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‘‘He went down like a shot,” Mulholland said. ‘‘When I saw him get hit on the temple, I knew that it would be bad, but when he went down like that, I was nervous. He didn’t go completely out, but he was definitely not all there.”

In fact, Bieber suffered what his neurologist diagnosed as a severe concussion. He was taken from the field to the hospital, and to this day has no recollection of the collision or the events immediately after it.

‘‘I haven’t looked at the game tape. I only know what happened from what people have told me and I don’t really remember anything about that day at all now,” Bieber said. ‘‘The first memories I have are of the nurse coming into my room the next morning.”

Bieber’s concussion was so significant that he had trouble sleeping and reported headaches for three weeks after the impact. His optic nerves were bruised, causing him to have double-vision for two weeks, and the injury forced him to miss the rest of the season.

Concussions of that severity are considered ‘‘catastrophic” and are rare. According to Dr. Barry P. Boden, an orthopaedic surgeon at Shady Grove Adventist Hospital in Rockville, the incidences of severe catastrophic head injuries among high school football players were 0.67 injuries per 100,000, a number significantly smaller than dying in a plane crash (1 in 20,000) and on par with dying in an earthquake (1 in 131,000). But, Boden found that the incidences of high school football players suffering concussions, almost always less severe than Bieber’s, are not isolated events.

In a study published in the July issue of the American Journal of Sports Medicine, Boden identified concussions as a serious risk in high school football players, because according to researchers, players sustaining minor concussions may be more susceptible to multiple and potentially more serious ones later.

‘‘High school football players have more than three times the risk of catastrophic head injury than their college peers,” Boden said. ‘‘This may indicate that the younger brain is more susceptible to brain injury.”

But what may also be a factor, at least according to some research and some coaches, is a lack of experience with the game and skill in its fundamentals. Mulholland, as well other coaches in the county, emphasizes proper tackling technique. But players also need to inform coaches of any symptoms that may require attention, such as dizziness or headache.

‘‘Football is a macho sport,” Boden said. ‘‘Athletes are taught to play through pain. But concussions are not like fractures. They range in severity and symptoms so all a player might experience is a headache several hours after impact. They need to be educated on the symptoms and self-report. If they are feeling headaches or nausea or dizziness, they should not go back to the field.”

A study in prevention

In conjunction with the National Center for Catastrophic Sports Injury Research at the University of North Carolina, Boden studied 94 cases of severe football head injuries, like Bieber’s, reported during the 13 football seasons between 1989 and 2002.

While researchers found 0.67 severe head injuries per 100,000 players in high school, at the college level that number dropped to .21 per 100,000 players.

‘‘You definitely see [concussions] more at the high school level,” Mulholland said. ‘‘I’m taking an educated guess, but I think it is because the fundamentals are not here yet. At the college level, even in Division III where I coached, all the players know how to tackle correctly.

‘‘In high school, you have kids that will go flying into the play without knowing what they are doing, and that can be like running into a wall.”

According to a report by Michael P. McClincy of the University of Pittsburgh Medical Center that appeared in the January 2006 issue of the medical journal Brain Injury, more than 62,000 high school football players suffer a mild traumatic brain injury, such as a grade 1, or mild, concussion each year. Concussions that share Bieber’s symptoms are considered a grade 3, or the most severe, concussion, and again are very rare.

McClincy studied the results of 104 high school football players from around the country, using a computerized cognitive testing program, called ImPACT, to get baseline neuropsychological readings at the start of the season then compared those results to the readings after an athlete sustained a concussion.

What he found was that in many of the athletes, cognitive abilities — such as processing speed, reaction time and verbal and visual memory — remained impaired as many as 14 days after sustaining the injury.

That’s longer than the typical amount of time a player may miss after sustaining a mild concussion, which may vary from the remainder of a game to a week.

Looking at Boden’s study, the danger of going back on the field after suffering even a mild brain injury can be serious. He found that 59 percent of players who sustained catastrophic injuries in his study had a history of previous head injury.

‘‘We’re finding that the younger you are, the longer it takes to recover,” Boden said. ‘‘It is possible that if you go out and play too soon, the chances increase for a catastrophic injury.”

Heart versus head

In a scrimmage at the end of August, Kennedy High’s Melvin Harris, who often plays quarterback, lined up as a wide receiver. As he gathered a pass over the middle, he was hit twice. The first shot grazed Harris, but spun him into the onrushing safety, who delivered a hard hit that knocked Harris to the ground.

Even though he was sent reeling, and lay on the turf in pain, Harris, The 2006 Gazette Player of the Year, stayed in the game.

‘‘For about 20 seconds I did not know where I was,” he said. ‘‘When you get hit like that it is a straight shock and it’ll test your heart. But, if your heart is big enough, you’ll get back up.”

Yet, what can often be difficult for a coach is how to recognize when the effect of a collision is not just a matter of ‘‘heart” but also the cause of a concussion.

Damascus High coach Dan Makosy, who has built a perennial state championship contender on the foundation of a bruising, physical ground attack, often relies on his previous experience to determine the severity of a collision.

‘‘When a player gets hit on the side of the head, that is usually the knockout blow,” he said. ‘‘You can tell right away when they get up. But, our school has certified medical trainers at every game, and as soon as something like that happens, we leave it in their hands.”

In fact, the Montgomery County Public Schools has trained emergency medical technicians or paramedics at every varsity and junior-varsity football game. In addition, coaches are required to be certified in first aid and are licensed in CPR and the use of a defibrillator.

According to Dr. William G. Beattie, MCPS director of athletics, learning, diagnosing and limiting the lingering effects of concussions is a top priority.

‘‘We have made available to schools a DVD about reducing the risk of concussions, and last year we had a pilot program at Blake High where athletes underwent baseline [cognitive] testing [using the ImPACT program] so that there was a record to determine the severity of a concussion,” he said. ‘‘While the schools make their own decisions about equipment, all the helmets that we have on the bid list are the safest that you can get.”

Wootton High recently held a fundraiser to buy new ‘‘concussion-proof” helmets, which have padding along the side of the face and jaw to protect against blows to the side of the head. Damascus and Kennedy have players that use those helmets, while other schools, like Walter Johnson, use helmets that offer similar padding.

‘‘I’d love to discover a helmet that can fix this, but I am not sure that it is out there,” Boden said. ‘‘Rules need to be enforced. Players should be discouraged from head-to-head tackling, or what is called spear tackling. And, it’s tough because it puts the burden on the coach, but they have to play a proactive role.”

A tough decision

In Bieber’s case, as this football season approached, he was still feeling the lingering effects of his concussion. Though his double-vision had abated — he no longer had to have his mother, Sarah, read his class notes back to him — he still suffered from short-term memory loss. And, as he found at his homecoming dance, even brief exposure to flashing lights like strobe lights gives him a headache. His neurologist advised him not to play football, and he reluctantly agreed.

‘‘To be honest, it’s pretty awful to be on the sidelines,” Bieber said of missing his senior season. ‘‘Even though we’re at Walter Johnson and we lose all the time — not just lose, we get crushed — you want to be on the field with the guys. You want to feel it with them to help them through it.”

Though he lost a starting player on a team that is undermanned, Mulholland not only agreed with the decision, he was one of the voices discouraging Bieber to play.

‘‘I know that it was killing him,” Mulholland said. ‘‘Back in the day, we used to call what happened to him ‘getting your bell rung,’ but as a coach, you start to notice that once it happens, the same guys start getting their bell rung over and over. It was more important that he get healthy and remain healthy for the rest of his life.”