “energy” drinks appeared in gas stations and supermarkets, consumers yawned, until now.

Today brands like Monster Energy and Red Bull are household names and a $20 billion a year business. One third to one half of teens and young adults will try them. As the use of these drug vehicles has increased, so have reports of problems. Most people are familiar with the common problems of caffeine- jitters, insomnia, and anxiety. Energy drinks kick that list up a notch, to include seizures, strokes, and at least 13 possible deaths. There are now 20,000 emergency department visits a year related to energy drinks. Kids with preexisting medical conditions, especially those of the heart or brain, are particularly vulnerable. Recently, the makers of Monster Energy moved to sidestep the FDA requirement that they report any problems with their products by calling them “beverages.” This moves Monster to a different aisle in the supermarket and lets them sweep bad news under the rug.

“But wait a minute, Dr. Abraham. Aren’t you just being a caffeine cop?  How much caffeine is in an energy drink in the first place?” Answer: about one to three cups of coffee. How bad can that be? This year 18 experts on child nutrition said how bad in a letter to the FDA. They pointed out that a caffeine drink is different from a cup of tea or coffee in a number of important ways.

Caffeine in coffee or tea is in a natural, botanical form, while the caffeine in energy drinks is added by the manufacturer. Another difference is that chemically concocted caffeine drinks contain a wild mix of Frankenchemicals: compounds not often mentioned in polite company that have little or no connection to normal human nutrition. Occasionally these chemicals do things to you. Guarana, one energy additive, for example, has one of the highest concentrations of caffeine in any plant, triple the caffeine in coffee.

A third important difference is a matter of the use of energy drinks by children. There is no minimum legal age to buy them. If a child consumes a drug at a dose intended for an adult, this is an invitation to an overdose. The smaller the child, the greater the trouble. This among other thoughts led a committee of the American Academy of Pediatrics to say, “…caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents.”

That brings me to the cultural differences between coffee, tea and energy drinks. Hot tea or coffee is sipped slowly. People meet for coffee. They serve coffee and tea at the book club. They drink tea together at the Chinese restaurant. The makers of energy drinks live on another planet. An ad for Monster Energy on Amazon says it all. The 16 oz. can of Monster “packs a vicious punch but has a smooth flavor you can really pound down.” Not exactly “meeting a friend for coffee.” This Brave New World of “beverages” may explain a recent study where Australian teens suffered cardiac and neurological toxicity after drinking three to eight bottles of energy drinks at a clip.

From a public health point of view, the greatest harm from an energy drink is when it is mixed with alcohol. Being drunk is bad enough, but being wide-awake drunk is stepping on the accelerator with your eyes closed. Under no circumstance should an energy drink be thought of as a cure for alcohol intoxication. It’s not.

Now before the proprietors of Starbucks and Peet’s take out a contract on me, let the record show that I am not a caffeine cop. Coffee is my favorite drug- er, drink. Of all the drugs I worry about, coffee is not even a warning blip on my radar. Its benefits vastly outweigh the risks. Its psychological and health effects are varied and proven. It reduces the risks of Alzheimer’s disease, certain cancers, heart disease, and type II diabetes.

Should teens drink coffee? It depends. As kids enter the teen years their clocks for sleeping and waking, like daylight savings time, spring ahead an hour or two. That means when adults are getting sleepy, kids are getting ready to rock. That also means that the next morning, as the world awakens, teenagers are zombies. This also means for many teens early morning classes are cruel but usual punishment. Short of starting the school day later, a cup of tea or coffee may work wonders for the early morning zombie. It does for many of us. But it’s not for everyone. Steven Spielberg never drank a cup of coffee in his life. Voltaire drank 30 cups a day. They both turned out all right.

Categories: Opinion Editorials

The Second Most Dangerous Year

April 9th, 2009 No comments

This spring hearts will flip-flop over fat envelopes in the mailbox, as high school kids and their parents pick colleges for the coming year. But too little thought may be given to whether the college getting the acceptance check is healthy and safe, even though as kids moves into the ages of 15 to 24, their death rate jumps fivefold, the largest percent increase in the entire life cycle. If asked to pick the most dangerous year after infancy, it would be the first year after high school, because of the misuse of alcohol.

Yes, college is the place for kids to find their own way. Yes, youth is the time for experimenting. And yes, Americans have the highest minimum drinking age in the world. That said, a third of our college kids in a study from the Harvard Medical School still met clinical criteria for alcohol abuse. Other studies have found that 1700 kids die a year in alcohol related events, 600,000 suffer alcohol related injuries, and 100,000 suffer alcohol related sexual assault. Parents sending their kids off to college are sending them into a war zone replete with risk, harm and occasional tragedy.
Certainly, college presidents can’t miss that their campuses are awash in alcohol. As one former college president now hiding out in a think tank told me, “Drugs and alcohol were the bane of my existence.” Colleges teach less when they have to devote time and resources to policing students and picking up pieces of the campus after the party.
A large part of the problem is that kids drink to get drunk, not to enhance a meal by candlelight. Why they do is complex. Compared to a first run night at the movies alcohol is cheaper, faster, and from the mouths of babes, “funner.” Research shows that the alcohol industry aggressively markets to children. One measure of their success is the marriage between drinking and watching professional, college, and now high school sports. Given the forces of fun, money, sports, ads, and normal experimenting, what’s a parent to do?
One important act is the choice of a college. Is the school on national radar as a “party school?” Does drinking start on Thursday night and run to Sundays?   Is the school a national Division 1 champion or contender in some sport? Any school with a football stadium greater than 75,000 is in the entertainment business, not the business of education. How about the ratio of students to fraternities? The number one party school, according to the Princeton Review, is the University of Florida in Gainesville. It has 46,000 students and 62 fraternities. Then there’s Haverford College in Pennsylvania, with 1,168 students and no fraternities. Haverford is not a party school. (Not everyone gets in, either, as I personally know). This is not to diss big schools in favor of small. Virginia Tech, for example, has an alcohol abuse prevention center and a pretty good football team.
But there is no substitute for knowledge on the ground. Picking a college without a visit is a mistake. Once there, parents and students need to ask about the school’s drug and alcohol policies and problems. Undergrad guides are likely to be refreshingly candid. A parent should look around for telltale signs of the prior night’s activities- bottles, cans, kegs, puke, and the beery smell of kids at a college where leaders hold their noses and look the other way. Parents may still be willing to do the same and shell out $40,000 a year for the privilege, but my bet is that they just want their kid out of the house- badly. But choosing a college is a vote for more of the same. Parents have power waiting to be used.

Marijuana and Parents: Yes, No, Undecided

December 28th, 2008 No comments
The Belding-Abrahams Unstoned

The Belding-Abrahams Unstoned

On Nov. 4 2008 voters in Massachusetts will get to decide if people caught with an ounce or less of marijuana will still be charged as criminals. The penalties for a first offense are mild. The crime is a misdemeanor, but there can be a fine of $500 and six months in prison. Since many users are among the young, parents will take a particular interest in this question.

The good news for those of us who toil in the fields of troubled kids and their parents is that in the last ten years the percentage of high school seniors trying pot has drifted downward from 50 to 42%. The bad news is when your kid is nailed with a pot rap. The current law appears stiffer than its application. The usual first timer gets off with probation, drug education, and community service. But in rare cases a pot offense can stand in person’s way out of proportion to the crime. As crazy as it sounds, a web of Federal and state rules prevents a person from adopting a child, driving a car, getting food stamps or a loan for school. That means even if a user gets treatment and remains in recovery our marijuana law can keep punishing.

But for most parents, the practical question is at home. What are the kids using, and besides criminalization, while bad enough, what are the consequences? It’s encouraging that kids’ negative attitudes about pot have increased in the last ten years. But regarding stopping the flow of pot into this country, the War on Drugs and the $200 billion spent in the last ten years have failed. Essentially the same number of high school seniors in 2007, 84%, reports pot is easy to get, compared to kids in 1997.

Is pot dangerous? An old joke went, “Sure, marijuana is dangerous. A ton of it can crush a man.” But for the majority of kids a ton of dope is never at play. Saturday night adventurers are likely to be at no greater risk than abstainers. Far greater dangers await a kid using the gateway drugs tobacco and alcohol. The problems from pot arise in daily smokers, half of whom will move onto the felony drugs of cocaine, heroin, and the like. And pot should never be used by vulnerable persons, such as the mentally ill or addicts in recovery. If a kid claims to need pot as self-medication, he needs professional care, not backwoods chemistry.

So what’s a parent to do? Straight talk with your child is a start. You can set the limit of zero tolerance, but short of locking up your Rapunzel in a tower, a parent can’t control every choice of a teenager. Neither can schools. This is where openness and good sense at home can rule the day. Parents need to live and teach that there are better things to do with a mind on Saturday night than parking it.

Parents can’t control everything in a kid’s life, but they can control a lot. Finding tobacco or weed in a kid’s room and saying nothing is practicing a dangerous form of denial. Fighting tooth and nail the battle over teen smoking is probably the single healthiest thing a parent can do.

A more subtle problem lurks in reducing pot penalties. That policy falls between two extremes, each of which brings its own problems. The first is prohibition, which describes our current laws. Prohibition as we know from Hollywood and police reports is very good for drug dealers and the prison industry. The greater the police work, the greater the street price. Prohibition is very bad for those scientists seeking better answers through research to the questions of drugs, disease and medicinal possibilities. The other extreme is drug freedom without limits. Decriminalization isn’t legalization, but it’s not far away. And if it is, isn’t that a slippery slope to commercialization by Big Tobacco? And what about pot dependence? Surely those numbers will go up, and at what cost? The vote on November 4 will be a test to see if we can keep our balance as we move between the extremes of prohibition and license. The former has fed the coffers of drug gangs the world over. The latter has led to the fall of empires.