IT takes courage to play football. Sometimes it takes more to walk away from the game, especially for a teenager.

Kevin (not his real name) had played organized tackle football in Hawaii for several years, working his way up to a starting position on his high school team. His father — who played all through school himself — is proud of Kevin’s progress.

But Kevin’s father presented him with information prompting a difficult and important decision. Kevin will no longer play football, because of the possibility of brain injury and potential long-term effects of concussions.

"I made him read a Time magazine article and watch an HBO special," said Kevin’s father, who had several football concussions himself. "We spoke about it at length. Some of my concern is the disparity in size of players in high school these days. And I have a big problem with the way the game is coached, such as leading with the head.

"I sat down and asked myself, ‘Why do I want my son to play football?’ I believe in the virtues of football, but I realized he could get those virtues elsewhere. I realized I wanted him to play because I want to watch him play. And that’s not a good enough reason.

"But it was ultimately his choice."

Kevin learned about the possible results of multiple concussions, including dementia pugilistica ("punch drunk" syndrome associated with boxers with symptoms including memory, speech and mental processing problems), clinical depression and Alzheimer’s disease.

Said Kevin: "It was not easy to decide, but I know it’s best for my future."

WITH FOOTBALL SEASON approaching, the issue of concussions comes to the forefront again — with unprecedented concern at all levels of the game.

Shortened football careers and health problems due to hits to the head are not new; 49ers quarterback Steve Young, Cowboys quarterback Troy Aikman and Steelers running back Merril Hoge are among the most famous of many NFL players who retired early because of concussions. But as more conclusive medical information becomes available and awareness increases, this scenario may replay itself often.

Awareness, though, can also lead to more accurate diagnoses of concussions and players not returning to the field sooner than they should, improving safety and prolonging careers.

The Hawaii Athletic Trainers Association held a symposium in June to educate athletes, parents, coaches and officials about concussion diagnosis and treatment. Part of HATA’s focus is eliminating conflicts about when it is safe for an athlete to return to play.

HATA’s effort dovetails with similar emphasis by the National Federation of High Schools (NFHS), the NCAA and the NFL.

"It’s becoming a political issue," said Dr. Michael Koester of the NFHS. "The NFL, NCAA and NFHS all testified before Congress. (NFL commissioner) Roger Goodell got smacked around. NFHS? We came out pretty good because we’ve been proactive."

Laws regarding concussions have been enacted or are pending in 22 states. Hawaii is not among them.

The NFHS has guidelines, but "we can’t tell the states what to do," Koester said.

Ross Oshiro is the athletic health care specialist coordinator for the state Department of Education. He said there are advantages to a law requiring concussion education for all involved in organized sports.

"If the law is written correctly to address all participants in sports, not just football, and addresses athletes, parents, coaches, athletic youth associations, educators, athletic administrators, physicians and athletic trainers, then everyone would be on the same page as to what a concussion is and how to manage one," he said. "Addressing only interscholastic athletics is too narrow, we have thousands of young athletes participating in youth football, soccer, martial arts, baseball, basketball (and other sports).

"Educating our coaches about current concussion management prior to the start of the season is essential to reducing conflicts," he added.

Oshiro said 320 concussions were reported by Hawaii high school students while participating in sports during the 2007-2008 school year, representing 6.07 percent of all student-athletes. Football players were 83 percent of the 320.

But it is impossible to quantify how many concussions went undiagnosed and unreported.

"A lot of it is kids don’t know they got a concussion, parents don’t know," Oshiro said. "Education is a big thing."

Chris Chun, the executive director of the Hawaii High School Athletic Association, said he will be meeting with Oshiro within the next few days and a committee will be formed to adopt guidelines.

"We are a little different than most states because every school has an athletic trainer," Chun said. "I believe only Hawaii and the District of Columbia have athletic trainers at every state (or district) tournament event."

CONFLICTS OFTEN ARISE between coaches and trainers or other medical personnel in deciding if a player should leave a game or practice, and when players should return. Game officials can get caught in the middle, too.

"If an athlete shows any signs or symptoms of concussion, he or she should be pulled, not to return that day," Oshiro said.

It’s not always easy, and medical personnel must often make tough decisions. Sometimes they have to stand up against powerful coaches and popular players.

Dr. Andrew Nichols, the University of Hawaii football team physician, found himself in such a position in 2007.

Nichols declined comment when asked if quarterback Colt Brennan was medically cleared to play the week following a concussion during UH’s undefeated season. Brennan played against Nevada (just a few snaps, where there was almost zero chance of contact) six days after he lost consciousness after a head-to-head hit and suffered a concussion.

"Generally a week is enough for a football player," Nichols said. "But of course you never want to push that along."

Last April the NCAA mandated that member schools have a concussion management plan. At UH, Nichols has produced a plan that is in the final stages of approval.

"There have been concussions forever, and treatment forever," Nichols said. "Back (in the 1980s) the treatment was nearly identical: Be very conservative when symptoms arise."

Highlights from the proposed policies for UH include making sure athletes understand risks and report symptoms, that trainers and other medical staff make ultimate decisions on return-to-play, education for coaches, and baseline assessments to facilitate diagnosis.

"And some specific no-nos," Nichols said. "If you have symptoms you shouldn’t play. It sounds pretty obvious, doesn’t it?"

High school and college athletes may be more susceptible than adults to devastating brain injuries due to a rare condition called second-impact syndrome — when a second concussion occurs before symptoms of a prior one have subsided. It causes severe swelling of the brain, and can be fatal.

Other more common symptoms plague many football players of all ages, but doctors are still studying long-term effects. Many aging former NFL players suffer dementia, Parkinson’s and early Alzheimer’s.

Bengals receiver Chris Henry died last year at age 26. Researchers discovered he had chronic traumatic encephalopathy (CTE), a form of degenerative brain damage caused by multiple hits to the head. Henry’s youth, and the fact that he played a position that produces less contact than most, raised more alarm.

The NFL has started an awareness campaign of its own, including posters in locker rooms warning players.

There is some talk that football could fundamentally change because of the danger of concussions. Hits leading with the head is again a point-of-emphasis for college officials this year. It has also been proposed that linemen not be allowed to use a 3-point stance, with the result being less head-to-head contact.

It’s almost impossible to find a former NFL player who didn’t have at least one concussion — even if at the time they didn’t know that’s what it was.

"I got knocked out in a Monday Night game. It took two broken ammonia capsules to get me up," said former UH assistant coach Dennis McKnight, who played 10 seasons in the NFL. "They didn’t call it a concussion then. They called it getting your bell rung."

Linnea Garcia-Tatupu, who was the wife of Punahou sports legend and 15-year NFL player Mosi Tatupu, said she thinks concussions may have contributed to his death in February at age 54.

"After his first game as a pro we went out to dinner, and he had to go outside and throw up," she said. "It had nothing to do with the food or anything like that. My father, who was a career Marine, he knew exactly what it was. He told him he had a concussion. And I know he had more than that one."

Kevin’s father played high school football in the 1970s.

"I don’t ever recall ever being told not to lead with the head. I do recall techniques to deliver blows to the head. It was implicit you would lead with your head a lot," he said. "Battle paint (from opposing helmets) was revered. Gouges were even better."

Helmet design won’t eliminate brain injuries, Koester said.

"Nobody’s designed the perfect helmet and no one will," he said. "They’re not to prevent concussions, they’re to prevent skull fractures."

Trainers and other medical personnel agree education and awareness buttressed by legislation can help keep football players healthy — that, and the willingness to use their heads by not using their heads.

"Having a concussion was like a badge of courage," Nichols said. "Guys say proudly, ‘I played with a headache all the time.’"