High LD/ADHD rates for UNC football raise new questions about the sport’s safety
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Are college football recruits arriving on campus suffering from the effects of brain injuries sustained during youth and high school play?
And are those injuries and effects making it harder for them to study and learn, as well as putting them at increased risk for misdiagnosed concussions and additional damage?
Those are two of the unsettling questions raised by a largely overlooked research paper recently published in the The Journal of Scientific Practice and Integrity. Titled “Cognitive Deficits and LD/ADHD Among College Football Athletes and Undisclosed Inclusion in Concussion Research,” the paper is as complicated as it sounds.
But when it comes to the possibility that athletes are exiting Pop Warner and prep football suffering from brain damage, the gist is relatively simple.
Analyzing nine years of internal UNC documents released to the public in the aftermath of a high-profile academic fraud scandal, the paper presents evidence that the school’s incoming football players from 2004-2012 were diagnosed with remarkably high rates of learning disabilities (LD) and attention-deficit/hyperactivity disorder (ADHD).
In 2009-10, for example, 44 percent of the school’s scholarship football players were diagnosed with LDs or ADHD.
By comparison, the paper states, approximately 2.95 percent of all American college undergraduates had the same conditions in 2011-12.
While a causal relationship between brain injury and LDs or ADHD has not been established, both conditions have been linked to previous injury.
Moreover, neuropsychological test scores for many of UNC’s incoming football players were consistent with those of people who have suffered brain injuries—even though said players had yet to participate in a college practice, let alone a game.
“The first thing we said when we saw these numbers was ‘holy s—t,’” says Don Comrie, one of the paper’s co-authors and a scientific consultant who has advised the National Football League Players Association and a group of objectors to the league’s concussion settlement.
“It’s very, very odd. There is no easy explanation for this. There’s no population that exhibits that kind of LD and ADHD symptoms. We don’t believe this can just be explained by developmental [factors]. So is it brain damage?”
To understand how Comrie and paper co-author Ted Tatos came to be so alarmed, it helps to go back in time.
In 2014, an independent investigation led by former federal prosecutor Ken Wainstein found that over the course of nearly two decades, thousands of North Carolina students—including football players—took bogus “paper classes” that largely existed to help keep athletes academically eligible to play sports.
As part of its response to the scandal, the school made nearly two million internal documents available online. That caught the eye of Tatos, a University of Utah economics professor and consultant whose mother attended UNC.
Digging through the documents, Tatos noticed that many involved LD and ADHD testing for athletes. One number stood out: in 2006 and 2007, 61 percent of the school’s incoming football and women’s basketball players were diagnosed with one or both conditions.
According to the Centers for Disease Control and Prevention, ADHD diagnoses rates in American children ranged from 6.9 percent in 1998-2000 to 9.0 percent in 2007-09.
“Why were the rates for incoming athletes so much greater than those in the general population?” Tatos says.
One possible clue can be found in a 2009 ESPN article. A former Florida State University learning specialist told reporter Tom Farrey that more than a third of the school’s football players and three-quarters of its men’s basketball players had been diagnosed with LDs—figures that dwarfed an estimated 5-10 percent incidence rate for the general adult population.
The article also laid out how bogus LD diagnoses could be abused by athletic departments to keep academically marginal or deficient athletes eligible by qualifying them for an array of special services and waivers, including special note takers, books on tape, additional testing time, and permission to take fewer classes than otherwise required by the National Collegiate Athletic Association.
So were UNC’s diagnoses legitimate? On one hand, fakery would help explain the eye-popping rates of both conditions among the school’s athletes.
On the other, Tatos says, email exchanges among UNC’s learning specialists and others working for and with the school didn’t show subterfuge. Instead, everyone seemed to be acting in good faith—so much so that athletes diagnosed with ADHD appeared to be receiving symptom-treating stimulant medications such as Adderall and Ritalin from a school doctor.
“I know there is pressure to get [academic] accommodations, because it gives athletes more time to focus on their sports,” Tatos says. “But going back to the very first email that caught my attention, these appear to be legitimate diagnoses.
“The individuals doing the testing seemed focused on the welfare of the athletes. They were concerned about these diagnoses. So my thought was, ‘what’s going on?’”
Tatos began sharing some of UNC’s documents on Twitter. Comrie took notice. A New York City-based consultant who helps pharmaceutical companies design clinical trials for neurological drugs, he previously studied brain injuries suffered by American soldiers in Iraq.
Comrie reasoned that if the school’s sky-high rates among incoming football players could be taken at face value, then youth and high school football might be more dangerous than previously believed.
Medical science has not established a causal connection between brain injuries and LDs or ADHD—no one can say with certainty that suffering a concussion or getting repeatedly hit in the head can or will produce either condition in any given individual.
However, evidence suggests that previous brain injuries are risk factors for both conditions.
As far back as 1968, American medicine’s official Big Book of mental disorders, the DSM-II, noted that in children, “mild brain damage often manifests itself by hyperactivity, short attention span, easy distractibility, and impulsiveness”—all symptoms now characteristic of ADHD.
More recently, a 2016 study co-authored by UNC concussion researcher Kevin Guskiewicz of roughly 8,000 male high school and college athletes, mostly football players, found that those who self-reported three or more previous concussions were: a) twice as likely to have LDs and; b) almost three times more likely to have ADHD than those who reported fewer or no concussions.
That same year, a study of more than 6,500 high school athletes found that those with ADHD were significantly more likely to report a history of one or more concussions. Another study of nearly 35,000 adolescent athletes found that those with LDs, ADHD, or both conditions reported a greater prevalence of prior concussions than those without.
Last year, a study of 187 children who had been hospitalized for either brain or orthopedic injuries suffered between the ages of three and seven found that the brain injury victims were more likely to subsequently develop ADHD—some as late as six years after their injury.
Meanwhile, youth and high school football are known vectors for brain injury. Football consistently ranks alongside hockey and soccer as the prep sports with the highest rates of reported concussions, and a NFL-funded National Academy of Sciences report released in 2013 found that high school players are nearly twice as likely to suffer concussions (11.2 percent) as their college counterparts (6.2 percent).
Though less research has been done on concussions in youth football, University of Washington investigators who followed a Seattle-area youth league for two seasons found that five percent of players ages 5 to 14 suffered a concussion each season.
Then there’s repetitive head trauma. A 2013 study of 40 high school players in North Carolina found that they absorbed more than 16,500 combined head hits in a single season, while an earlier Purdue University study of Indiana prep players recorded hits of magnitudes up to 289 Gs—that is, 289 times the force of gravity, or nearly three times as forcefully as a dummy hits the windshield in a 25-mile-per-hour car crash.
In a pair of studies, Virginia Tech and Wake Forest University researchers found that 7- and 8-year-old boys received an average of 80 head hits per football season, while boys ages nine through 12 received 240 hits. Some of the impacts were 80 Gs or more.
“Look, there are guys in college football who go to Harvard [University] and Stanford [University], and guys who have PhDs in math,” Comrie says. “They don’t have a lot of damage on them. So if something is happening, it’s not absolute.
“But what’s the thing that’s common with the [UNC football players]? Football has a lot of head strikes. Could the type of symptoms they’re having be an expression of brain damage?”
And that wasn’t Comrie’s only concern. He also feared that incoming college football players with LDs and ADHDs would be at greater risk for future brain injuries.
Why? Both conditions make it more difficult to diagnose concussions—and to determine when concussed athletes can safely return to play.
With rest and a gradual return to regular activity, most athletes who suffer a single concussion experience no lasting ill effects. But athletes who suffer a second concussion while still recovering from a previous one face a greater risk of prolonged or permanent symptoms, ranging from headaches to cognitive impairment. Those athletes also can suffer second-impact syndrome, a rare condition in which the brain swells rapidly and catastrophically, causing severe disability or death.
As such, sports medicine has a simple mantra managing concussions: “When in Doubt, Sit Them Out!”
To reduce doubt, many doctors, trainers, schools, and sports organizations rely on neuropsychological tests that measure how well or poorly different brain regions and functions are working. Some of those tests are administered via pencil and paper. Others, like the popular ImPACT test, are given by computer.
Either way, athletes typically are tested before sports seasons, with their scores serving as a baseline—that is, a reference point for how their brain works when healthy. After athletes have been concussed or are suspected of suffering concussions, they retake the tests; comparing their new results to their previous baselines helps doctors determine the extent of their impairments and the progress of their recoveries.
Problem is, LDs and ADHD can throw a monkey wrench into this process by skewing test scores—making it difficult for clinicians to correctly interpret them.
“Most of the thresholds for diagnosing concussions and recovery are very small changes,” Comrie says. “The worry is that if you can’t figure out their condition, you put people back in prematurely. They might seem well enough to function, but that doesn’t mean they’re not still vulnerable.
“And then they’re going to be hurt again prematurely. You are going to be compounding their brain injuries.”
Comrie reached out to Tatos in early 2016. Tatos spent the next three years examining UNC emails, data tables, reports, published and unpublished studies, and neuropsychological testing results for 137 de-identified football players.
From 2004 to 2012, he determined, the school’s athletic department used a neuropsychologist named Lynda Johnson to screen and test incoming athletes for LDs and ADHD. That usually took place during the summer prior to freshman year, and athletes identified with either condition subsequently received a full assessment—basically, a more detailed and elaborate series of tests.
While some of those tests changed over the years, LD and ADHD diagnoses rates remained consistently high:
In 2003-04, the first year covered by the school’s document dump, 29 percent of UNC’s football players were diagnosed with LDs. No ADHD numbers were reported.
From 2005 through 2007, 24 of 40 freshman football players (60 percent) were diagnosed with LDs (6), ADHD, (4), or both (14).
In 2007-08, 21 of the team’s 85 scholarship players (24 percent) were diagnosed.
In 2009-10, that overall number rose to 37 diagnosed players—nearly half of UNC’s scholarship roster.
In 2011-12, 13 of 24 incoming players (54 percent) were diagnosed.
“The more we dug into this, the more crazy it became,” Comrie says.
Two related findings were particularly perplexing. First, the stimulants given to some of the football players diagnosed with ADHD can mask the symptoms of concussion on neuropsychological tests—a potential problem made worse by the school’s apparent practice of administering baseline tests prior to prescribing medication.
“So you’re off meds when you baseline, and you start with an accurately low number,” Comrie says. “But when you have a trauma event, you are on your meds. They artificially lift your number. Only that doesn’t mean your brain injury went away. It just changed my ability to read the damage you have.
“They could have been pharmaceutically sandbagging the tests. That’s very disturbing.”
Second: between 2005-09, 30 percent of UNC’s incoming football players scored lower than what would be expected of recent brain injury patients on a test of complex attention, while 17.6 percent scored lower on a test for cognitive flexibility.
More unsettling, 18 percent of incoming players from 2010-12 scored low enough on tests of verbal and visual memory to be considered brain injury victims by the standards of the U.S. military’s special forces.
“Leaving LDs and ADHD out, these athletes are reporting with what looks like the result of brain damage,” Tatos says. “And they are incoming freshmen! That is extraordinary.”
“Why are we seeing guys scoring this low, given that they didn’t go down ropes from a Blackhawk [helicopter] head first, or weren’t eight inches from breaching blasts, night after night?” he says. “How many guys at UNC have been in a Stryker that was blown up and thrown down a road? Zero.”
If UNC’s documents are accurate—and there’s no reason to believe otherwise—then Comrie and Tatos’ findings have multiple implications for college football.
Athletes may be coming to campus with preexisting brain damage. Scientists believe that the still-developing brains of children and adolescents may be uniquely vulnerable to head trauma; a growing body of evidence shows that youth and high school football can result in acute and chronic brain injuries, cognitive dysfunction, brainchanges that are consistent withinjuries, and increased risk of developing earlier symptoms from neurodegenerative diseases such as chronic traumatic encephalopathy (CTE).
Higher rates of LDs and ADHD may be one more sign of trouble.
While competing at the college level, those athletes may be at higher risk of misdiagnosed concussions, mismanaged concussion care, and additional and more severe brain injuries.
LDs and ADHD directly affect studying and learning. Universities exist to protect and nurture young minds—does it make ethical sense for them to be in the business of a sport that not only damages brains, but also does so in a way that makes it harder to obtain an education?
“There’s nothing pro-educational about being exposed to repeated hits to the head,” Tatos says. “It’s antithetic to education. There’s no question about that.”
Of course, there are significant caveats to all of the above. UNC is a single school—it’s possible that elevated LD and ADHD rates among its football players are fluky, and not indicative of rates at other major college football programs or across the sport in general.
In their paper, Tatos and Comrie note that media reports and academic studies have indicated high rates of LDs and ADHD among football players at Louisiana State University, football and basketball players at Florida State, and athletes across all sports at Pennsylvania State University. One recent study found that 27 percent of football players at the University of Florida were diagnosed with one or both conditions.
It’s also possible UNC’s rates are, at least in part, a bogus byproduct of academic shenanigans. In 2014, former Tar Heels football player Tydreke Powell told a North Carolina radio station that athletes were instructed to fail learning disability assessment tests in order to receive extra academic assistance—however, he also claimed that athletes were tested in Durham, which is not where Johnson or others mentioned in UNC’s publicly available records conducted their work.
(If there’s any truth to Powell’s unsubstantiated allegation, then the school’s scandal may have been deeper and more troubling than publicly admitted, violating academic and medical ethics).
In addition, LD and ADHD diagnoses for incoming college athletes might not indicate previous brain injury. Instead, a casual relationship might run in the opposite direction, with both conditions making brain injuries more likely to occur and be diagnosed by clinicians during childhood and adolescence.
In an emailed statement, a UNC spokesperson told Hreal Sports that “the rates of LD/ADHD and those athletes taking stimulant medication among UNC student-athletes were not abnormally high.”
UNC’s statement did not answer questions from Hreal Sports about whether the school accounted for LDs, ADHD, and the use of prescription stimulants when providing medical and concussion care to its football players from 2005-2012, or if during the same time period the school performed baseline tests on athletes who were off stimulants but post-concussion tests on athletes who were taking those medications.
Wherever the truth lies, Comrie says, UNC’s numbers deserve more scrutiny—both by the school and by the scientific community.
“We’ve looked at different explanations for this,” he says. “None of them are very positive. Is this brain damage? Is it medical malpractice? Are they getting over on academic fraud? Was the instrument they were using to screen [athletes] really appropriate? I want to hear UNC explain where they got these numbers from. Because they make no sense.”
More to the Story
Speaking of things that need more explanation, much of Comrie and Tatos’ paper deals with a related issue—the apparent failure of UNC concussion researchers to account for LDs, ADHD, and stimulant medication use in their work.
As noted above, all three can affect the results of the neuropsychological tests by muddling and masking the symptoms of brain injury. Because concussion studies employ those tests, people with LDs, ADHD, or taking stimulant medications have been treated as a separate population within—or outright excluded from—those studies for the last two decades.
According to the paper, however, UNC researchers didn’t do this in a number of published studies.
Why does this matter? The school is a major concussion research hub, and has produced multiple studies on how tackle football and other collision sports affect the brain. If those studies contain flawed data, then other research that contains or relies on that data also may be flawed—leading to underestimates of how much brain injury risk athletes in those sports face, and inadequate policies designed to mitigate said risk.
UNC’s emailed statement included a quote from Guskiewicz, the concussion researcher who is now the school’s interim chancellor:
“I stand by our concussion research 100 percent. Our research protocols go through a robust internal review process, and in most cases an additional external grant review process. Our research has been peer reviewed by hundreds of respected neuroscientists and sports medicine researchers before being published. I am proud of the work my colleagues at the Gfeller Center and other scholars who contributed to this work have done to help improve concussion prevention and care for athletes and service members. Every journal has its own disclosure policies; we have always fully complied with those guidelines.”
Like I said at the start, Comrie and Tatos’ paper is complicated. And trying to figure out if UNC has been producing crappy concussion research that also has polluted outside concussion research in a way that is making collision sports more dangerous is a bit beyond the investigative resources and purview of this newsletter—which, as you’ll notice, comes to your inbox for free.
However, you’re in luck: The Athletic has conducted a lengthy investigation into this exact issue, and published a three-part video series and accompanying article about it today. You can—and should!—watch and read them here.
I’ve written an awful lot about brain injuries in football. If you’re interested in learning more about the medical and ethical issues involved at the youth, high school, and college levels, here are three pieces that will deepen your understanding:
The first CTE trial to be heard by a jury threatens to expose the historical and ongoing reluctance of college sport’s governing body to protect football players.
A Las Vegas school board candidate and a handful of others are arguing football has no place in public education, where the goal is to nurture, not harm, young minds.
A parent's dilemma: Should your child play youth tackle football?
The Cost of Doing Business With China
When I was a Georgetown University undergraduate studying international relations way back in the 1990s, a prominent school of thought held that we were experiencing the End of History—that is, American-style liberal democracy and capitalism were essentially the world’s final social form, and as autocratic regimes such as China’s enjoyed the economic fruits of the latter, they would naturally adopt the political values of the former.
Late last week, Houston Rockets general manager Daryl Morey tweeted support for Hong Kong’s pro-democracy protesters, a sentiment that the Chinese government—and many others in the country—did not find inspiring. As the Washington Post reports, the both the Rockets and the NBA have since found themselves:
… engulfed in a backlash from seething Chinese fans and fac[ing] cries for a boycott.
Forty-eight hours later, China’s state broadcaster said it would not show games of what had been one of China’s most beloved sports teams. Corporate sponsors peeled away. The Chinese Basketball Association — headed by former Rockets star Yao Ming — also cut ties.
Practically overnight, the Rockets were grounded by an increasingly powerful force in global business: Chinese nationalism.
Morey responded by deleting his Tweet and issuing a kinda-sorta apology. Rockets owner Tilman Fertitta—a man who is hardly shy in expressing his admiration for Donald Trump and support of GOP governance—tweeted a Stick-to-Sports walkback, stating that Morey "does NOT speak for the @HoustonRockets" and that his franchise is "NOT a political organization." Rockets star James Harden apologized, too. The NBA put out a passive voice statement of non-support for Morey in English, and a more forcefully disappointed, borderline apologetic one in Chinese. The league did not comment on a subsequent statement from Brooklyn Nets owner and Taiwanese-Canadian billionaire Joe Tsai—a co-founder of Chinese tech and e-commerce giant Alibaba—that took Morey, the western press, and China’s critics to task for not understanding the country’s ongoing sense of national humiliation and grievance over, uh, the Boxer Rebellion.
Why is a wildly-successful American professional basketball league that ostensibly prides itself on supporting freedom of expression and worthy social causes backing down over Hong Kong? Simple. It wants continued access to China’s enormous market—or, to use a term of art, money and lots of it.
In this regard, the NBA is hardly an anomaly. Supplication to China’s authoritarian whims—big and small—is the cost of doing business within the world’s second-largest economy.
After a Marriott Rewards employee "liked" a tweet by the "Friends of Tibet" group praising an company questionnaire that listed Taiwan, Tibet, Hong Kong, and Macau as "countries", Chinese authorities called in Marriott officials for questioning, shut down their Chinese website and mobile apps, and demanded an apology. Marriott CEO Arne Sorenson’s [subsequent] apology parroted the language the Communist Party uses to describe groups that stand opposed to Chinese repression or advocate for Tibetan autonomy.
International companies have long complained that China has strong-armed them into handing over trade secrets in exchange for market access. In some sectors, Beijing will only let foreign firms operate through joint ventures in which Chinese partners have the majority stake.
The partnerships have often delivered blockbuster sales, but they have also raised concerns that they lead to Chinese companies getting their hands on their foreign partners' technologies.
International automakers are "training their future competitors and receiving only a fraction of what their intellectual property would earn" if they were allowed to go it alone in China, said Mary Lovely, a professor at the Peterson Institute for International Economics.
This leverage also extends to universities with campuses in China or joint ventures with Chinese universities. Many top American universities maintain a presence in China, through summer language programs like the Harvard Beijing Academy; institutes such as the Stanford Center at Peking University that serve as platforms to attract students, fund-raise, allow faculty to conduct research, and host events; or even full campuses, like New York University–Shanghai and Johns Hopkins Nanjing.
Those institutions in China are “hostages,” said Pei, the Claremont McKenna professor, because the universities don’t want to jeopardize the status of their satellite institutions. Beijing “could make their life miserable in many ways,” he said—for instance by restricting visas, ramping up health and safety inspections, and even issuing threats of closure. “If you’re Stanford or Harvard and you have operations in China, are you going to host a famous dissident to speak?” he asked.
The NBA is the latest American institution to learn that when cutting a deal with China, there’s no guarantee that you’ll get what you pay for—but you’ll always end up paying for what you get. Turns out history didn’t end!
The Racial Injustice of College Sports Amateurism
As you’ve likely heard already, a California bill signed into law last week and scheduled to take effect in 2023 will allow athletes at the state’s colleges and universities to earn income from their names, images, and likenesses (NILs)—something prohibited by the NCAA’s current amateurism rules.
There’s a lot to discuss and unpack about this. In fact, I’ll have more to say in the next edition of this newsletter. For now, though, one angle is kinda-sorta blowing my mind: politicians are saying, in public, that the NCAA’s arguably illegal and inarguably immoral suppression of campus athletes’ basic economic rights is, in part, a racial injustice.
Why? Because the system essentially funnels wealth created by predominantly African-American labor to overwhelmingly white management.
Here’s California Gov. Gavin Newsom, who signed the bill into law, stating as much on The Daily Show:
And lest you think this is solely the province of progressives, here’s Florida Republican Man and Rep. Matt Gaetz on Twitter:
SportsCenter @SportsCenter.@RSherman_25 hopes the Fair Pay to Play Act is the end of the NCAA. https://t.co/nJHdTHOIGt
Back in 2016, I reported and wrote a deep dive for Vice Sports on this topic. The title pretty much gives away the thrust of the piece: “Four Years a Student-Athlete: The Racial Injustice of Big-Time College Sports.”
At the time, I didn’t think what I had written was particularly controversial. It was completely rooted in facts. Nevertheless, a good number of people, particularly white people, found it upsetting and even offensive.
Fast-forward three years, and, well … things have changed. The idea that black athletes are especially getting ripped off by NCAA amateurism to benefit the white people in charge of making the rules is pretty much conventional wisdom—so much so that Rep. Mark Walker, a North Carolina Republican who is sponsoring Congressional bill that would give college athletes nationwide to cash in on their NILs, brought it up to me when we spoke for a Los Angeles Times piece I wrote in March.
In the same piece, Sen. Christopher S. Murphy (D-Conn.) told me athlete compensation was “a civil rights issue.”
“More than half of the athletes playing big-time football and basketball are African-American,” he said. “And almost all of the adults getting rich off their exploits are white. And civil rights is not just about race. You have workers here being denied an adequate return on their labor.”
Look, I’m happy people are seeing the light on this. But I’d be lying if I said that I wasn’t also just a little astounded.
This has been Hreal Sports, a weekly newsletter written by Patrick Hruby about sports things that don’t stick to sports. If you have any questions or feedback, contact me at my website, www.patrickhruby.net. And if you enjoyed this, please sign up and share with your friends.