Interassociation Recommendations for Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns at the Secondary School Level: A Consensus Statement

During the 2012–2013 academic year, 7.7 million secondary school students took part in organized interscholastic sports, compared with just 4 million participants during the 1971–1972 year.1 Many student-athletes define themselves by their identities as athletes.2 Threats to that identity may come in the form of struggling performance; a chronic, career-ending, or time-loss injury; conflicts with coaches and teammates; or simply losing the passion for playing their sport.3–5 These challenges and associated factors may put the student-athlete in a position to experience a psychological concern or to exacerbate an existing mental health concern.2The types, severities, and percentages of mental illnesses are growing in young adults aged 18 to 25 years, an age group a little older than secondary school student-athletes.6 Given that mental illnesses being reported in the 18- to 25-year-old age group may well start before or during adolescence and given the overall numbers of student-athletes at the secondary school level, clinicians are certain to encounter student-athletes with psychological concerns. The goal of this consensus statement is to provide recommendations for developing a plan to address the psychological concerns of student-athletes at the secondary school level. The recommendations will discuss education on mental disorders in young adults, stressors unique to being a student-athlete at the secondary school level, recognition of behaviors to monitor, special circumstances faced by student-athletes that may affect their psychological health, collaborating with secondary school professionals to assist student-athletes with psychological concerns, and legal considerations. Also addressed are educational efforts for student-athletes, coaches, and parents, as well as practical steps to consider when proposing a psychological-concerns plan to administration. The interassociation work group that developed these recommendations included representatives from 8 national organizations and an attorney experienced in sports medicine and health-related litigation; all members had a special interest in and experience with psychological concerns in student-athletes. This multidisciplinary group of professionals included experts in athletic training, general medicine, psychology, psychiatry, pediatrics, secondary school counseling, sport psychology, critical-incident stress management, and law.Recommendations of the consensus statement are directed at the athletic health care team, athletic department administration and staff, and secondary school administration. This includes athletic trainers (ATs); team physicians; coaches; athletic department administrators; administrators such as principals and superintendents; secondary school nurses; and secondary school counselors. It is imperative to remember that the student-athlete is first and foremost a student of the school district and in most cases a minor child; therefore, collaboration with secondary school departments is a must.Two points about this consensus statement are critical. First, the terms psychological concern and mental disorder are used instead of mental illness because only credentialed mental health care professionals have the legal authority to diagnose a mental illness. Suspecting a mental illness in a student-athlete that affects the student-athlete's psychological health is a concern that noncredentialed mental health care professionals have. Thus, we selected psychological concerns for the title, although that term and mental disorder are interchangeable within the statement. Second, only credentialed, licensed mental health care professionals are to legally evaluate, diagnose, treat, and classify a student-athlete with a mental illness. The credentialed mental health care professional should perform that medical-legal duty and not a noncredentialed individual, no matter how caring that person may be. This consensus statement was produced to inform ATs about developing a plan to recognize potential psychological concerns in secondary school student-athletes and to establish an effective mechanism for referring the student-athlete into the mental health care system for assessment and treatment by a credentialed mental health care professional. This consensus statement does not make recommendations regarding mental illness evaluation or care. Rather, our intent was to assist the AT, in collaboration with the athletic department and secondary school administration, in facilitating the evaluation and care of the student-athlete suspected of a psychological concern by credentialed mental health care professionals. Throughout this statement, the terms psychological and mental are used; various authors in both the text and in literature citations chose to use one or the other. Although the terms are synonymous, the focus of the statement is recognition and referral, not treatment; treatment is left to the credentialed mental health care professional. Additionally, in this statement, the term secondary school is interchangeable with high school as found in the literature.This statement mirrors the 2013 document "Interassociation Recommendations for Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns at the Collegiate Level: An Executive Summary of a Consensus Statement."2 That statement was designed for use by the AT practicing at the intercollegiate level. The current statement is designed for use by ATs practicing at the secondary school level, or in the absence of an AT at a particular secondary school, administrators may use this statement to develop a plan to address their student-athletes' psychological concerns. Ideally, a certified AT will help to develop and implement the recommendations of this consensus statement. The information contained in the collegiate and high school statements is similar but is targeted for each audience, and each statement is to be regarded as a stand-alone document for the indicated setting.The purpose of this consensus statement is for the reader to take the information provided and develop an appropriate plan for his or her institution to address the psychological concerns of student-athletes as part of a comprehensive sports medicine health care program. Specific goals of the statement are toThis consensus statement is organized as follows:The recommendations in this consensus statement use the Strength of Recommendation Taxonomy (SORT) criterion scale proposed by the American Academy of Family Physicians,7 which are based on the highest quality of evidence available. Each letter designation characterizes the quality, quantity, and consistency of evidence in the available literature to support a recommendation.Although this consensus statement uses SORT level C evidence for best practices, the educational component of mental illness in young adults is based on SORT level A evidence.Category: ACategory: ACategories: B, CCategories: A, BCategories: B, CCategory: CSimilar to physical injuries, psychological concerns can range from mild to severe, with varying effects on the life of the adolescent. In addition, some of these conditions can be lifelong, whereas others may be short-lived. Normal adolescence is a period of great change and maturation, during which emotional and behavioral difficulties are commonplace; however, the incidence of diagnosed mental health conditions remains consistent across studies, and psychological concerns must be appropriately recognized and treated.In 2001, the US Surgeon General10 defined mental health as "the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity." Approximately 1 in every 4 to 5 youths in this country experiences impairment during his or her lifetime as a result of a mental health disorder.11 The prevalence of many emotional and behavioral disorders in children and adolescents is higher than that of some well-known physical ailments, such as asthma and diabetes.11The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),8 states that "a mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning." The definition8 further states that mental disorders are "usually associated with significant distress or disability in social, occupational, or other important activities." It is important to note that classifying a mental disorder only describes the mental disorder an individual has; it does not describe the individual.8 Thus, labeling a student-athlete as a "maniac" or a "druggie" further stigmatizes individuals with mental disorders. The diagnosis of a mental disorder should also have clinical utility, meaning it should assist clinicians in determining the treatment plan and prognosis for the patient. Having the diagnosis of a mental disorder is not equivalent to needing treatment.8Most DSM-5 disorders have a numeric International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code, and the DSM-5 disorders are grouped into 22 major diagnostic classes, categorizing hundreds of mental disorders.8 The DSM-5 diagnosis is applied to an individual's current presentation, not to a previous diagnosis.8 It is imperative that the DSM-5 not be applied by untrained individuals. Only those with appropriate clinical training and diagnostic skills may diagnose an individual with a mental disorder. The criteria in the DSM-5 serve as a guideline for the mental health care professional to form a clinical judgment and are not merely a recipe to follow.8In a recent study, nearly 1 in 3 adolescents (31.9%) met the criteria for anxiety disorder, 19.1% were affected by behavioral disorders, 14.3% experienced mood disorders, and 11.4% had substance-use disorders.11 The early onset of major classes of mental disorders has been documented.6 Of the affected adolescents,11 half experienced symptoms of their anxiety disorder by age 6, of their behavioral disorder by age 11, of their mood disorder by age 13, and of their substance-use disorder by age 15. Comorbidity rates of affected individuals have been reported at 40%, and 22.2% described having a mental disorder with severe impairment or distress that interfered with daily life.11The average age of onset for major depression and dysthymia is between 11 and 14 years of age.12 The rate of outpatient treatment for depression13 increased markedly in the United States between 1987 and 1997, with 75.3% of those individuals being treated with antidepressant medication in 2007.The US Substance Abuse and Mental Health Services Administration6 reported in 2012 that 45.9 million American adults aged 18 or older, 20% of the survey population, experienced a mental illness in 2010. Of those aged 12 to 17 years, 8% (1.9 million) had experienced a major depressive episode in 2010, which was defined as having a depressed mood or loss of interest in daily activities that lasted at least 2 weeks.6Most seriously impairing and persistent mental disorders found in adults are associated with onset during childhood or adolescence and have high comorbidity.14 Of adolescents aged 13 to 17 years who had experienced childhood adversity (ie, parental loss, parental maltreatment, parental maladjustment, or economic hardship), 58.3% reported at least 1 childhood adversity and 59.7% reported multiple childhood adversities; childhood adversities were strongly associated with the onset of psychiatric disorders. The prevalence ranged from 15.7% with fear disorders to 40.7% with behavioral disorders. A total of 28.2% of all onsets of psychiatric disorders were associated with 1 or more childhood adversities.15 Disorder onset was somewhat predictable and provides clues to the best times for intervention. The median age of disorder onset was 6 years for anxiety, 11 years for behavior, 13 years for mood, and 15 years for substance use.16Epidemiologic surveys estimate that as many as 30% of the adult population in the United States meet the criteria for a year-long DSM mental disorder.17,18 Fewer than half of individuals diagnosed with a mental disorder receive treatment.19,20 Mental disorders are widespread, with serious cases concentrated in a relatively small proportion of patients with high comorbidity.21Anxiety disorders are reported often in mental-disorder surveys21 and appear to exact significant and independent tolls on health-related quality of life.22Mental health care professionals are discovering more information on various mental health disorders. For example, intermittent explosive disorder is much more common than previously recognized.23 The typical onset is at age 14 years, with significant comorbidity of mental disorders that have later ages of onset. Only 28.8% of patients ever received treatment for their anger.23Anxiety disorders, such as panic disorders and social phobia, were the most common conditions, affecting 31.9% of teens. Next were behavioral disorders, including ADHD, which affect 19.1% of teens. Mood disorders, including major depressive disorder, were third at 14.3% and substance-use disorders were fourth at 11.4%.2 Comorbidity is also a significant concern within this age group, given that nearly 40% of patients with 1 class of disorder also met the criteria for a second class of disorder at some point in their lives.In a landmark study funded by the National Institute of Mental Health, the prevalence of a broad range of mental disorders in a nationally representative sample of US adolescents was examined. Participants in the National Comorbidity Survey Replication–Adolescent Supplement consisted of youths aged 13 to 18 years. One in 10 children had a serious emotional disturbance that interfered with daily activities. In addition, few affected youths received adequate mental health care. Mood disorders affected 14.3% of teens, including twice as many girls as boys. The prevalence of these disorders increased with age: a nearly 2-fold increase between age 13 to 14 years and age 17 to 18 years. One in 3 adolescents (31.9%) met the criteria for an anxiety disorder, ranging from 2.2% for generalized anxiety disorder to 19.3% for a specific phobia. These disorders are more common in girls.11Concerns about adolescent mental health are shared by many countries. In a review24 of community survey studies from around the world, approximately one-fourth of youths experienced a mental disorder during the past year and about one-third did so across their lifetimes.The incidence of depression increases with age. It is 1% to 2% at age 13, climbs to 3% to 7% at age 15, and continues to increase throughout early adulthood. Results are mixed when it comes to the effects of social class, race, and ethnicity.11 Although rare in children, the prevalence of bipolar disorder (mania and hypomania) ranges from 0% to 0.9% in those aged 14 to 18 and from 0% to 2.1% over a lifetime. As far as comorbidity, both major depressive disorder and bipolar disorder are associated with multiple other conditions, including ADHD, anxiety disorder, oppositional defiant disorder, and conduct disorder.25,26 Half of all adult mental disorders have their onset during adolescence, and suicide is the third leading cause of death among adolescents.27Data from the National Health and Nutrition Examination Survey28 revealed the following regarding adolescent medication use for psychological concerns:By 2020, it is estimated that psychiatric and neurologic conditions will account for 15% of the total burden (in terms of both prevalence and financial costs) of all diseases. Identified gaps in resources for childhood mental health that can be targeted for improvement can be categorized as economic, staffing, training, and policy.24 Approximately 25% of affected youth will have a second mental health disorder. This incidence actually increases 1.6 times for each additional year from age 2 (18.2%) to age 5 (49.7%). In addition, children with a physical illness are more likely to develop depression and those with an emotional disorder have an increased risk of developing physical disorders.29,30Considering the number of student-athletes within secondary school athletic departments and the statistical data on mental disorders in the United States, particularly those affecting adolescents, there is a high probability that most secondary school athletic teams include student-athletes who experience 1 or more psychological concerns. The AT, in collaboration with the athletic department and secondary school administration, should develop a plan to recognize student-athletes with psychological concerns and facilitate an effective referral system to mental health care professionals for evaluation and treatment.To maintain a competitive advantage, universities may recruit increasingly younger players, which affects secondary school coaches, student-athletes, and their families. Many student-athletes report higher levels of negative emotional states than non–student-athlete adolescents and have been identified as having higher incidence rates for sleep disturbances, loss of appetite, mood disturbances, short tempers, decreased interest in training and competition, decreased self-confidence, and inability to concentrate.Some of these changes in mood can also be related to overtraining.31,32 Due to pressures to win, competitions for athletic scholarships, and the adoption of professional training methods to ensure these outcomes, overtraining has become a way of life for many of our young athletes. They may compete year-round, often with multiple teams, and both train and compete multiple times each week. However, an emphasis on work without time for rest and recovery can lead to physical and psychological staleness and burnout.33–35Student-athletes often exhibit sport identity foreclosure,36 and the greater this rigid identification, the more negative the psychological reaction can be when real and perceived barriers arise in their sporting lives. Stressors of athletic participation may include being cut from a team, dealing with injury, performance challenges, mistakes in play, dealing with success, pressure to overspecialize or overtrain, and early termination from sport.37–39Demands and stressors on the student-athlete can be physical (eg, physical conditioning, injuries, environmental conditions), mental (eg, game strategy, meeting coaches' expectations, attention from media and fellow students, time spent in sport, community-service requirements, and less personal and family time), and academic (eg, classes, study time, projects, papers, examinations, attaining and maintaining the required grade point average to remain on the team, and earning and maintaining a collegiate or academic scholarship). These stressors place numerous expectations on a student-athlete.40Pressure on a student-athlete is common when there is no off-season and training continues throughout the year. The student-athlete is exposed to a predictable pattern of lack of sleep and underrecovery, putting him or her at risk for anxiety and depression.41–53 Recovery is closely related to well-being and performance, yet many student-athletes are mired in persistent cycles of chronic fatigue.46 For student-athletes, the complex combination of long-term training and uncontrollable life variables often leads to overtraining, putting them at risk for physical, mental, and emotional health problems.All too often, athletes are portrayed as superhuman, larger than life, and unaffected by stress or concerns of a clinical nature.54–58 Although many individuals are equipped to meet these physical and mental expectations, a segment of the student-athlete population will have difficulty. The stressors of being a student-athlete can trigger a new psychological concern, exacerbate an existing concern, or cause a past concern to resurface. Triggering events and stressors to be aware of are described in Table 1.The AT, team and others in the athletic department (eg, athletic coaches, academic support staff, school are in to and with student-athletes on a daily In most athletic department and secondary school have the of the and the student-athlete may to them for or with a personal concern or during a student-athletes may or students, or family However, some student-athletes, will not be aware of how a is affecting or are will not inform These student-athletes may in a way to others that is when a AT, team or a student-athlete's health, the is of a physical and on participation the student-athlete's mental health may be However, both physical and mental health are important for the student-athlete's that may be symptoms of a psychological concern in a student-athlete are provided in Table although the is not may or in may be in and may range in to a mental health care professional should be as the number and of behaviors increase or the behavior is a change from the student-athlete's of the 2 most common mental disorders, depression and anxiety, are found in 3 and AT, and should consider the student-athlete's psychological to a physical matter how it is a cause of stress to the Each student-athlete is so the or symptoms described by 1 student-athlete may not be the as those experienced by with the injury, particularly one that is time or may be a significant of to stress in various it with little whereas others or A student-athlete who an for the first time at the secondary school level will a for the physical and emotional to and which the AT can help the student-athlete During this time of psychological and physical stress associated with an injury, the student-athlete's behavior should be symptoms of psychological concern is part of the comprehensive care plan for often fear their to The AT should be aware of this the student-athlete of his or her to and the student-athlete for symptoms that a developing psychological of includes the and psychological effects on student-athletes this A student-athlete who a should be for changes in behavior or psychological a student-athlete experiences a the school is to with the In the absence of a school AT, the should work to and psychological changes in the US for substance-use disorders is whereas and is and and is With there is a to increase in the prevalence of these disorders, which to be somewhat more in Of collegiate student-athletes who experienced psychological concerns, particularly reported high rates in high A total of of US high school students indicated that some or use during the school and of to that of with or on social other to on the use of by student-athletes are exposed to use in high In a collegiate population for as well as anxiety, and other psychiatric reported high levels of and associated with were found between reported and depression and psychiatric care should be to the of substance and use among their athletes to Having an mental illness anxiety, bipolar disorder, or it more likely that student-athletes will use or the adolescent and young adult population, the prevalence of behavior disorders, including ADHD, is disorder affects to in a more than 3 to 1 and impairing behavior result in levels of or or their a chronic is often characterized by levels of or and meet the criteria for in both to the the of is by the number of as well as the level of impairment in social and work is in patients with many symptoms in of those required for symptoms that are severe, or significant impairment as a result of the is diagnosed in individuals symptoms are between minor and in children and adolescents can be it is important that all the diagnostic criteria are met conditions are and other conditions that can cause symptoms are including the Disorder and can be by parents, and adolescents and are in symptoms of are found in Table disorders affect twice as often as but the incidence in both increases with age. is In studies of adults, the estimated lifetime prevalence of disorders is relatively to for and to for who not meet criteria for disorders of or into a of disorder not In the clinical to be diagnosed more than or some the focus on and behaviors Although of such as or is associated with disorders, some athletes may develop a substance-use and symptoms of disorders are found in Table is a of youth and can cause physical, social, and academic The by not only affects the but can also affect and and the overall health and of and The for and as by youth or group of youths who are not or current that an or perceived and is multiple times or is likely to be may or distress on the targeted including physical, psychological, social, or educational young person can be a a or can take place physical, or social methods of and can in person or In of being include the loss of playing or of or or sports In addition, adolescent athletes are to their or coaches have been to and to remain of the on revealed that a student is being include the that a student be others include the that the AT who a student is or being first the and the school The to this is similar to the required an AT that an is a mental health The AT is not to address the with the student and in a However, a referral to the and school that the AT has the