Risk Compensation Revisited

A few years ago I got interested in risk behavior, and wrote about it on this same infrequently updated blog. Fast forward 3 years and we now have a son. Theoretically and stereotypically, sons dream of playing football. Julia and I have joked about that before, and I say a manly son of mine is free to play football... so long as he's the kicker. Lewis has been growing at a rate that leaves us scratching our heads compared to our two daughters. He weighed at 3 months what they weighed at a year. (And they were right in the middle of the growth curve. So I guess he's about average too, if he were a small baby elephant.) Obviously growth patterns can fluctuate with age, but if he were to keep this up he'd be a fairly huge young man, ripe for competitive sports one might think. Grace wants to try out basketball and soccer, and who knows what Violet will take an interest in. Given her wild 3-year old independent streak it would seem full contact gymnastics would be right up her alley.

Julia just referred me to this interesting piece which is yet another article in the  popular press on the risks of concussions in football. Part of that article is a brief consideration of helmet technology, and whether or not we can invent our way out of this problem. As should be obvious from my take on seat belt laws and the like, I would argue no. In fact some people say we should get rid of facemasks and remove protective equipment to alter player behavior. The safer a player feels, the more risks they will take is the theory, and I think there's good evidence from other arenas of life to back that notion up. More on that later.

The literature on concussions largely uses the concept of Athletic Exposures. An Athletic Exposure (A-E) is generally defined as one athlete participating in one practice or a game/match. So, what is the rate of injury (in this case concussion) across various sports? Studies vary, but generally high school football is around 0.5-0.6 concussions per 1000 A-E (see Lincoln et al and Gessel et al). Those numbers may be under-appreciated. With time the rate of concussions seem to be going up. The argument is often made that we're just increasingly aware of concussions and diagnosing them more, and that may be. But how do other sports compare? According to this paper by Marshall and Spencer the concussion rate for rugby is 3.8 per 1000 A-E. That's admittedly a small study, but the article does contain a review of other published studies on the topic, and most of them are significantly higher than what the estimates are for American football. Ice hockey in various studies is also north of 3 per 1000 A-E, and individual contact sports (boxing, martial arts, etc) are higher still. So when they propose a mixed martial arts club at your kid's high school in 15 years, say no. 

Also, girls seem to be at more of a risk of concussion injury than boys. The Lincoln data show that for similar sports (basketball, soccer, baseball/softball) girls have a rate of concussion more than double that of boys. 

And girls' soccer had the second highest incidence of concussion after football. I can't help but wonder how accurate the reporting is here when we are comparing boys' and girls' sports. It would not surprise me at all to learn that the culture of boys' sports encourages them to "tough it out" and not report symptoms of concussion. But that's another topic entirely. 

From that epidemiological data, flawed though it may be, it would seem that American Football is not as bad as  some alternatives. It is the most risky of all the sports we play here though. It is also the sport that captures the national attention (sorry baseball), and the sheer volume of young men playing it means that we're talking about a whole lot of A-Es here. So what can we do about the concussions? Will better monitoring and better protective equipment reduce that rate of injury? So far, signs point to no. The monitoring has only served to make us more aware of concussion. This paper has a nice rundown on what is involved in monitoring head forces in football with the HITS system and what it has been showing (hint: 25g forces applied to the head about 10-15 times per A-E). What can we say about concussion risk and protective equipment? Virginia Tech has done some nice work comparing different helmets, but this is matching impact data in a lab with incidence data and drawing conclusions on which would be the most protective. There is no evidence that I can find that shows players wearing one type of helmet have a lower risk of concussion than those wearing another type. 

Padded headgear made no difference in head injury or concussion risk in rugby. In soccer (or football to all the rest of the world) there is mixed evidence. Some retrospective studies suggest headgear is protective. But controlled studies in the lab suggest that headgear doesn't provide significant protection, and broader reviews of the literature have not found a consensus agreement that they do any good. There's similarly mixed evidence on full face protection in hockey (it may be helpful in reducing severity of concussions). But in the discussion of most of these papers there is always the specter of our good friend risk compensation. This summary paper goes through what limited data there are on how interventions alter risk taking behavior. The authors note that in the 1940s American football players were taught to initiate contact with the shoulder. After the introduction of the plastic helmet they were taught to strike first with the head, and that tackling drill fatalities increased after the introduction of the plastic helmet. Surveys of rugby players showed that 67% felt more confident and able to tackle harder if wearing protective headgear. 35% of those involved in ski/snowboarding fatalities were wearing a helmet, which is well above what was average for the time in those not injured. 

In the end, most academic papers on the matter make mention of one common factor that seems to mitigate increased risk taking behavior, and makes more of a difference in injury rates than advancing technology and protective equipment. That factor? Changing the rules of the game. Commentators and good ole boys may whine about how new rules are making football not football anymore. If we banned heading the ball in soccer there would be a similar outcry I'm sure. But what we're learning is that the human skull/brain combo aren't well suited to running into things with force. Things like other skulls, the ground, the inside of a Humvee, etc. But equipment can't make inherently unsafe activities safe. Safer, maybe, but still risky to the millions of young people participating. If we really want to protect them, we have to change the games they're playing. 

Abandon All Hope, Ye Who Vomit Here

I am the last of my kind: the lone healthy survivor of the gastroenteritis that destroyed our household empire at the end of 2009.  It attacked the smallest among our ranks first, and then nefariously turned her against us, as she became an agent of disease, spreading the sickness wherever she crawled and cuddled.  It worked its way up the ranks from there, as the eldest child complained of "tummy hurts" from bath time until bedtime, and then vomited soon after going to bed.  Having somehow never experienced this most unpleasant sensation in her four years of life I had to explain to her that what she was doing was called throwing up.  "Why am I throwing up?" she asked innocently and imploringly.  Curse you evil virus! Curse you!

Not satisfied with taking our young, the creature aimed higher, and Julia was in its clutches from midnight on.  Rest was fleeting at best, as every 10-15 minutes someone would need attention, or a sip of water, or a run to the lavatory.

Now I sit alone in my household, the last healthy member of the family.  Every female human is passed out asleep under heavy blankets, but mercifully keeping their fluids to themselves.  I don't know how much longer I have.  I'm trusting in my immune system's years of hospital exposures to get me through this.  It's either that, or sheer willpower, because man I cannot emphasize enough how much I loathe vomiting.

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The Delightful Paradox

The decision to have a child was not a hard one for me. I love kids. I went into pediatrics because of the patients, not the medicine. But I have to admit, there was some serious trepidation on my part about having a second child. What would it do to my relationship with Grace? What would it mean for us as a family? Underlying it all, the nagging question: can I love two kids equally? Or would I then be splitting the love I have for Grace between two kids?

The answer to this is that I don't have to worry so much. There is a model readily established for dealing with dividing your love between two people... your first kid. Grace, too young to be stymied by logical arguments and mutual exclusivity, when professing her love for her parents will often say to me: "I love you better. I love Mommy the most." Yeah. I can't really say it much better than that, so thank you not-yet-four-year-old. I will always treasure Grace as my first child, the first one to evoke such deep rooted sensations of love and protection in me. I love Violet the same way, and yet differently. She didn't cause such a sea change in the makeup of our family as Grace did. But in her own way she has dramatically altered who we are as a family, and how I view myself as a dad. Now I am the father of kids, not just a kid. She looks (I think) more like me than Grace does. She sleeps differently, she babbles differently, and in many ways I have no idea yet what kind of little person she'll become. The excitement/uncertainty that was present with Grace is still very much there, I just have a bit more experience now.

So it's with this in mind that I have to approach the daunting task of preparing to adopt, which is how we've elected to expand our family to five. There is a whole new realm of murkiness and doubt in this. Will I be able to love my nonbiological child as much as my biological kids? Will I deal well with all the complexities and loss this child will face as he/she ages with me as a parent instead of the person who gave them life? Two worked out all right, but will I be able to split my love between three children?

But I know now that there is no splitting involved. The love you have for your kids is not a bag of candy, at constant risk of being emptied the more you dip into it. It's a living and growing thing, perhaps a fruit tree that's never out of season. And very large. And the fruit grows really fast. And you can't pick it all, because more will replace it. And... yeah, it's like that. I'm not so good at analogies. Maybe it's just a bettermost tree.

GraceCast #1 - Candy

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One Man and a baby

OK, toddler. Due to the recent sad events in Julia’s family, she’s off to be with her family for the weekend. This means it is Grace and me (and the dog) left to our own devices for two days.

So far things have been pretty good. When she woke up this morning to find that Mommy was gone there was a period of 10-15 minutes of pouting, not wanting to be in the same room as me, etc. We got over that pretty quickly though, and things have been pretty smooth since. We have come to terms with the fact that “Mommy on plane, see Nana and Granddaddy” although we’ll see how that goes tonight.

Lunch was a fun experience. Grace has been on quite the non-eating kick of late. We had a showing of the house at 11:00 this morning, so after some frantic house cleaning, bathing, snow shoveling and dog walking we jumped in the car to go to a local burger/hot dog joint. Two weekends ago the three of us went there to be out of the house when people came to see it, and at that point Grace was very into french fries. I thought perhaps I could capitalize on this to get her to eat something. It worked! Well, sort of. She greatly loved dipping french fries in ketchup. She also loved sucking the ketchup off of the fries. Eating the fries? Not so much. There were some solid (albeit not the most healthy) calories consumed though. Afterwards we got a cup of chocolate ice cream. Gracie devoured it. By which I mean she devoured it the way a glacier devours a mountain range. I might have saved us both some time and just acquired a milkshake. But, by the time she was done converting herself into a messy chocolate monster it was time for us to go back home, so I can’t complain.

Some other things I’ve learned this afternoon:

• Grace lies. She will tell you she wants to go upstairs and go night-night at nap time. Do not believe her.

• Grace hates Guitar Hero and Rock Band. I’m not sure why, but something about that guitar controller sets her off. Needless to say, I won’t be making much progress this weekend on either game.

• Grace has a renewed love with keys. Every infant loves to jingle them around. Now that she’s figured out what they’re for, she goes around sticking my keys into everything: door knobs, cabinet pulls, DVD players. Some of these tolerate unlocking better than others.

• Grace is a harsh music critic. Guitar Hero aside, she also makes amazing snap judgements on whatever music we’re playing on the stereo. Within about two notes on some songs she will loudly declare “no like song” followed imploringly by “diffint song”.

So far so good though. I may be singing a different tune if I can’t get her to bed until 10:30 or something, but I choose to be optimistic. Now I have to run, before Grace tries to unlock the dog or something.

Daddysitting

Tonight Julia is off doing grown up things, leaving me (however unwisely) in charge of the child.

6:30- We eat dinner. Sort of. By eat dinner I mean that I set food in front of Grace, which she plays with for awhile, but refuses to eat. This is par for the course. So far I am not a failure as a parent. We are however very excited by peas ("peez") and eat a few of them.

6:40- We go out to walk the dog, Grace strapped to my back in the Ergo. Grace is very helpful in holding the plastic bag should any business be taken care of by Abbey. ("Poo poo" is a favorite word. As I discovered last night it's exceptionally hilarious if you can get her to whisper it to you.)

6:47- We talk on a toy cell phone left by our babysitter. I am not sure what message this is sending our daughter. Grace clamps her finger in the clamshell halves. I kiss it, unsure of whether or not I am a failure yet or not.

6:50- Grace chases the dog ("Aaa") around and tries to hold the phone up to her massive doggy head. Dog is amazingly tolerant of this, but uninterested in talking on the beeping Minnie Mouse cell phone. I cannot blame her. Earlier finger trauma seems forgotten. My prospects of being a successful father are restored.

6:52- Grace holds on to a blanket and waves it frantically around while throwing little toy children up in the air. Soon this gives way to putting the blanket in my lap, pointing at it, and grunting incomprehensible baby noises. I am unclear on what I am meant to do.

7:01- Grace flaps her arms up and down as if a bird. Unable to fly she resorts to gathering toys and piling them up on the stairs. I throw the blanket over her head a great many times. It does not get old.

7:09- Grace attempts to type on this laptop. She is disturbingly proficient at using the mouse. Typing becomes difficult. Thankfully our attention span is very short and we go back to playing with foam block thingies.

7:14- We spend some quality time with said foam block thingies. They have cutouts in the center of them with various shapes. We try to put the shapes back into their proper squares. Grace masters ball, all else is up to me. Grace seems awed by my seemingly mystical ability to get a shape back into its square with one good push.

7:17- We put the foam squares back into the toybox.

7:19- We get the foam squares out of the toybox.

7:29- After making me put all the pieces in the squares we put the foam squares back in the toybox.

7:30- We get the foam squares out of the toybox.

7:37- Grace runs the foam inserts in and out of the kitchen. They seem to enjoy the tour.

7:39- Minnie Mouse is calling Grace again. I am allowed to browse the internet.

7:44- Browsing is over. My job of putting foam cutouts in their squares is needed.

7:48- Foam squares are put back in the toybox. I smell something fairly noxious.

7:49- Grace checks out clean in the diaper department. I narrow my eyes at the dog.

8:00- I ask Grace if she wants to go night-night. She repeats "night-night". I am not sure if she knows what she's saying. However, she then points up at the stairs, so I feel reassured.

9:15- I return downstairs. The last hour and 15 minutes have consisted primarily of me practicing for a job with the CIA. After torturing my own child by refusing to pick her up when she is in “I don’t want to sleep in my crib” distress for about an hour, I feel well equipped to waterboard terrorism suspects. How much harder can it be? Eventually Grace caves and falls asleep, I count it a small victory that she still wanted to be held by me until the bitter end, despite the fact that I was clearly a horrible and uncaring parent.

9:45ish- Julia returns. All is set back to right in the world. Until next time.