Youth Football and the Epidemic of Pediatric Brain Injury

BACKGROUND AND OBJECTIVES: Sports-related traumatic brain injury (TBI) is among the most common causes of long-term neurologic and psychiatric morbidity in children and young adults. Football, in particular, has been implicated as a leading source of TBI, yet large-scale comparative studies across sports and developmental stages are limited. The objective of this study was to quantify the burden of football-related TBI in youth compared with other sports and recreational activities, and to evaluate long-term neurologic and psychiatric outcomes across developmental stages. METHODS: This retrospective cohort study used the TriNetX Research Network, encompassing >150 million patients. Children and young adults (≤25 years) with a first TBI and activity cause of morbidity recorded on the day of injury were identified based on ICD-10 codes. Patients with TBI were compared with patients with lower leg fractures in the same activity with no recorded TBI on neurologic, psychiatric, and developmental outcomes. Attributable risks were calculated between TBI and lower leg fracture patients matched 1:1 on age category and sex. Prevalent cases were excluded. Multivariate Cox proportional hazard models adjusted for age category, sex, and activity compared the risk of each outcome across activities. RESULTS: Compared with other sports, football had the greatest quantity and severity of TBIs. Football accounted for 19.4% of 72,025 identified activity-related TBIs (mean age, 13.9 years; 32% female). Repeat TBI occurred in 37% of football injuries (32% overall). Attributable risks of football TBIs included neurologic outcomes (chronic headache, 23%; visual impairment and blindness, 5%; and neurodevelopmental disorders, 0.5%) and psychiatric outcomes (anxiety disorders, 5%; depressive disorders, 3%; substance use disorders, 1%; and violence and suicidality, 0.5%). TBIs at early ages were associated with mood and developmental disorders, while TBIs at later ages were associated with substance use disorders. DISCUSSION: Football is the single leading source of pediatric sports-related TBI, associated with high recurrence rates, substantial neurologic and psychiatric sequelae, and altered developmental trajectories. These findings highlight football as a critical public health priority and support stronger preventive measures, including delaying tackle football participation and regulating institutional promotion of youth football.