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As brain injury researchers strike blow after blow against contact sport, parents are faced with difficult choices about what they will allow their children to play.Taylor Callery/The Globe and Mail

It remains Canada's national sport, a way to forge our identity, feed our passion. But for parents worried about the health of their children, hockey is no longer the game of choice.

Faced with a near daily stream of new research about the alarming and often long-term effects of concussions on youth, more and more parents are balking at hockey's dangers, which includes a significantly higher risk of attempting suicide; links to anxiety and depression; and such emotional and cognitive symptoms as disturbed sleep, difficulty concentrating, frustration and forgetfulness. Confronted with all that, parents are enrolling their children in seemingly safer sports.

While the high cost of outfitting a player and the time commitment involved are contributing factors in hockey's declining numbers, concern about head injury is eating away at hockey's core: One survey, conducted by Charlton Strategic Research, noted that 70 per cent of parents with kids playing at the midget age group (15 to 17) were worried about injuries. Three in 10 parents said they have a player who had suffered a concussion. In Ontario alone, researchers now believe as many as 36,000 players suffer concussions yearly.

Hockey Canada has just tallied its registration numbers and discovered it is lighter by more than 5,600 players in the 2013-14 season. Though girls' hockey has grown, the same can't be said for boy's hockey, which has been on the slide for three consecutive seasons.

Hockey executives are taking notice.

Don Fehr, executive director of the National Hockey League Players' Association, gave the keynote address at a University of Toronto symposium focused on better understanding the effects of concussion on athletes.

Society as a whole, he said, allows and often applauds people for partaking in hyper-dangerous activities. "The question becomes what do we permit and under what regulations, and that's what I think we're now beginning to really re-examine," he said. "What we are engaged in I think, is the beginning – at least in connection with a couple of sports – of a fairly thorough re-evaluation of how things are going to be done."

The ultimate question, Fehr said, is who decides.

"Who gets to decide what activities that kid engages in and under what conditions? Some group, some organization, the government, or mom and dad? I don't think there's any clear answer and I think it changes with time, it changes with perception and it changes with circumstances."

In Marshall, Tex., best known for its appearance in the legendary football movie Friday Night Lights, the school board decided in February to replace entry-level tackle football for Grade 7 students with flag football. That call drew interest around the continent.

"Canadians are as passionate about hockey as Americans are passionate about football," says Dr. Paul Comper, a clinical neuropsychologist at Toronto's University Health Network who also works as a consultant for the NHLPA.

And though Canadian boys dream of playing in the NHL, "at the lower level, the reality is these kids are not going to be professional hockey players," Comper added. "They should not have to worry about head injuries. … We want kids to be active, but at what point does the needle move to where the risks outweigh the benefits?"

Hockey Canada insists safety is a top concern.

"When we talk to parents, we want to make sure they know that making the game safe is a top priority for us," says Todd Jackson, a senior manager at Hockey Canada. "If we want to build up registration numbers, we've got to continue to work on safety."

Last year, the game's governing body implemented a controversial nationwide ban on bodychecking for players 13 and under to reduce the incidence of concussion. Later in June, the Greater Toronto Hockey League – the world's biggest minor hockey league – will vote on taking that measure a step further: A motion before the board will, if approved, extend the no-bodychecking rule to all A-level players (not AA or AAA), regardless of age.

A survey of thousands of parents, players, team and club officials found that more than 64 per cent favour removing bodychecking in A-level hockey. (That percentage slipped to just over 57 per cent when respondents considered that these teams may not then be eligible to play in tournaments and championships involving other Ontario Hockey Federation leagues that still allow bodychecking.)

It's a monumental shift in how kids play the game. With his association struggling to attract new players (despite population growth, registration has flat-lined), the GTHL's executive director hopes this extended emphasis on safety will help.

"The game is changing now, but people saw [Chicago Blackhawk] Brent Seabrook's hit on [St. Louis Blues] David Backes and think that's what happens in the minor hockey," Scott Oakman says. "We're trying to make our game safer, but image issues take time to change."

Even with heightened awareness, it is still difficult to determine the exact incidence of concussion. Parents have to fill out an injury report for a player who is hurt during team activities, a copy is kept by the league, and if a player has a concussion, he can't return to the ice until cleared by a doctor.

It's a well-intended system, but not foolproof.

"Concussions are, as you can imagine, tough to track as many occur at the local levels and do not necessarily get reported to us," says Jackson of Hockey Canada. "This makes it difficult to get a true picture of the number occurring."

Some teams are now conducting preseason baseline tests via questionnaires. The results are used as a comparison when a player suffers a head injury.

Hockey Canada approves of baseline testing, but does not make it mandatory. Paul Carson, the organization's vice-president of development, notes the decision to test belongs to the individual minor hockey associations.

"If an association thinks that is a healthy choice for kids, then good for them," Carson says. "I just don't want it to be another expense when parents have said that [financial cost] is a concern for them."

As for the GTHL, member clubs will vote on extending the bodychecking ban on June 14 – the GTHL board is recommending that if the rule change is accepted, it be deferred to the 2015-16 season. For parents tired of watching players helped off the ice after being hit in the head, that might not be good enough.

"Parents are tired of it," says Robert Deutschmann, a father of three minor hockey players in Toronto. "I think it is commendable for the GTHL to be doing this, but we should go forward and do it this year."

Soccer years behind hockey in understanding head injury

It's fun, it's inexpensive and it continues to grow in popularity. In 2013-2014 alone, 20,000 new players registered for soccer, pushing the total number in Canada to almost 866,000.

The way parents see it, soccer is a safe haven for their kids, a game without serious risk.

But scientists and doctors are picking a hole in that argument, specifically when it comes to heading the ball. Though the exact risk isn't known, researchers suggest it may contribute to cognitive decline or impairment, with studies on long-term effects pointing to greater memory, planning and perceptual deficits. Increasingly, they're calling for more comprehensive research on soccer players, and more awareness from kids, their parents and professional players as they re-examine the risk of the beautiful game.

"The goal is to come up with a far better understanding of concussions so it can turn into clinical practice," said Dr. Paul van Donkelaar, director of the School of Health and Exercise Sciences at the University of British Columbia's Okanagan campus.

"I'd say soccer information is four to five years behind hockey."

Toronto researchers raised red flags in February with a study that concluded that concussions accounted for 5.8 per cent to 8.6 per cent of the total number of injuries that occurred during soccer games.

The study, co-authored by Monica Maher, a neuroscience master's student, pointed to the long-term effects – verbal and visual memory loss – for soccer players who suffered more than one concussion or had "sub-concussive" head injuries. Those involve repeated blows to the head without the athlete presenting concussive symptoms such as headaches, dizziness and nausea.

Also in February, Boston University made a discovery that stunned the soccer world. Doctors found chronic traumatic encephalopathy (CTE) in a 29-year-old soccer player who had died in 2012 from amyotrophic lateral sclerosis (ALS). Researchers admitted they need more information before they could say conclusively that heading a soccer ball results in CTE, and that CTE contributed to development of ALS.

Van Donkelaar says soccer could take a page from the playbook of other sports to lower concussion risk for kids.

"In baseball, if you're under a certain age, you're only allowed to pitch a certain number of throws or innings. That stops them and it saves the arms of young kids so they're not used up by 15," he said. "In soccer, there is an inkling to limit the number of times a player heads the ball. It would only be allowed at a certain age, like hitting in hockey."

The cost of concussion is high. "A developing brain with a major injury is far reaching," he added.

The undeveloped brain: Why treat kids like adults?

When adults suffer a concussion, they're told to rest at least seven days. When kids suffer a concussion they're told the same thing.

Dr. Michelle Keightley disagrees with that identical treatment plan.

The clinical neuropsychologist at the Holland Bloorview Kids Rehabilitation Hospital in Toronto is convinced the current concussion protocol designed for adults is inappropriate for children.

"Before, it was all about the adults. They were told it was a seven to 10-day recovery so kids were told that, too," Keightley said. "[But] we found their brains take longer to recover because they are still developing."

The Greater Toronto Hockey League has been working with Holland Bloorview. After suffering a head injury, players may require weeks to months of rest, along with an MRI so that doctors have a better understanding of the neural impact.

Dr. Blaine Hoshizaki, a professor at the University of Ottawa's Faculty of Health Sciences, says there's still much to learn.

"I think there are more concussions involving children than reported, likely much higher than in adults," he said. "I would agree with Dr. Keightley that we should be treating children more conservatively until we have more research involving children."

At Mind Matters, a University of Toronto symposium on concussion and sport, researchers noted that younger athletes report longer recovery times: about 10 days for professional athletes, 20 days for university athletes and 45 days for high-school students. But that doesn't necessarily mean that recovery time would be longer for even younger athletes.

Dr. Doug Richards, chief medical officer of the Canadian Sport Institute Ontario, said younger athletes may be telling the truth about ongoing symptoms, where professional athletes may lie to get back into play sooner. The Canadian Paediatric Society recommends "conservative, cautious and individualized" return-to-play decisions for athletes.

Researchers simply don't know if a younger brain takes longer to recover. "There may be issues that we don't understand," Richards said. But, he noted, when it comes to getting accurate information from young athletes, a real challenge is "hovering parents" – kids simply aren't comfortable answering questions about sexual activity and substance use in front of mom and dad.

New research points to the importance of understanding emotional changes during the recovery stage as well. Tension, depression, anger, fatigue and confusion levels rise post-concussion – and not simply because athletes aren't able to play the games they love.

Athletes, concludes Dr. Lynda Mainwaring, professor at the University of Toronto, often don't report emotional disturbance because they don't realize it's a symptom related to their injury. "Assessment of post-injury emotional functioning could help to inform return-to-play decisions so that athletes do not return to play with emotional disturbance, which might create a risk for further injuries," she writes.

With files from Sarah MacWhirter

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