BACKGROUND:

In ice hockey and soccer, age restrictions exist for body checking and heading because of injury risk. There are currently no age restrictions for tackling in youth football.

METHODS:

We surveyed a nationally representative sample of US parents regarding their support for age restrictions on tackling in football with responses of “yes,” “no,” and “maybe.” We then generated regression models, attempting to predict support for age restrictions in tackling using demographic variables, parent perceptions of the risk of concussion in youth football, and the intensity of football support. All analyses were stratified by sex given effect modification.

RESULTS:

There were 1025 parents who completed the survey (52% response rate; 56% female sex). The majority (61%) supported age restrictions for tackling, and an additional 24% indicated they maybe would support age restrictions. For female respondents, a greater perceived risk of tackle football (odds ratio [OR] 3.83; 95% confidence interval [CI] 1.06–13.83) and greater educational attainment (OR 3.97; 95% CI 1.61–9.80) were associated with greater odds of supporting age restrictions for tackling. For male respondents, having a child 6 to 12 years old was associated with greater odds of maybe supporting age restrictions for tackling (OR 2.34; 95% CI 1.19–4.62).

CONCLUSIONS:

A majority of US parents across sexes would support age restrictions for tackling in football. This information should inform discussions when guidelines about tackling in youth football are revisited.

What’s Known on This Subject:

Tackling accounts for half of the injuries in football, yet youth football currently has no age restrictions for tackling. In other sports, a minimum age is recommended for contact associated with high risk of injury (body checking and heading).

What This Study Adds:

A majority of parents support age restrictions for tackling. Highly educated female parents who perceive a high risk of injury due to football are the most supportive of age restrictions, but there is also high support among male parents.

There are 44 million youth who play sports annually in the United States,1 and sports participation provides context and motivation for physical activity,2 thereby decreasing the likelihood of chronic disease3 and positively impacting emotional health,4,6 cognitive function,7 and social engagement.8 However, sports are not without risk. Recently, researchers have raised concerns regarding sport-related concussion in youth and whether the risk of concussion in contact sports is balanced by potential benefit.9 Although the incidence of concussion in youth sports is relatively low,10,11 estimates suggest 1.1 million to 1.9 million US youth 5 to 18 years old sustain sports- and recreation-related concussions each year given the large number of youth who play sports.12 Concussion has short-term impacts on school and social function13 and may have long-term consequences if youth sustain multiple concussions.14 Researchers have also voiced concerns about the potential negative impact of chronic exposure to subconcussive hits, or head impacts below the threshold to cause concussion,15 such as those that occur in contact sports.

Athletes in elementary and middle school are thought to be at greater risk for brain injury due to the rapid myelination that occurs from 8 to 13 years of age.16 Given the potential benefit of reducing exposure to high-risk contact during this vulnerable time period, some youth sports organizations have recommended restricting high-risk contact to older youth. For example, US Soccer recommends limiting heading in soccer to youth age 11 years and older,17,18 and USA Hockey has similar recommendations limiting body checking to youth age 13 years and older.17,18 Research after the passage of hockey age restrictions has supported limiting high-risk contact as a means to mitigate injury risk, with clear reductions in brain injury rates seen after age limits for body checking were set.19,22 The impact of heading restrictions on injury in youth soccer is still under study.

Football is one of the most popular youth sports for boys, with 5 million youth players annually,1 and has concussion rates for middle school–aged athletes that are similar to those in hockey or soccer.10 Tackling, or the attempt to stop the ball carrier from moving upfield using one’s body, accounts for half of the injuries incurred in football, particularly concussion,23,31 and is responsible for many of the repetitive head impacts that occur in the sport.32 Some research has suggested that early exposure to tackle football (<12 years old) in athletes who go on to play collegiate or professional football is associated with negative long-term outcomes, such as cognitive impairment and depression.33,34 Other studies have found no long-term differences in youth who played football compared with controls.35,36 There are no prospective data on the association between youth football participation and long-term health risks; however, it is clear that limiting full-contact during football practices (as has occurred because of legislation in some states) results in decreased exposure to repetitive head-impact forces.37 

Given the age limitations on body checking and heading, researchers have suggested limiting tackling in football to older youth, who are both better able to coordinate their tackling style and more advanced in brain development, as a means of mitigating risk.38,39 However, it is important to consider whether age limits on tackling would be met with public support. Organizations that make recommendations regarding public health are striving to decrease morbidity and mortality while not hampering individual liberties.40 As such, their recommendations are necessarily a balance of costs and benefits and a consideration of the societal value of these costs and benefits. Some have argued that there is a benefit of early introduction to high-risk contact in sport in that such exposure might develop skills that would prevent later injuries.41 However, injury rates in ice hockey after the institution of age restrictions suggest no such protective effect.42 Moreover, programs can be developed to train youth before the introduction of high-risk contact, as has been done with body checking.43 A consideration of whether to recommend age limits for tackling in youth football requires an appraisal of the net balance of cost and benefit and thus an assessment of the societal value of such costs and benefits.

We undertook this study to determine the level of national support from parents of school-aged youth for age limits on tackling. We also explored demographic patterning and the role of factors such as the perceived risk of football (ie, estimates of injury risk) and perceived benefit of football (ie, level of football support) in guiding the decision to either support or not support potential age restrictions. Parents who perceive significant injury risk from football are likely to believe that risks of early introduction to tackling outweigh benefits and thereby to support age restrictions. In contrast, parents who perceive significant benefit from football might be less likely to support age restrictions on tackling, perhaps out of concern that such restrictions would diminish the skill and training of future players or elevated perceptions of the benefits of tackle-football participation relative to what they consider to be the costs of tackling.

Risk-related decision-making is also influenced by risk attitudes, or comfort with a certain level of risk.44 Individuals who are older,45,47 of female sex,46,50 and nonwhite47 tend to be risk averse, meaning that for a given level of perceived risk of football, they would be more likely to support age restrictions on tackling. Increased education might also make individuals more risk averse because such education could increase their understanding of the potential risk of injury due to exposure to high-risk contact. Responses may be self-referential, and thus, having a child who is either young (and therefore more in need of protection) or school aged (and thus more likely to benefit from age limits) might make parents more risk averse when considering age limits on tackling.51 

We thus conducted a nationally representative survey with US parents of school-aged youth to explore public support for a minimum age for tackling in football and demographic patterns of such support with a goal of providing data to inform the continued discussion about potential age restrictions on tackling in football.

We conducted a cross-sectional online survey in October 2017 of individuals using the market research company Growth from Knowledge (GfK) (gfk.com), specifically selecting parent participants. GfK sampled households from its KnowledgePanel, a probability-based Web panel designed to be representative of the United States. KnowledgePanel is the largest probability-based online panel in the United States with ∼60 000 members. It is an address-based panel that uses the Delivery Sequence File of the US Postal Service, covering ∼97% of the US population. For this study, the target population consisted of adults age 18 years and older who were parents of at least 1 child age 5 to 18 years residing in the United States. GfK sampled 2110 individuals, of whom 1025 completed the survey for a response rate of 51.5%. Respondents were able to complete the survey in either English or Spanish.

Participants in this survey completed survey items regarding demographic data (age, sex, race and/or ethnicity, geographic region, parental education, and age of the children with whom the parents resided) using standard US census measures as available. Additional questions were asked regarding interest in specific sports, including professional football (“not interested at all,” “a little bit interested,” “fairly interested,” or “very interested”). To measure perceived risk of football, parents were asked to estimate how many youth out of 100 would sustain a concussion during 1 season of high school football. Parents were also queried as to whether they would support age limits for tackling in youth football (“yes,” “no,” or “maybe”) and, if so, at what age tackling should be introduced (“elementary school,” “middle school,” “high school,” or “college”).

Data were weighted by GfK to approximate the population of adults age 18 years and older by using an iterative proportional fitting (raking) procedure to produce the final weights. The March 2017 Current Population Survey was used for the raking adjustment of weights on the basis of sex, age, race, ethnicity, census region, metropolitan status, education, and language proficiency. All analyses were conducted by using weighted analysis procedures and stratified by respondent language. We divided individuals by their support for age limits on tackling in football (“yes,” “no,” and “maybe”) and reported the demographic characteristics of each group. Participant characteristics were entered into separate multinomial logistic regression models predicting support for age limits (“yes” and “maybe” versus “no”). Predictor variables included the following: (1) age quartile of parent respondent; (2) sex of respondent; (3) race and/or ethnicity; (4) level of education (less than high school, high school, some college, bachelor’s degree, or greater); (5) region of country; (6) presence of child 0–5 years old, 6–12 years old, and/or 13–17 years old in the household; (7) level of interest in professional football; and (8) respondent estimate of the number of youth out of 100 who would sustain a concussion in 1 season of high school football (<10, 10–<25, 25–<50, or 50+). We examined 2-way interactions of all variables, finding evidence for effect modification by sex. We therefore completed the remaining analyses stratified by sex. Variables that were independently associated with support for age limits were included as candidates in sex-stratified multivariable models, and models were reduced by using backward selection with a criterion for removal of P > .10. The presence of a child 6 to 12 years of age and perceived risk were forced into the model to streamline the comparison of sex-stratified models. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. All analyses were completed by using SAS version 9.4 (SAS Institute, Inc, Cary, NC). The study was approved by the institutional review boards at Seattle Children’s Research Institute and the University of Washington.

There were 1025 adults age 18 years and older who were parents of at least 1 child age 5 to 18 years and resided in the United States who completed the survey (11% in Spanish). Respondents were 56% female sex with an age range of 21 to 68 years (Table 1). An estimated 63% of female parents and 58% of male parents (overall 61%; 95% CI 58%–64%) would support a minimum age for tackling in football; an additional 25% of female parents and 22% of male parents (overall 24%; 95% CI 21%–27%) maybe would support such a minimum age, and 19% of female parents and 11% of male parents (overall 15%; 95% CI 13%–17%) would not support a minimum age. Of those who would support or maybe support a minimum age for tackling, the majority believed that the age limit should be either middle school (45%) or high school (37%), with a smaller number choosing elementary school (7%) or college (9%).

TABLE 1

Demographics of a Nationally Representative Sample of Parents of School-Aged Youth Stratified by Support or Lack of Support for a Minimum Age for Tackling

Favor Minimum Age for Tackling
Yes (N = 623), n (%)Maybe (N = 245), n (%)No (N = 152), n (%)
Female respondent 364 (58.4) 145 (59.1) 65 (42.5) 
Age quartile, y    
 <35 135 (21.7) 60 (24.6) 19 (12.2) 
 35–40.9 153 (24.6) 63 (25.7) 37 (24.3) 
 41–46.9 152 (24.4) 56 (23.0) 45 (29.5) 
 47+ 182 (29.3) 65 (26.7) 52 (34.0) 
Education    
 Less than high school 53 (8.5) 42 (17.1) 19 (12.8) 
 High school 145 (23.2) 64 (26.3) 45 (29.8) 
 Some college 171 (27.5) 70 (28.5) 38 (24.7) 
 Bachelor’s degree or higher 254 (40.8) 68 (28.0) 50 (32.7) 
Geographic region    
 Midwest 127 (20.3) 54 (22.0) 33 (21.5) 
 Northeast 92 (14.7) 45 (18.4) 30 (19.4) 
 South 236 (37.9) 87 (35.7) 61 (40.1) 
 West 168 (27.0) 58 (23.9) 29 (18.9) 
Race    
 Non-Hispanic white 355 (57.0) 134 (54.8) 87 (57.4) 
 Non-Hispanic African American 73 (11.7) 27 (10.9) 17 (11.2) 
 Non-Hispanic, 2+ races 8 (1.2) 2 (0.7) 3 (1.7) 
 Hispanic 135 (21.6) 65 (26.4) 31 (20.1) 
Presence of child age 5 y or younger 191 (30.7) 61 (25.1) 39 (25.4) 
Presence of child age 6–12 y 373 (59.9) 161 (65.6) 79 (52.2) 
Presence of child age 13–17 y 302 (48.5) 137 (56.2) 80 (52.5) 
Interest in professional football    
 Not at all 253 (45.5) 115 (54.4) 62 (45.8) 
 A little bit  129 (23.2) 35 (16.7) 22 (16.1) 
 Fairly  86 (15.5) 24 (11.2) 19 (14.2) 
 Very 157 (28.3) 45 (21.4) 46 (33.8) 
How many youth out of 100 do you believe would sustain a concussion in 1 season of high school football?    
 <10 90 (14.7) 55 (23.5) 30 (20.4) 
 10–<25 179 (29.2) 75 (31.6) 53 (36.1) 
 25–<50 174 (28.4) 61 (25.8) 25 (16.5) 
 50+ 169 (27.7) 45 (19.1) 40 (27.0) 
Favor Minimum Age for Tackling
Yes (N = 623), n (%)Maybe (N = 245), n (%)No (N = 152), n (%)
Female respondent 364 (58.4) 145 (59.1) 65 (42.5) 
Age quartile, y    
 <35 135 (21.7) 60 (24.6) 19 (12.2) 
 35–40.9 153 (24.6) 63 (25.7) 37 (24.3) 
 41–46.9 152 (24.4) 56 (23.0) 45 (29.5) 
 47+ 182 (29.3) 65 (26.7) 52 (34.0) 
Education    
 Less than high school 53 (8.5) 42 (17.1) 19 (12.8) 
 High school 145 (23.2) 64 (26.3) 45 (29.8) 
 Some college 171 (27.5) 70 (28.5) 38 (24.7) 
 Bachelor’s degree or higher 254 (40.8) 68 (28.0) 50 (32.7) 
Geographic region    
 Midwest 127 (20.3) 54 (22.0) 33 (21.5) 
 Northeast 92 (14.7) 45 (18.4) 30 (19.4) 
 South 236 (37.9) 87 (35.7) 61 (40.1) 
 West 168 (27.0) 58 (23.9) 29 (18.9) 
Race    
 Non-Hispanic white 355 (57.0) 134 (54.8) 87 (57.4) 
 Non-Hispanic African American 73 (11.7) 27 (10.9) 17 (11.2) 
 Non-Hispanic, 2+ races 8 (1.2) 2 (0.7) 3 (1.7) 
 Hispanic 135 (21.6) 65 (26.4) 31 (20.1) 
Presence of child age 5 y or younger 191 (30.7) 61 (25.1) 39 (25.4) 
Presence of child age 6–12 y 373 (59.9) 161 (65.6) 79 (52.2) 
Presence of child age 13–17 y 302 (48.5) 137 (56.2) 80 (52.5) 
Interest in professional football    
 Not at all 253 (45.5) 115 (54.4) 62 (45.8) 
 A little bit  129 (23.2) 35 (16.7) 22 (16.1) 
 Fairly  86 (15.5) 24 (11.2) 19 (14.2) 
 Very 157 (28.3) 45 (21.4) 46 (33.8) 
How many youth out of 100 do you believe would sustain a concussion in 1 season of high school football?    
 <10 90 (14.7) 55 (23.5) 30 (20.4) 
 10–<25 179 (29.2) 75 (31.6) 53 (36.1) 
 25–<50 174 (28.4) 61 (25.8) 25 (16.5) 
 50+ 169 (27.7) 45 (19.1) 40 (27.0) 

N is weighted throughout; adjustments are used to ensure the data represent the appropriate proportion of the population.

In bivariate analyses, age <35 years, female sex, the presence of a 6- to 12-year-old child, less interest in professional football, and a greater perceived risk of tackle football were significantly associated with greater odds of supporting or maybe supporting age limits on tackling (Table 2). Interactions were noted between sex and other variables, and as a result, additional analyses were stratified by the sex of respondent. Race and/or ethnicity, geographic region, and presence of either younger or older children in the home were not predictive of support for age limits on tackling and thus were not included in additional analyses.

TABLE 2

Results of Bivariate Multinomial Logistic Regression Modeling of National Survey Data Regarding Factors That Impact Odds of Supporting Age Limits for Football Tackling

Favor Minimum Age for Tackling: YesFavor Minimum Age for Tackling: Maybe
OR95% CIOR95% CI
Female respondent 1.91a 1.30–2.81 1.96a 1.26–3.04 
Age quartile, y     
 <35 Reference — Reference — 
 35–40.9 0.57 0.29–1.12 0.52 0.25–1.10 
 41–46.9 0.46b 0.24–0.89 0.39a 0.19–0.79 
 47+ 0.48b 0.26–0.90 0.39a 0.20–0.77 
Race and/or ethnicity     
 Non-Hispanic white Reference — Reference — 
 Non-Hispanic African American 1.05 0.56–1.97 1.02 0.49–2.09 
 Non-Hispanic, 2+ races 0.71 0.30–1.71 0.40 0.12–1.28 
 Other 0.89 0.35–2.29 0.80 0.26–2.52 
 Hispanic 1.08 0.67–1.76 1.38 0.81–2.36 
Geographic region     
 Midwest Reference — Reference — 
 Northeast 0.80 0.44–1.46 0.93 0.47–1.83 
 South 1.00 0.60–1.65 0.87 0.49–1.54 
 West 1.51 0.81–2.79 1.24 0.62–2.46 
Education     
 Less than high school Reference — Reference — 
 High school 0.85 0.45–1.62 1.52 0.76–3.02 
 Some college 1.43 0.85–2.40 1.31 0.73–2.36 
 Bachelor’s degree or higher 1.61 0.97–2.65 0.97 0.54–1.75 
Presence of child age 5 y or younger 1.30 0.84–2.03 0.98 0.59–1.64 
Presence of child age 6–12 y 1.37 0.93–2.00 1.75b 1.12–2.71 
Presence of child age 13–17 y 0.85 0.58–1.24 1.16 0.75–1.80 
Interest in professional football     
 Not at all Reference — Reference — 
 A little bit  0.85 0.46–1.56 0.67 0.34–1.34 
 Fairly  0.71 0.38–1.34 0.58 0.29–1.18 
 Very 0.65 0.38–1.11 0.41a 0.22–0.77 
How many youth out of 100 do you believe would sustain a concussion in 1 season of high school football?     
 <10 Reference — Reference — 
 10–<25 1.12 0.64–1.97 0.79 0.43–1.49 
 25–<50 2.19b 1.13–4.22 1.12 0.54–2.32 
 50+ 1.28 0.70–2.34 0.51 0.26–1.02 
Favor Minimum Age for Tackling: YesFavor Minimum Age for Tackling: Maybe
OR95% CIOR95% CI
Female respondent 1.91a 1.30–2.81 1.96a 1.26–3.04 
Age quartile, y     
 <35 Reference — Reference — 
 35–40.9 0.57 0.29–1.12 0.52 0.25–1.10 
 41–46.9 0.46b 0.24–0.89 0.39a 0.19–0.79 
 47+ 0.48b 0.26–0.90 0.39a 0.20–0.77 
Race and/or ethnicity     
 Non-Hispanic white Reference — Reference — 
 Non-Hispanic African American 1.05 0.56–1.97 1.02 0.49–2.09 
 Non-Hispanic, 2+ races 0.71 0.30–1.71 0.40 0.12–1.28 
 Other 0.89 0.35–2.29 0.80 0.26–2.52 
 Hispanic 1.08 0.67–1.76 1.38 0.81–2.36 
Geographic region     
 Midwest Reference — Reference — 
 Northeast 0.80 0.44–1.46 0.93 0.47–1.83 
 South 1.00 0.60–1.65 0.87 0.49–1.54 
 West 1.51 0.81–2.79 1.24 0.62–2.46 
Education     
 Less than high school Reference — Reference — 
 High school 0.85 0.45–1.62 1.52 0.76–3.02 
 Some college 1.43 0.85–2.40 1.31 0.73–2.36 
 Bachelor’s degree or higher 1.61 0.97–2.65 0.97 0.54–1.75 
Presence of child age 5 y or younger 1.30 0.84–2.03 0.98 0.59–1.64 
Presence of child age 6–12 y 1.37 0.93–2.00 1.75b 1.12–2.71 
Presence of child age 13–17 y 0.85 0.58–1.24 1.16 0.75–1.80 
Interest in professional football     
 Not at all Reference — Reference — 
 A little bit  0.85 0.46–1.56 0.67 0.34–1.34 
 Fairly  0.71 0.38–1.34 0.58 0.29–1.18 
 Very 0.65 0.38–1.11 0.41a 0.22–0.77 
How many youth out of 100 do you believe would sustain a concussion in 1 season of high school football?     
 <10 Reference — Reference — 
 10–<25 1.12 0.64–1.97 0.79 0.43–1.49 
 25–<50 2.19b 1.13–4.22 1.12 0.54–2.32 
 50+ 1.28 0.70–2.34 0.51 0.26–1.02 

—, not applicable.

a

P < .01.

b

P < .05.

Female respondents with a bachelor’s degree had 4 times greater odds of supporting age limits for tackling compared with those with less than a high school degree (OR 3.97; 95% CI 1.61–9.80; Table 3). Female respondents who estimated that 25% to 50% of youth would sustain a concussion in 1 season of youth football (ie, those who reported greater perceived risk) had 4 times greater odds of supporting age limits on tackling compared with those who estimated <10% of youth would sustain a concussion (OR 3.83; 95% CI 1.06–13.83). The presence of a child 6 to 12 years old in the household was not significant for female respondents in the multivariate analysis.

TABLE 3

Results of Multivariable Multinomial Logistic Regression Modeling of National Survey Data Regarding Factors That Impact the Odds of Supporting Age Limits for Football Tackling: Female Respondents Only

Minimum Age for Tackling: YesMinimum Age for Tackling: Maybe
OR95% CIOR95% CI
Presence of child age 6–12 y 1.15 0.59–2.23 1.35 0.66–2.76 
Education     
 Less than high school 1.30 0.48–3.50 1.24 0.42–3.67 
 High school Reference — — — 
 Some college 2.06 0.86–4.90 1.98 0.77–5.06 
 Bachelor’s degree or greater 3.97* 1.61–9.80 1.47 0.54–4.01 
How many youth out of 100 do you believe would sustain a concussion in 1 season of high school football     
 <10 Reference — — — 
 10–<25 0.55 0.21–1.44 0.48 0.18–1.33 
 25–<50 3.83* 1.06–13.83 1.73 0.46–6.58 
 50+ 1.15 0.43–3.03 0.33* 0.12–0.94 
Minimum Age for Tackling: YesMinimum Age for Tackling: Maybe
OR95% CIOR95% CI
Presence of child age 6–12 y 1.15 0.59–2.23 1.35 0.66–2.76 
Education     
 Less than high school 1.30 0.48–3.50 1.24 0.42–3.67 
 High school Reference — — — 
 Some college 2.06 0.86–4.90 1.98 0.77–5.06 
 Bachelor’s degree or greater 3.97* 1.61–9.80 1.47 0.54–4.01 
How many youth out of 100 do you believe would sustain a concussion in 1 season of high school football     
 <10 Reference — — — 
 10–<25 0.55 0.21–1.44 0.48 0.18–1.33 
 25–<50 3.83* 1.06–13.83 1.73 0.46–6.58 
 50+ 1.15 0.43–3.03 0.33* 0.12–0.94 

—, not applicable.

*

P < .05.

For male respondents, the presence of a child 6 to 12 years old in the household was associated with twice the odds of maybe supporting a minimum age for tackling (OR 2.34; 95% CI 1.19–4.62; Table 4). Perceived risk of football (number of youth out of 100 who would sustain a concussion in 1 season) was not associated with support or lack of support of age limits for tackling.

TABLE 4

Results of Multivariable Multinomial Logistic Regression Modeling of National Survey Data Regarding Factors That Impact the Odds of Supporting Age Limits for Football Tackling: Male Respondents Only

Minimum Age for Tackling: YesMinimum Age for Tackling: Maybe
OR95% CIOR95% CI
Presence of child 6–12 y old in household 1.71 0.98–3.00 2.34* 1.19–4.62 
How many youth out of 100 do you believe would sustain a concussion in 1 season of high school football?     
 <10 Reference — — — 
 10–<25 1.46 0.70–3.04 1.09 0.45–2.61 
 25–<50 1.38 0.62–3.10 0.96 0.37–2.54 
 50+ 0.99 0.43–2.30 0.68 0.25–1.88 
Minimum Age for Tackling: YesMinimum Age for Tackling: Maybe
OR95% CIOR95% CI
Presence of child 6–12 y old in household 1.71 0.98–3.00 2.34* 1.19–4.62 
How many youth out of 100 do you believe would sustain a concussion in 1 season of high school football?     
 <10 Reference — — — 
 10–<25 1.46 0.70–3.04 1.09 0.45–2.61 
 25–<50 1.38 0.62–3.10 0.96 0.37–2.54 
 50+ 0.99 0.43–2.30 0.68 0.25–1.88 

—, not applicable.

*

P < .05.

In this nationally representative survey of US parents of school-aged youth, 61% of parents were in support of a minimum age for tackling in football, and an additional 24% maybe would support such limits. Although female parents had significantly greater odds of supporting age restrictions, a majority of both male and female respondents would support age limits. Other characteristics hypothesized to be associated with support of age limits, such as geographic region, socioeconomic status, race and/or ethnicity, and being a football fan, were not significant in multivariate analyses. Of note, education and socioeconomic status were collinear and thus could not be evaluated separately.

To our knowledge, no previous studies have evaluated popular support for age limits on tackling in football. Fishman et al39 surveyed pediatricians regarding sport safety, reporting that 77% would not allow their children to play tackle football, and 81% supported age limits on tackling. Our survey indicates a majority of parents (85%) also support limiting tackling for youth, and predictors of support differ between male and female respondents. For female respondents, greater perceived risk of concussion in youth football was associated with support of age limits, but for male respondents, perceived risk was not significantly associated with support. Male respondents were more inclined to maybe support age limits if there was a child 6 to 12 years old in the house, perhaps because of an increased salience of their parental role.52 The differences observed regarding parent sex are consistent with those seen in previous research about variations in risk attitudes between male and female respondents.53 Fathers tend to view their role as exposing their children to appropriate risk and teaching them to be tough (particularly their sons), whereas mothers view their role as preventing injury.54,55 

In 2015, the American Academy of Pediatrics Council on Sports Medicine and Fitness (COSMF) reviewed the literature regarding injury in youth football and considered supporting age limits on tackling in football, stating that such limits “would likely lead to a decrease in the incidence of overall injuries, severe injuries, catastrophic injuries, and concussions.”41 However, the COSMF did not make a clear recommendation about age limits on tackling, instead suggesting that leagues consider expanding nontackle options (ie, flag). Unfortunately, without nationally supported recommendations regarding football contact, opportunities for flag football or other low-contact substitutes for tackle football may lag in rural or impoverished areas.56 The COSMF statement discussed potential costs of age limits, such as concern about greater severity of injuries when tackling is introduced, due to a lack of early exposure.57 However, studies in hockey have found no evidence for greater injuries in individuals who did not have early introduction to high-risk contact, suggesting no protective effect of early exposure.42 The recent Clinical Report on sports concussions from COSMF58 only referenced the 2015 recommendations regarding youth football tackling and did not offer any additional discussion regarding costs and benefits of youth tackling.

Research regarding the long-term risk of exposure to tackling in football has not found chronic effects of exposure to tackling itself in the absence of injury.33,36 However, tackling is associated with a high risk of acute injury,23,31 and officials in similar sports, such as soccer and ice hockey, have chosen to mitigate the risk of injury to their youngest participants using age restrictions on contact. Given the known risks of tackling in youth football and restrictions on contact for youth in similar sports, such as ice hockey and soccer, new American Academy of Pediatrics guidelines should discuss whether the risks of early exposure to tackling are acceptable relative to potential benefits. Our study indicates that a majority of parents support age limits on tackling, suggesting that for this important group of stakeholders, the benefits of age limits outweigh the potential costs of limiting early exposure to tackle football.

The primary limitation of this study is that we asked parents about their potential support for age limits on tackling, and their responses might be different from how they would feel if such restrictions were enacted. In addition, we chose to survey a nationally generalizable sample of parents to provide the most information regarding these types of limitations, but we were unable to determine how such attitudes might vary in parents who are most impacted by such a rule change: those whose children play football. Further research might explore similar questions among parents of youth football athletes.

Sports have many advantages for youth, but they also carry risk for injury. Throughout the history of sport, rules have been an important tool in improving the safety, and they have evolved in concert with new evidence about risks and changes in public support.59 US parents are willing to accept age limits on tackling in youth football. Organizations that are responsible for shaping public discourse about this topic (such as the American Academy of Pediatrics) may find it useful to consider US parents’ attitudes regarding age limits on tackling, alongside research quantifying the risk of tackling, when they revisit this topic.

Dr Chrisman conceptualized and designed the study, oversaw data analysis, drafted the initial manuscript, and incorporated all revisions and comments; Dr Rivara conceptualized and designed the study, coordinated and supervised data collection via the national survey, and critically reviewed the manuscript for important intellectual content; Drs Herring and Kroshus assisted with the conceptualization and design of the study and reviewed and revised the manuscript; Ms Schwien assisted with the conceptualization and design of the study, oversaw all data collection, and reviewed and revised the final manuscript; Ms Whitlock conducted data analysis and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Funded by the Seattle Children’s Hospital Academic Enrichment Fund, the Seattle Pediatric Concussion Research Collaborative, and the Sports Institute at the University of Washington School of Medicine.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-0519.

     
  • CI

    confidence interval

  •  
  • COSMF

    Council on Sports Medicine and Fitness

  •  
  • GfK

    Growth from Knowledge

  •  
  • OR

    odds ratio

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Herring is one of the team physicians for the Seattle Seahawks; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.