Pediatric health care providers, as well as teachers, coaches, and parents, must be closely involved in the healthy development of these athletes.
(Editor’s note: This is the second of a 2-part series on student athletes and mental health. You can read part 1 here: https://www.contemporarypediatrics.com/view/mental-health-concerns-in-student-athletes-after-injury).
The mental health of young student athletes can be challenging to nurture, particularly when these athletes are highly competitive in their sport. A significant burden and emphasis are put on their training, coaching, and accompanying teamwork, especially for those standout student athletes who are particularly gifted and dedicated; their athletic identity becomes synonymous with their self-image. As such, they invest a tremendous amount of identity into this role and for many of them, the sport becomes an inseparable, dominant feature in their lives. This “all-in” mentality can often outweigh their investment in education, and sometimes even living with their families if they need to train elsewhere. Moreover, peer relationships can also suffer significantly, as athletes may often miss out on spending valuable time with friends who may not be in training and do not need to follow the rigorous schedules that athletes must regularly keep.
Whether in middle school or at the collegiate level, student athletes can receive applause and acclaim for their accomplishments and are emotionally rewarded by their peers and society at large when they excel in their sport. However, it can be easy to underestimate how much that association matters to them, especially as they emerge from later adolescence and think about potentially moving on to a professional team or the Olympics. Their chosen sport becomes a driving force in their lives.
The pressure of being a star athlete
Coping with the associated mental pressure of winning a game, making the next level or seed, or moving on to a final or championship game can depend on several different factors. This is where pediatricians can talk to parents and caregivers about the need to have a balanced perspective regarding the athlete’s goals so that athletics is not the only factor living and flourishing in their young athlete.
“Unfortunately, in many cases, the coaches who are involved with these very high-performance athletes see their own success as tightly linked to the student athlete and, in fact, their future economics and reputation may depend on the success they achieve with a particular athlete. Their own self-interest is often very much enmeshed in the athlete’s performance and therefore it can become overwhelmingly important to that coach. Sometimes the parents are frustrated athletes themselves and then their sense of self-esteem and identity could also become enmeshed in the student athlete’s performance. If the self-interest of the adults becomes paramount, then the young athlete’s predicament, especially excessive stress and failure, can go from very serious to critical and in their mind, it may become a life-and-death situation, as so much of their identity hinges on being a successful athlete,” noted Michael S. Jellinek, MD, a professor of psychiatry and of pediatrics at Harvard Medical School in Boston, Massachusetts.
Extreme scenarios: suicide and suicidal ideation
Sadly, the “life-or-death” aspect of this kind of excessive stress is all too real. The incidence of suicide ideation and suicidal behavior peaks among adolescents and young adults, with a global prevalence of lifetime suicidal ideation between 12% and 33% and lifetime suicidal behavior between 4% and 9%.1 Findings from one recent study showed that approximately 1 in 6 athletes involved in international elite athletics have experienced suicide ideation.2
There can be a fine line between suicide ideation and taking the next step to suicide, observed Jellinek. Often, many factors are involved in this mental process for the athletes, including shortcomings in their athletic success and/or failing in academics due to overfocusing on their sport, which can affect their future career choice (which may not involve athletics because they feel they are not good enough to successfully rise in their sport). Additionally, overbearing coaches, teachers, and parents can make the student’s athletic achievements an absolute priority. According to Jellinek, one of the cardinal elements of depression and suicide as a result of the reaction to these issues is an extreme sense of helplessness.
“If student athletes feel hopeless because they missed their chance to compete at the Olympics, to make the professional level, or get into the college they thought was essential to their future, feelings of loss, hopelessness, and helplessness…can quickly overcome them,” Jellinek added.
Other manifestations of mental health issues
Additionally, for pediatricians, being aware of an adolescent’s family history is important, especially regarding depression, anxiety, and substance use. According to Jellinek, approximately 30% of teenagers who have a parent who has been depressed are going to experience depression themselves3; this rate can be even higher if both parents have had depression. Thus, pediatricians must be wary and remember this element in the family history when caring for student athletes.
It is normal and motivating for student athletes to experience some level of anxiety before a competition4; however, when the anxiety becomes severe (sleep disorders; excessive investment in training, which can result in overuse injuries; eating disorders, especially anorexia that is more commonly seen in females), that is when alarm bells for both health care providers and caregivers should go off.
Moving into older age groups
Normal adolescent development is a path that evolves from a student athlete’s family to more meaningful investments in other adults such as teachers, coaches, and guidance counselors; it also involves finding peer groups the athlete can associate with and developing an identity based on those adult and peer relationships. However, it is not uncommon for younger standout athletes to be prematurely associated with older student athletes and therefore exposed to the activities of the older group, including sex, drugs, and alcohol. Pediatricians and other medical health care professionals caring for student athletes can help by closely counseling and appropriately advising them in terms of age-appropriate themes and development, as well as referring them to a therapist when needed.
Although it is an achievement to be a younger athlete playing in an older group, such athletes often skip the steps typically made by students of their own age. According to Jellinek, this premature association can have far-reaching repercussions in terms of normal age-appropriate development. Younger student athletes want to fit in, and they need those peers to help them separate from their family and become adults. However, those peers are often too old, and younger athletes may find themselves in very difficult social situations they are not ready for and have not practiced for in a step-by-step manner. This can include being prematurely exposed to conversations concerning alcohol and sexual relationships and succumbing to peer pressure regarding non–age-appropriate themes.
“I believe it is important for the caring physicians, teachers, coaches, and parents to watch out for the younger student athlete who jumps 3 to 4 years [ahead] in their age group and think about supporting peer relationships [with those who are of] the same age. Clearly, this can be very challenging because those athletes are often in training camps or in settings where there aren’t any children as young as they are,” Jellinek said.
Treating the student athlete
The good news is that in recent years, there has been much more attention given to these stressors and on helping the athlete to overcome them. “Currently in sport psychology, there is an increased emphasis on the importance of practicing relaxation techniques, mental rehearsals, tracking emotional well-being, and other forms of cognitive behavioral approaches that try to maximize the performance in the context of the expected stress,” Jellinek noted.
Synchronized efforts from teachers, coaches, and parents can help to mitigate the stresses and anxiety experienced by younger athletes. Here, Jellinek said it is crucial that the adults in the room are self-aware of how much their identity is connected to the child’s achievement so that they do not push the adolescent beyond what is reasonable for the child’s or adolescent’s own needs, wishes, and overall development. Pediatricians can appropriately counsel the adults concerned and remind them that the pressure these guiding figures put on the athlete can negatively influence the student athlete and lead to overwhelming levels of anxiety and depression.
“The adults should look in the mirror and decide what’s important in life, how much they are going to prioritize athletics, and how much it really matters to them versus who the athlete is as a person. One might be reluctant to send the student athlete away for training at too young an age, allow for certain breaks so that they can have some relief from stress or be around peers their own age, allow for normal relationships to the extent that they can, and have some thoughtful discussions when putting them in groups that are a lot older than the younger student athlete,” Jellinek said.
Unfortunately, it is uncommon for student athletes to seek out professional mental help. According to Jellinek, elite athletes intrinsically push through or put aside their feelings and become totally dedicated to their sport and excellence. Part of what may make them “great” is this singular focus reinforced by their high achievement, sense of satisfaction, success, and acclaim. This combination of denial and focus can be seen with many professional athletes who limit their personal lives and emotions but then may experience problems regarding alcohol, substance use, violence, premature marriage, or having children out of wedlock. Again, pediatricians can help to mitigate these detrimental factors by getting to know the student athlete better through close and more frequent counseling and offer them advice regarding the age-appropriate development of the student athlete.
“In my experience, there are 2 groups who really ignore their inner emotional needs. One of them is recent immigrants, who have to struggle to survive as they do not have the luxury of listening to their inner emotions until they are safe, both financially and socially. The other is high-achieving individuals, who put all their energy into that achievement but really don’t listen to their own emotions. Especially for younger athletes, well-balanced adults are required to see what’s happening, closely listen to the adolescent, and recommend help when needed,” Jellinek said.
Apart from regularly controlling student athletes’ overall physical health, helping them to maintain a healthy weight, and treating overuse injuries, medical professionals who take care of adolescent and collegiate student athletes should also try to talk to these athletes about the areas of normal development. These include school progress, friends, activities, and the athlete’s general mood, as well as family relationships, to assess if there is a healthy balance.
“Pediatricians who take care of elite athletes should probably see them more often than [they see] the average adolescent and should schedule visits with them 4 times a year instead of once a year. It is very important to try and get to know them on a personal level and to be observant as to the balance of forces on their lives. In addition, they should try and pay attention to the people surrounding the student athlete to see if that athlete is being used by others or if they are sincerely…able to see the adolescent’s overall needs,” Jellinek said.
1. Turecki G, Brent DA. Suicide and suicidal behavior. Lancet. 2016;387(10024):1227-1239. doi:10.1016/S0140-6736(15)00234-2
2. Timpka T, Spreco A, Dahlstrom O, et al. Suicidal thoughts (ideation) among elite athletics (track and field) athletes: associations with sports participation, psychological resourcefulness and having been a victim of sexual and/or physical abuse. Br J Sports Med. 2021;55(4):198-205. doi:10/1136/bjsports-2019-101386
3. Weber SR, Winkelmann ZK, Monsma EV, Arent SM, Torres-McGehee TM. An examination of depression, anxiety, and self-esteem in collegiate student-athletes. Int J Environ Res Public Health. 2023;20(2):1211. doi:10.3390/ijerph20021211
4. Ford JL, Ildefonso K, Jones ML, Arvinen-Barrow M. Sport-related anxiety: current insights. Open Access J Sports Med. 2017;8:205-212. doi:10.2147/OAJSM.S125845