Youth Football and the Epidemic of Pediatric Brain Injury: Neurologic and Psychiatric Outcomes in a Multinational Cohort of 72,025 Concussions
Isaac Thorman1, Ariel Sacknovitz1, Aryan Malhotra1, Michael Schubert2, Fawaz Al-Mufti3, Patricia McGoldrick4, Carrie Muh3, Steven Wolf4
1School of Medicine, New York Medical College, 2Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, 3Department of Neurosurgery, Westchester Medical Center, 4Department of Pediatric Neurology, Boston Children's Health Physicians
Objective:
To quantify the burden of football-related traumatic brain injury (TBI) in youth compared with other sports and recreational activities, and to evaluate long-term neurological and psychiatric outcomes across developmental stages.
Background:
Sports-related TBI is a leading cause of long-term neurological and psychiatric morbidity in children and young adults. Football, in particular, has been implicated as a major source of injury, yet large-scale comparative studies across sports and developmental stages are limited.
Design/Methods:
This retrospective cohort study used the TriNetX Research Network, encompassing >150 million patients. Children and young adults (≤25 years) with a first sports- or recreation-related TBI were identified using ICD-10 diagnosis and activity codes and compared with patients with lower-leg fractures from the same activity and no recorded TBI. Outcomes included repeat TBI, post-concussion syndrome, chronic headache or migraine, anxiety, mood, and substance use disorders, and suicidal ideation or behavior. Attributable risks were calculated between matched cohorts (1:1 by age category and sex). Multivariate Cox proportional hazards models adjusted for age, sex, and activity compared risks across sports.
Results:
Football accounted for 19.4% of 72,025 activity-related TBIs (mean age, 13.9 years; 32% female). Repeat TBI occurred in 37% of football injuries (32% overall). Attributable risks were significantly elevated for neurological outcomes (chronic headache, 23%; visual impairment, 5%; neurodevelopmental disorders, 0.5%) and psychiatric outcomes (anxiety, 5%; depression, 3%; substance use, 1%; suicidality or violence, 0.5%). TBIs sustained at younger ages were associated with developmental and mood disorders, while those at older ages were associated with substance use disorders.
Conclusions:
Football is the single leading source of pediatric sports-related TBI, associated with high recurrence and substantial neurological and psychiatric sequelae. Developmental timing of injury shapes long-term risk. Findings highlight football as a critical public health priority and support delaying tackle participation and regulating institutional promotion of youth football.
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