TAMPA — When the coach gathered his team around at halftime, he started with a question heard on football sidelines from peewee leagues to the pros. "Hit or be hit?" he asked. For the team of 9- and 10-year-olds, the answer was easy. "Hit!" they yelled back. Ask the same question on another Friday night 12 miles north, and the answer is different. Neither. The risk of concussions is too high. While the NFL has been battling high-profile lawsuits and headlines connecting football and concussions, youth leagues in the Tampa Bay area and across the country are left with their trickle-down effects. The increased attention shows up in Florida hospitals, which saw a 62 percent rise in children with football-related concussions from 2010-15. Hillsborough's hospitals lead the state; Pinellas ranks third. And it shows up on the field: Experts say the heightened awareness is one reason the number of kids playing tackle football has dipped 14 percent since 2005. Octavio Jones | Times Tackling in youth leagues has become more controversial since concussion awareness has become a national topic. Octavio Jones | Times Flag leagues for younger childen are gaining traction across the country as an alternative to tackle. In its place, flag football has grown as a viable alternative, if not replacement, before high school. One local league ballooned to 2,000 participants in its first year and a half. But tackle's supporters say the worries are overblown; thanks to more information on brain injuries and tackling techniques, they argue, the risks from contact are no greater than most other sports. The differing philosophies played out on Friday nights this spring, in leagues separated by more than the 20-minute drive. At Tampa's Skyway Park, boys as young as 7 slammed into each other in an evolving offshoot of the tradition-rich Tampa Bay Youth Football League. And at Carrollwood's North Lakes Park, children in neon cleats chased each other in flags, not pads, as participants in the country's fastest growing youth sport through the Under the Lights league. The concussion concerns might be most visible in the NFL, where highly paid professionals are old enough to weigh the risks and rewards. But far from that spotlight, almost 4 million children ages 6-14 and their parents are deciding how to balance the fun and fear that comes with playing America's favorite sport. Concussion 101 To see why the concussion cloud lingers over every field across the nation, you have to understand the two main concerns surrounding football and brain injuries: The long-term accumulation of many hits and the short-term effects of big ones that used to be dismissed as a ding or getting your bell rung. "We don't use those terms anymore," said Dr. Patrick Mularoni, a sports medicine physician at Johns Hopkins All Children's Hospital in St. Petersburg. "If you hear those words coming out of your mouth, put them back in … because that means concussion." And that means a traumatic brain injury, caused by the brain bouncing or twisting inside the skull. Some leave few, if any symptoms; only about 10 percent result in the loss of consciousness. Others are more serious, causing memory loss, headaches and cognitive issues that can keep children out of school for days. Cost of a concussion: In October 2015, Land O'Lakes High School defensive back Bryce Noble slammed heads with an opponent and was airlifted to Tampa General Hospital. Symptoms of the severe concussion lingered in the then-18-year-old. It took almost four months for the mood swings to stop and 16 to get his memory back to (almost) normal. Octavio Jones | Times Bryce Noble sustained a serious concussion during a Land O'Lakes High School football game in 2015. He missed three straight weeks of school, and it took him about four months before he felt normal again. Initial days of school missed: 15 Additional days missed (including partial days): 10-20 Days in the hospital: 3 Total cost: $100,000 Cost of helicopter not covered by insurance: $26,700 Doctor visits: 17 Physical therapy sessions: 10 Different medications taken: 6 Football isn't the only cause of concussions — soccer, cheerleading and skateboarding are culprits, too — but it's one of the biggest. Of the 200 suspected concussions Florida Hospital trainers reported in Pasco County's 13 public high schools in 2015-16, 60-70 came from football. From 2010 through 2015, Florida hospitals and emergency rooms saw more than 73,000 football-related injuries in children under age 19. Almost 5,100 (6.9 percent) were concussions, according to a Tampa Bay Times analysis of hospital intake data. The 1,014 concussions they reported in 2015 is up 62 percent since 2010. Football infirmary A look at the football-related injuries Florida hospitals and emergency rooms saw in children under age 19 in a six-year span: Category201020112012201320142015TotalChange 2010-2015 All football injuries 10,413 11,265 11,695 13,010 12,515 14,723 73,621 41.4% Flag 491 432 440 510 587 739 3,199 50.5% Tackle 9,922 10,833 11,255 12,500 11,928 13,984 70,422 40.9% Concussions that Florida hospitals and emergency rooms saw in children under age 19 in a six-year span: Category201020112012201320142015TotalChange 2010-2015 All concussions 626 795 816 986 868 1,014 5,105 62.0% flag 31 27 24 43 47 58 230 87.1% tackle 595 768 792 943 821 956 4,875 60.7% %all 6.01% 7.06% 6.98% 7.58% 6.94% 6.89% 6.93% null %flag 6.31% 6.25% 5.45% 8.43% 8.01% 7.85% 7.19% null %tackle 6.0% 7.1% 7% 7.5% 6.9% 6.8% 6.9% null Note: Participation numbers for youth leagues are not readily available, so it's unclear how many more kids compete in tackle vs. flag. No county saw more than Hillsborough's 452. Pinellas County (428) was third, behind Broward (429). Tampa Bay a concussion hot spot Hospital CountyCombined Concussions Hillsborough 452 Broward 429 Pinellas 428 Duval 414 Miami-Dade 349 Palm Beach 329 Orange 328 Polk 206 Brevard 185 Volusia 157 Manatee 141 Marion 133 Alachua 131 Collier 126 Escambia 121 Pasco 98 Santa Rosa 94 Seminole 84 Osceola 80 Leon 70 Sarasota 67 Charlotte 56 Martin 56 Hernando 54 But Mularoni said those figures are incomplete because most routine concussions don't require hospital screenings; children can be treated by pediatricians or sports medicine professionals. That means the real number is much larger. The biggest short-term danger comes from rushing back to the classroom or field before the brain heals. "That's what we don't want to happen in the immature brain," said Barbara Morris, the director of community wellness at Florida Hospital Wesley Chapel. That's because more stress from sports or schoolwork delays recovery and prevents symptoms from disappearing. Another hit to a still-injured brain may cause second-impact syndrome, a drastic swelling inside the skull that can be fatal. Multiple hits, including subconcussive ones, that add up over a career can be dangerous, too. The most publicized risk is chronic traumatic encephalopathy, a degenerative brain condition caused by excess protein in the brain. The disease, abbreviated as CTE, has been linked to dementia, mood swings, memory loss, depression, suicide. And football. Ex-NFL safety Andre Waters was diagnosed with it after killing himself on the back porch of his North Tampa home in 2006. So was former Tampa Bay Buccaneers lineman Tom McHale, who was found dead of a drug overdose at a Wesley Chapel apartment in 2008. Boston University researchers have posthumously examined the brains of 94 former NFL players; they have found CTE in 90 of them. "I think the concussion issue is probably the most serious issue we've faced in sports in my lifetime. …" said University of Central Florida professor Richard Lapchick, who has studied sports for more than three decades. "The evidence is so compelling out there and across the board that you would have to live under a shell not to know how serious it is." Researchers are still trying to learn the scope of CTE: How many former players are affected? How dangerous are the small hits that happen on almost every snap? What other factors cause some players to spiral out of control while others seem unaffected? But preliminary findings suggest the damage might start in youth football. Another Boston University brain study of living NFL alumni found that players who began tackling before age 12 had more memory and thinking difficulties than those who waited until they were teenagers. The Mayo Clinic's Jacksonville brain bank saw evidence of CTE in 32 percent of males who played contact sports as children or young adults. None of the other 198 brains it examined showed signs of the disease. The science, however, is not yet settled. That's why Mularoni — who has seen 3,000 concussions in his career — says he isn't afraid of football. His son will begin tackling with the Northeast Bandits at age 7 next fall. Case for flag Spend an evening on the sidelines at North Lakes Park, and you'll meet plenty of parents like Tampa's Hosie Grimsley. His 9-year-old son, Gabriel, has spent two years begging to play football, like NFL superstar Odell Beckham Jr. His parents kept saying no, because of the risk of concussions. They finally relented this spring to let Gabriel play for the Buckeyes in the Under the Lights flag league. "It's a compromise," his dad said. Octavio Jones | Times Hosie Grimsley, right, watches his son, 9-year-old Gabriel, play football with his oldest, Hollis, left, during the Under the Lights flag football league at North Lakes Park in Tampa.Park in Tampa. And it's one that's becoming more common. Although half a million more children ages 6-14 played tackle football than flag in 2015, the gap is shrinking. The number of kids in flag football jumped 8.7 percent from 2014-15, according to the Physical Activity Council's annual participation report. That's a higher increase than softball, soccer, baseball or basketball. And it cuts against the slide in youth tackle football. From 2005-15, the number of children ages 7-17 who played the traditional game dropped from 5.1 million to 4.4 million, according to the National Sporting Goods Association. "Today's parents are very concerned about the safety and the head injuries that are occurring in physical sports like football…" said John Kaleo, who runs Under the Lights. "There's a large group of kids that still want to play football, but they're hesitant to put a helmet and shoulder pads on." And there's a large group of parents that are hesitant to let them. Lutz mother Tennille Alvarado wants her 8-year-old son to have fun, get exercise and learn life lessons like teamwork and leadership. "This is for fun," Alvarado said as her son, Aidan, warmed up in Carrollwood. "Why put him at risk for something that's not that serious?" Octavio Jones | Times Team Clemson defender Aidan Alvarado, 9, left, watches Team Ohio State wide receiver Gabriel Grimsley, 9, center, catch a pass while playing in the Under the Lights flag football league at North Lakes Park in Tampa. As a Tampa-based private quarterback coach, Kaleo didn't want to lose children like Aidan to soccer or baseball. So the former University of Maryland and Tampa Bay Storm quarterback decided to experiment with Under the Lights in 2014. Kaleo wanted the game to be part of the sport's natural progression, so he modeled its rules after the 7-on-7 format high schools use in the offseason. Players run everything from trendy jet sweeps and bubble screens to the century-old Statue of Liberty play. Some teams use wristbands to keep track of their sophisticated plays and fakes. When Kaleo's first local league attracted 400 children from kindergarten through middle school, he knew he was onto something. Three years later, Under the Lights has a major sponsor (Under Armour). More than 7,000 children have participated in its 10 local sites, from St. Petersburg to Land O'Lakes. Case for tackle Spend an evening on the sidelines at Skyway Park, and you'll meet plenty of parents like Tampa's Girard Pringle. His 10-year-old son, Girard Jr., has been playing football since he was 5. It's not that Pringle and other parents at the Tampa Bay Youth Football League's spring offshoot aren't worried about concussions. They are. But they also believe coaches and leagues are addressing the danger through rule changes, awareness and technology, to make it as safe as soccer or lacrosse. "If you play the game with fear," Pringle said, "you might as well not play." But 3,000 do play each fall in the TBYFL — a number that has held steady despite the national trend. Its spring league had more than 50 teams. Although it promises to let children "play the game the way it was meant to be played," the league has changed drastically since president Scott Levinson played in it 45 years ago. "Over the years you come up with rules…" Levinson said. "My job is to make it as safe as we can." Octavio Jones | Times Leonard Long Jr., an assistant coach for the Pinellas Park Hawks, talks to his players during a timeout in the Tampa Bay Extreme football league at Skyway Park in Tampa. Each age group has weight limits to protect smaller players. Centers can't be hit until they're ready to defend themselves. A paramedic or trauma nurse is on the sidelines for every fall game — a luxury many high school programs can't offer. Dark helmet visors are banned because they prevent medical professionals or coaches from checking on players quickly. Its six-game spring league is a slimmed-down version designed to let newcomers try the sport or returners experiment with a new position. The 20-minute halves feature a running clock and no special teams to limit contact. The old tackling mantra — Get your hat on the ball — is gone. Levinson looked into USA Football's Heads Up Football, a method backed by the NFL. He rejected it, in part because of a lack of evidence to support its safety claims. His league, which reports about two diagnosed concussions each fall, prefers another tackling trend used by Plant High School and popularized by the Seattle Seahawks: Rugby tackling. Instead of keeping their heads up, tacklers get it out of the play altogether by leading with the shoulder, wrapping their arms around their opponents' legs and rolling to the ground. "Get your head out of the tackle," Levinson said. "Don't look at the ground." Octavio Jones | Times A Progress Village Panther is tackled by Pinellas Park Hawks defenders in the Tampa Bay Extreme football league this spring. There's not yet enough data to draw conclusions about how much rugby tackling limits concussions in football, or if they increase the likelihood of severe neck injuries. But Pasco High School coach Tom McHugh has seen a substantial drop in head injuries since he began teaching it two years ago. "I'm sure you're still going to get some helmet to helmet (hits)," said McHugh, a former youth league official. "But at least we're doing something proactive to stop it from happening." When those hits do happen, they take place within the context of greater concussion awareness. Medical professionals help the brain heal by easing children back to school, a class or two at a time. Kids receive extra accommodations, like shorter tests or help with note-taking, until their recovery is complete. In 2012, Florida passed a law requiring youth leagues to educate coaches, parents and athletes about concussions. A player with a suspected head injury must be immediately removed from the game and can't return without medical clearance. In Levinson's league, injured children must sit out at least five plays to be evaluated. Any coach who breaks that rule is suspended. But those steps focus on the short-term concerns. What about the accumulation of hits — concussive or subconcussive — believed to cause CTE? "I don't think anyone has a real handle on it yet," Levinson said. Search for middle ground After Tom McHale's death and CTE diagnosis, his widow, Lisa McHale, joined the Concussion Legacy Foundation as its director of family relations to educate other parents. "I want moms to know what I know," McHale said. And here's what McHale knows: There are easy ways to fix youth football. Every parent and coach should know the symptoms of a concussion — headache, nausea, vision/balance problems and sensitivity to light or sound. They should know to check on any child who takes a hard hit, just to make sure he seems fine. They should also know the risks of multiple hits, including the ones that happen on almost every snap. "They need to look at common-sense ways that we can reduce the cumulative trauma," McHale said. "Instead we're going in the opposite direction…" While the NFL, NCAA and almost every state high school association (including Florida's) have addressed the risk of repetitive head trauma by reducing contact, youth football has lagged behind, said Terry O'Neil, a former New Orleans Saints executive who promotes youth football safety. Some peewee leagues allow more full-contact practices than the NFL. Children can play in multiple leagues each year, not including full-contact camps like the four-day Offense-Defense Football Camp coming to USF in July. With at least one local league beginning tackling at age 5, children can hit and be hit for nine years before high school. Octavio Jones | Times Former NFL player Fred Flowers, left, and Jimmy Holmes coach campers how to prepare for a play on the scrimmage line during the Offense-Defense Camp held last summer at the University of Central Florida. "Players that need the most protection are the youngest ones," O'Neil said, "and they're getting the least protection." The solution, according to O'Neil and McHale, is to focus on flag football until high school. Although former Bucs offensive tackle Rob Taylor thinks NFL rule changes have made the league soft, he embraces the safety with children — including keeping his youngest son in flag until high school. Taylor told the kids he coached in Exciting Idlewild Baptist Church's flag league that the skills they learn translate well to tackle, if they choose to play it later. Running, catching and eye contact are all the same. The techniques to defend the pass and pursue the ball carrier are similar, too. "You do everything," said Taylor, who played for the Bucs from 1986-93. "You just don't deliver the blow." Levinson believes flag has its role in the sport and the Tampa Bay Youth Football League. His youngest group (age 4-6) uses it as an introduction to the game. But Levinson doesn't see it as a replacement for tackle. Some of his belief comes from safety. The force in blocks and tackles in the youngest age groups is small — more like bumper cars with low speeds and light bodies. But when players bend to pull a flag, they expose their heads to shots from others' knees or hips. Levinson points to a study published earlier this year by the University of Iowa. It monitored injuries in three youth leagues and saw no significant differences between the frequency of concussions in tackle and flag. Octavio Jones | Times Team Ohio State wide receiver Gabriel Grimsley, 9, left, anticipates the snap while playing in the Under the Lights flag football league at North Lakes Park in Tampa. In Florida, hospitals saw 4,875 children with tackle football-related concussions and 230 from flag football from 2010-15. But it's hard to compare the statistics directly because the state's youth participation numbers are not readily available. Some of Levinson's belief is philosophical. Working with 10 other teammates teaches the value of cooperation. By literally falling to the ground, children learn how to pick themselves back up. "If you're playing a game of H-O-R-S-E or 21 in basketball, you are nowhere near as intense as you are if you were playing a game of 5-on-5," Levinson said. "I believe it requires much more intense teamwork. I believe it requires much more trust…" Under the Lights' Kaleo used to feel the same way. He considered himself a football traditionalist. But the trends and conversations with uneasy parents convinced Kaleo that he was wrong. The concussion era is forcing football to change, at all levels. He had to change, too. "I've evolved," Kaleo said, "because today's society has forced me to evolve." Times staff writer Connie Humburg and correspondent Kelly Parsons contributed to this report. Contact Matt Baker at [email protected] Follow @MBakerTBTimes.