Journal of Athletic Training 2015;50(3):231–249
doi: 10.4085/1062-6050-50.3.03
Ó by the National Athletic Trainers’ Association, Inc
www.natajournals.org
consensus statement
Interassociation Recommendations for Developing a
Plan to Recognize and Refer Student-Athletes With
Psychological Concerns at the Secondary School
Level: A Consensus Statement
Timothy L. Neal, MS, ATC (Chair)*; Alex B. Diamond, DO, MPH†; Scott
Goldman, PhD, CC-AASP‡; Karl D. Liedtka, MS§; Kembra Mathis, MEd, ATC||;
Eric D. Morse, MD, DFAPA¶; Margot Putukian, MD, FACSM#; Eric Quandt, JD**;
Stacey J. Ritter, MS, ATC††; John P. Sullivan, PsyD‡‡; Victor Welzant, PsyD§§
*TLN Consulting, Liverpool, NY; †Vanderbilt University School of Medicine, Nashville, TN; ‡Universi ty of Michigan,
Ann Arbor; §Lebanon High School, PA; ||Bent onville High School, AR; ¶Carolina Performance, Raleigh, NC;
#Princeton University, NJ; **Scharf Banks Marmor, LLC, Chicago, IL; ††San Luis Sports Therapy, San Luis Obispo,
CA; ‡‡Clinical & Sports Consulting Services, Providence, RI; §§The International Critical Incident Stress Foundation,
Inc, Ellicott City, MD
D
uring 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.
2
The 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 psycholog-
ical health, collaborating with secondary school profes-
sionals to assist student-athletes with psychological
concerns, and legal considerations. Also addressed are
educational efforts for student-athletes, coaches, and
parents, as well as pract ical 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 administra-
tion. 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 psycholog-
ical 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,
Journal of Athletic Training 231
no matter how caring that person may be. This consensus
statement was produced to inform ATs about developing a
plan to recognize po tential 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 facil-
itating the evaluation and care of the student-athlete
suspected of a psychological concern by credentialed
mental health care professionals. Throughout this state-
ment, 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 ‘‘ Interassoci-
ation Recommendations for Developing a Plan to Recog-
nize 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.
Purpose of This Consensus Statement
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 to
1. Provide essential information on men tal illness in
adolescents.
2. Describe stressors unique to student-athletes and give
examples of triggers that may create a new mental
disorder or exacerbate an existing mental disorder.
3. Offer appropriate information for recognizing potential
psychological concerns in student-athletes through be-
haviors to monitor.
4. Review special considerations that may challenge a
student-athlete’s mental health.
5. Discuss considerations in developing a referral system so
that student-athletes can obtain psychological assistance.
6. Develop an ongoing relationship with secondary school
entities to assist in the referral, care, and disposition of
psychological issues in student-athletes.
7. Describe considerations during mental health emergen-
cies and catastrophic incidents.
8. Address legal liability for secondary schools when
developing a plan to refer student-athletes with psycho-
logical concerns.
9. Explain considerations in educating student-athletes,
coaches, and parents on psychological health.
10. Suggest considerations for collaborating with athletic
departments and school administrations in developing a
plan to effectively recognize, refer, and care for secondary
school student-athletes with psychological concerns.
Organization of Consensus Statement
This consensus statement is organized as follows:
1. Background and review of mental illne ss in adolescents,
recommendations for recognizing potential psychological
concerns in student-athletes through discussion of stress-
ors unique to student-athle tes, and triggering mechanisms
or events that may create a mental illness or exacerbate an
existing mental illness
2. Behaviors to monitor
3. Recommendations for special circumstances with poten-
tial effects on a student-athlete’s mental health: psycho-
logical response to injury; concussions; substance and
alcohol abuse; attention-deficit hyperactivity disorder
(ADHD) diagnosis, treatment, and documentation; eating
disorders; bullying and hazing considerations
4. Recommendations for collaboration among the AT,
school nurse, and school counselors to recognize
psychological concerns; preparticipation physical exam-
ination screening q uestions and tools to indicate a history
of prior mental disorder; approaching a student-athlete
with a potential psychological concern; and referring the
student-athlete to a secondary school counseling service
or a community mental health care professional, includ-
ing for an emergent mental health incident
5. Recommendations for confidentiality consider ations
6. Recommendations for attending to mental health emer-
gency incidents and mental health catastrophic incidents
7. Recommendations for legal considerations in developing
a plan to deal with the psychological concerns of student-
athletes, particularl y minor children
8. Recommendations for educating student-athletes, coach-
es, and parents on psychological health
9. Recommendations on collaborating with athletic depart-
ment and secondary school administration in developing a
plan and document to share with ATs, school nurses,
school counselors, team physicians, athletic administra-
tion, and coaches to effectively address student-athlete
psychological concerns
10. Conclusions
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.
A. The recommendation is based on consistent and good-
quality patient-oriented evidence.
232 Volume 50
Number 3
March 2015
B. The recommendation is based on inconsistent or limited-
quality patient-oriented evidence.
C. The recommendation is based on consensus, usual
practice, opinion, disease-oriented evidence, or a case series
for studies of diagnosis, treatment, prevention, or screening.
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.
EXECUTIVE SUMMARY
Education About Mental Disorders in Young Adults
1. The Plan for Recognition and Referral of Student-Athletes
With Psychological Concerns (also known as the Plan)
includes data on the prevalence of mental disorders in
American adolescents, including the definition of a mental
disorder according to the American Psychiatric Associa-
tion Diagnostic and Stat istical Manual of Mental Disor-
ders, fifth edition.
8
2. The Plan provides data on mental disorders in adolescents
and young adults.
3. The Plan reviews data on the comorbidity of mental
disorders and the risk factors in mental disorders affecting
adolescents and young adults.
Category: A
Recognition of Psychological Concerns in Student-
Athletes
1. The Plan lists stress ors unique to student-athle tes.
2. The Plan lists behaviors to monitor.
3. The Plan provides a list of depression symptoms.
4. The Plan offers a list of anxiety symptoms.
5. The Plan contains a nonexclusive list of special consider-
ations that may affect the student-athlete: psychological
response to injury or loss of playing time or career,
concussion, substance or alcohol abuse, ADHD, eating
disorder, bullying, and hazing.
Category: A
Referring Student-Athletes for Psychological
Concerns
1. The Plan considers the familiarity of the AT, school nurse,
school counselor, and team physician in identifying
potential psychological concerns at the secondary school
level.
2. The Plan offers questions regarding a student-athlete’s
history of a mental health concern or present psychological
status at the preparticipation physical examination, with
follow-up questionnaires if the student-athlete’s answers
indicate the need for further evaluation.
3. The Plan provides questions to consider asking when
approaching a stud ent-athlete with a potential psycholog-
ical concern.
4. The Plan addresses referring the student-athlete for
psychological concerns. The Plan recommendations in-
clude a secondary school district emerge nt-referral plan.
5. The Plan addresses suicide by providing facts and figures,
suicide risk and protective factors, suicide symptoms and
danger signs, steps to take in the presence of fears that a
student-athlete may take his or her life, and information on
surviving the loss of a loved one to suicide .
6. The Plan discusses confidentiality issues.
Categories: B, C
Student-Athlete Mental Health Emergencies and
Catastrophic Incidents
1. The Plan recommends the development of an Emergency
Action Plan that follows the recommendations in the
‘‘ National Athletic Trainers’ Association’s Position State-
ment: Emergency Planning in Athletics’’
9
that will be
implemented in the event of a student-athlete emergency
stemming from a mental health inciden t (attempted harm
to oneself or othe rs).
2. The Plan recommends the development of a Catastrophic
Incident Guideline, which will be implemented in the event
of a student-athlete mental health catastrophic incident
(suicide, homicide, permanent disability).
3. The Plan recommends developing, in collaboration with
counseling services and other crisis management organi-
zations, a crisis counseling plan to be implemented after a
catastrophic incident.
Categories: A, B
Legal Considerations
The Plan reviews legal implications to be shared with the
secondary school district general counsel when developing
the Plan and recommends general counsel approval of the
Plan before implementation.
Categories: B, C
Building Plan for Recognition and Referral of the
Student-Athlete With Psychological Concerns
1. Establish the need for the Plan with secondary school
administration and athletic department administration by
using data and other best-practices information found in
the consensus statement.
2. Write an initial draft of the Plan document by using
information found in the consensus statement.
3. Share the Plan d raft with secondary school administration
and staff and athletics administration for feedback from
and approval by all entities.
4. Once the Plan is approved, distribute it to all ATs, school
nurses, school counselors, team physicians, coaches, and
administrators invol ved in the Plan for referral.
5. Review the Plan annually and update as necessary,
including all involved entities.
6. Provide a psycho logical-health educational component to
student-athletes and their parents or guardians.
Category: C
BACKGROUND
Similar 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,
Journal of Athletic Training 233
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 General
10
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.
11
The 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 definition
8
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.
8
Most DSM-5 disorders have a numeric International
Classification of Diseases, Ninth Revision, Clinical Mod-
ification (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 appro-
priate 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.
8
In 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.
11
The average age of onset for major depression and
dysthymia is between 11 and 14 years of age.
12
The rate of
outpatient treatment for depression
13
increased markedly in
the United States between 1987 and 1997, with 75.3% of
those individuals being treated with antidepressant medi-
cation in 2007.
The US Substance Abuse and Mental Health Services
Administration
6
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.
6
Most 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 onse t was somewhat
predictable and prov ides 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.
16
Epidemiologic 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.
21
Anxiety disorders are
reported often in mental-disorder surveys
21
and appear to
exact significant and independent tolls on health-related
quality of life.
22
Mental 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.
23
Anxiety 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
Comorbid-
ity 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
234 Volume 50
Number 3
March 2015
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.
11
Concerns about adolescent mental health are shared by
many countries. In a review
24
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.
27
Data from the National Health and Nutrition Examination
Survey
28
revealed the following regarding adolescent
medication use for psychological concerns:
Approximately 6.0% of US adolescents aged 12 to 19
reported psychotropic drug use in the past month.
Antidepressants (3.2%) and ADHD drugs (3.2%) were used
most often, followed by antipsychotics (1.0%); anxiolytics,
sedatives, and hypnotics (0.5%); and antimanics (0.2%).
Boys (4.2%) were more likely than girls (2.2%) to use
ADHD drugs. Girls (4.5%) were more likely than boys
(2.0%) to use antidepressants.
Psychotropic drug use was higher among non-Hispanic
white adolescents (8.2%) than non-Hispanic black (3.1%)
and Mexican American (2.9%) adolescents.
About one-half of US adolesce nts using psychotropic drugs
in the past month had seen a mental health professional in
the past year (53.3%).
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.
29,30
Considering 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.
RECOGNITION OF PSYCHOLOGICAL CONCERNS IN
STUDENT-ATHLETES
Stressors and Trigg ering Events Unique to
Secondary School Student-Athletes
To maintain a competitive advantage, universities may
recruit increasingly younger players, which affects second-
ary 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 competi-
tion, decreased self-confidence, and inability to concen-
trate.
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.
33–35
Student-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.
37–39
Demands 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.
40
Pressure 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
Journal of Athletic Training 235
clinical nature.
54–58
Although many in dividuals 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.
Behaviors to Monitor
The AT, team physicians, and others in the athletic
department (eg, athletic administrators, coaches, academic
support staff, school counselors) are in positions to observe
and interact with student-athletes on a daily basis. In most
cases, athletic department and secondary school personnel
have the trust of the student-athlete, and the student-athlete
may turn to them for advice or assistance with a personal
concern or during a crisis. Other student-athletes may seek
out teammates or nonathlete students, teachers, friends, or
family members. However, some student-athletes, will not
be aware of how a stressor is affecting them, or even if they
are aware, will not inform anyone. These student-athletes
may act out in a nonverbal way to alert others that
something is bothering them.
3–5
Oftentimes, when a
student-athlete, AT, team physician, coach, teammate, or
parent considers a student-athlete’s health, the primary
thought is of a physical injury and its effect on participation
status; the student-athlete’s mental health may be second-
ary.
59
However, both physical and mental health are equally
important for the student-athlete’s well-being.
Behaviors that may be symptoms of a psychological
concern in a student-athlete are provided in Table 2,
although the list is not all-inclusive. Behaviors may occur
alone or in combination, may be subtle in appearance, and
may range in severity. Referral to a mental health care
professional should be considered as the number and
severity of behaviors increase or the concerning behavior is
a dramatic change from the student-athlete’s normal
presentation. Symptoms of the 2 most common mental
disorders, depression and anxiety, are found in Tables 3 and
4.
SPECIAL CONSIDERATIONS THAT MAY AFFECT
THE PSYCHOL OGICAL HEALTH OF THE STUDENT-
ATHLETE
Psychological Response to Injury or the Sudden End
of the Playing Career
The AT, physician, and coach should always consider the
student-athlete’s possible psychological response to a
physical injury. No matter how minor, it is still a cause
of stress to the student-athlete. Each student-athlete is
different, so the signs or symptoms described by 1 student-
athlete may not be the same as those experienced by
another, even with the same injury. Any injury, particularly
one that is time limiting, season ending, or perhaps career
ending, may be a significant source of stress. Student-
athletes respond to injury stress in various ways: Some
handle it well, with little effect, whereas others struggle
physically or emotionally (or both). A student-athlete who
sustains an injury for the first time while participating at the
secondary school level will display a learning curve for
Table 1. Triggering Events
3
Events may serve to trigger a new mental or emotional health concern
or exacerbate an existing condition in a student-athlete. Some
examples of these triggering events are
Poor performance or perceived poor performance by the student-
athlete
Conflicts with coaches or teammates
A debilitating injury or illness, resulting in a loss of playing time or
surgery
Concussions
Class concerns: schedule, grades, amount of work
Lack of playing time
Family and relationship issues
Changes in importance of sport, expectations by self/parents, role
of sport in life
Violence: being assaulted, a victim of domestic violence,
automobile accident, or merely witnessing a personal injury or
assault on a family member, friend, or teammate
Bullying or hazing
Adapting to school schedule
Lack of sleep
History of mental disorder
Burnout from sport or school
Anticipated end of playing career
Sudden end of career due to injury or medical condition
Death of a loved one or close friend
Alcohol or drug abuse
Significant dieting or weight loss
History of physical or sexual abuse
Gambling problems
Adapted with permission from the National Collegiate Athletic
Association.
Table 2. Behaviors to Monitor
3,59
Changes in eating and sleeping habits
Unexplained weight loss or weight gain
Drug or alcohol abuse
Gambling issues
Withdrawal from social contact
Decreased interest in activities that have been enjoyable or taking up
risky behavior
Talking about death, dying, or ‘‘ going away’’
Loss of emotion or sudden changes of emotion within a short period
of time
Problems concentrating, focusing, or remembering
Frequent complaints of fatigue, illness, or being injured that prevent
participation
Unexplained wounds or deliberate self-harm
Becoming more irritable or having problems managing anger
Irresponsible, lying
Legal concerns, fighting, difficulty with authority
All-or-nothing thinking
Negative self-talk
Feeling out of control
Mood swings
Excessive worry or fear
Agitation or irritability
Shaking, trembling
Gastrointestinal complaints, headaches
Overuse, unresolved, or frequent injuries
Adapted with permission from the National Collegiate Athletic
Association.
236 Volume 50
Number 3
March 2015
handling the physical and emotional responses to pain and
disability, which the AT can help the student-athlete
navigate. During this time of psychological and physical
stress associated with an injury, the student-athlete’s
behavior should be observed. Detecting any symptoms of
psychological concern is part of the comprehensive care
plan for student-athletes.
62
Student-athletes often fear reinjury upon their return to
participation. The AT should be aware of this possibility,
reassure the student-athlete of his or her readiness to
resume participation, and monitor the student-athlete for
any symptoms that might indicate a developing psycho-
logical problem.
63
Concussions
The evolving awareness of concussion sequelae includes
the cognitive and psychological effects on student-athletes
sustaining this injury.
64–69
A student-athlete who sustains a
concussion should be monitored for any changes in
behavior or self-reported psychological difficulties.
Once a student-athlete experiences a concussion, the
school nurse’s role is to collaborate with the AT. In the
absence of a school AT, the nurse should work to monitor
concussion resolution and any psychological changes in the
student-athlete.
70
Substance and Al cohol Abuse
Total US prevalence
11
for substance-use disorders is
11.4%, whereas drug abuse and dependence is 8.9% and
alcohol abuse and dependence is 6.4%. With age, there is a
5- to 11-fold increase in the prevalence of these disorders,
which tend to be somewhat more frequent in males.
71
Of
collegiate student-athletes who experienced psychological
concerns, particularly depression, 21% reported high
alcohol-abuse rates while in high school.
72
A total of 86%
of US high school students indicated that some classmates
drink, smoke, or use drugs during the school day, and 75%
of 12- to 17-year-olds said that seeing pictures of teens
partying with marijuana or alcohol on social networking
sites encouraged other teens to party.
73
Despite state laws on the use of alcohol by underaged
individuals, student-athletes are exposed to alcohol use in
high school. In a collegiate athlete population surveyed for
alcohol abuse as well as self-reported depression, anxiety,
and other psychiatric symptoms, 21% reported high levels
of alcohol abuse and p roblems associated with it.
Significant correlations were found between reported
alcohol abuse and self-reported depression and psychiatric
symptoms.
72
Health care providers should be alert to the possibility of
substance and alcohol use among their athletes to avoid
enabling them. Having an untreated mental illness (depres-
sion, anxiety, bipolar disorder, or ADHD) makes it more
likely that student-athletes will use substances or alcohol.
74
Diagnosis, Treatment, and Documentation of ADHD
In the adolescent and young adult population, the
prevalence of behavior disorders, including ADHD, is
8.7%. Attention-deficit hyperactivity disorder affects males
to females in a more than 3 to 1 ratio. Chronic and
impairing behavior patterns result in abnormal levels of
inattention or hyperactivity or their combination.
11,74
Considered a chronic neurobiological syndrome, ADHD
is often characterized by inappropriate levels of either
inattention or overactivity and impulsiveness. Athletes
sometimes meet the criteria for ADHD in both symptom
categories.
According to the DSM-5, the severity of ADHD is
determined by the number of symptoms, as well as the level
of impairment in social and work functioning. Severe
ADHD is present in patients with many symptoms in excess
of those required for diagnosis, several symptoms that are
severe, or significant impairment as a result of the
symptoms. Moderate ADHD is diagnosed in individuals
whose symptoms are between minor and severe.
Table 3. Depression Signs and Symptoms
60
Individuals may feel
Sad
Anxious
Empty
Hopeless
Guilty
Worthless
Helpless
Irritable
Restless
Indecisive
Aches, pains, headaches, cramps, or digestive problems
Individuals may present (with)
Lack of energy, depressed, sad mood
Loss of interest in activities previously enjoyed (hanging out with
friends, practice, school, sex)
Decreased performance in school or sport
Loss of appetite or eating more than normal, resulting in weight
gain or weight loss
Problems falling asleep, staying asleep, or sleeping too much
Recurring thoughts of death, suicide, or suicide attempts
Problems concentrating, remembering information, or making
decisions
Unusual crying
Table 4. Anxiety Disorders: Warning Signs and Symptoms
61
Common anxiety signs and symptoms:
Feeling apprehensive
Feeling powerless
Having a sense of impending danger, panic, or doom
Having an increased heart rate
Breathing rapidly
Sweating
Trembling
Feeling weak or tired
Other aspects to consider:
You feel like you’re worrying too much and it’s interfering with your
work, relationships, or other parts of your life
You feel depressed, have trouble with alcohol or drug use, or have
other mental health concerns along with anxiety
You think your anxiety could be linked to physical health problems
You have suicidal thoughts or behaviors (if so, seek emergency
treatment immediately)
Adapted with permission from the Mayo Clinic.
Journal of Athletic Training 237
Diagnosing ADHD in children and adolescents can be
challenging. Therefore, it is important that all t he
diagnostic criteria are met using objective data, any
comorbid conditions are identified, and other medical
conditions that can cause ADHD-like symptoms are
considered. Several objective symptom-assessment scales,
including the Brown Attention-Deficit Disorder Scales,
Vanderbilt Assessment Scales, and Conners Rating Scales,
can be completed by parents, teachers, and adolescents and
are helpful in evaluating ADHD symptoms.
75
Common
symptoms of ADHD are found in Table 5.
Eating Disorders
Eating disorders affect females twice as often as males,
but the incidence in both sexes increases w ith age. Total
prevalence
11
is 2.7%. In population-based studies of
adults, the estimated lifetime prevalence of eating
disorders is relatively low (0.5% to 1.0% for anorexia
nervosa and 0.5% to 3.0% for bulimia nervosa).
76–84
Youths who do not meet DSM-IV
85
criteria for eating
disorders of anorexia nervosa or bulimia nervosa fall into
a classification of eating disorder not otherwise specified
(EDNOS). In the clinica l setting, E DNOS tends to be
diagnosed more frequently than either anorexia nervosa or
bulimia nervosa.
85–87
For some athletes, the focus on weight management
becomes obsessive, and disordered-eating behaviors devel-
op. Although misuse of substances such as diet pills,
stimulants, or laxatives is commonly associated with eating
disorders, some athletes may develop a concurrent
substance-use disorder.
88
Signs and symptoms of eating
disorders are found in Table 6.
Bullying and Hazing
Bullying is a type of youth violence and can cause
physical, social, emotional, and academic issues. The harm
done by bullying not only affects the victim but can also
affect friends and families and the overall health and safety
of schools and neighborhoods. The Centers for Disease
Control and Prevention defines bullying as any unwanted
aggressive behavior(s) by another youth or group of youths
who are not siblings or current dating partners that involves
an observed or perceived power imbalance and is repeated
multiple times or is highly likely to be repeated. Bullying
may inflict harm or distress on the targeted youth, including
physical, psychological, social, or educational harm.
90
A young person can be a bully, a victim, or both.
Bullying can take place via physical, verbal, or social
Table 5. Attention-Deficit Hyperactivity Disorder Signs and
Symptoms
Student-athletes who have symptoms of inattention may
Be easily distracted, miss details, forget things, and frequently
switch from 1 activity to another
Have difficulty focusing on 1 thing
Become bored with a test after only a few minutes unless they are
doing something enjoyable
Have difficulty focusing attention on organizing and completing a
task or learning something new
Have trouble completing or turning in homework assignments,
often losing things needed to complete tasks or assignments
Not appearing to listen when spoken to
Daydream, become easily confused, and move slowly
Have difficulty processing information as quickly and accurately as
others
Struggle to follow instructions
Student-athletes who have symptoms of hyperactivity may
Fidget constantly
Talk nonstop
Dash around, touching or playing with anything and everything in
sight
Have trouble sitting still during dinner, school, or traveling
(constantly getting up and down in their seat, frequently walking
around the bus or plane)
Be constantly in motion
Have difficulty doing quiet tasks or activities
Student-athletes who have symptoms of impulsivity may
Be very impatient
Blurt out inappropriate comments, show their emotions without
restraint, and act without regard for consequences
Have difficulty waiting for things they want or waiting their turn in
line
Often interrupt conversations or others’ activities
Source: National Institute of Mental Health
Table 6. Eating Disorders: Signs and Symptoms
89
Anorexia nervosa
Extreme thinness (emaciation)
Relentless pursuit of thinness and unwillingness to maintain a
normal or healthy weight
Intense fear of gaining weight
Distorted body image, self-esteem that is heavily influenced by
perceptions of body weight and shape, or denial of the
seriousness of low body weight
Lack of menstruation among girls and women (amenorrhea)
Extremely restricted eating
Compulsive exercise
Other symptoms may develop over time, including
Thinning of bones (osteopenia or osteoporosis)
Brittle hair and nails
Dry and yellowish skin
Growth of fine hair all over the body (lanugo)
Mild anemia and muscle wasting and weakness
Severe constipation
Low blood pressure, slowed breathing and pulse
Damage to the structure and function of the heart
Brain damage
Multiorgan failure
Drop in internal body temperature, causing the person to feel cold
all the time
Lethargy, sluggishness, or feeling tired all the time
Infertility
Bulimia nervosa
Chronically inflamed and sore throat
Swollen salivary glands in neck and jaw
Worn tooth enamel, increasingly sensitive and decaying teeth as a
result of exposure to stomach acid
Acid reflux disorder and other gastrointestinal problems
Intestinal distress and irritation from laxative abuse
Severe dehydration from purging of fluids
Electrolyte imbalance (too low or too high levels of sodium,
calcium, potassium, and other minerals), which can lead to heart
attack
Additional source: National Institute of Mental Health
238 Volume 50
Number 3
March 2015
methods of aggression and can occur in person or through
technology (cyberbullying). In athletes, signs of being
bullied include the loss of focus, playing or performing
tentatively, feeling anxious, dropping out of tournaments or
competitions, or quitting sports altogether. In addition,
adolescent athletes are frequently reluctant to tell their
parents or coaches they have been bullied due to
embarrassment, shame, and wanting to remain ‘‘ part of
the team.’’
91,92
Studies on bullying
91,93
revealed that
High school students being bullied on school property
totaled 20%, although other studies showed that the overall
prevalence of bullying, regardless of location, ranged from
13% to 75%.
A total of 16% of high school students reported they were
bullied electronically.
Bullying occurred in 23% of public schools on a daily or
weekly basis. A higher percentage of middle school students
than high school students described being bullied.
Students reporte d being verbally bullied (18%), physically
bullied (8%), physically threatened (5%), the subject of
rumors (18%), and purposefully excluded from activities
(6%).
Warning signs that a student is being bullied include the
following:
unexplained injuries
loss of personal items
sudden loss of friends
difficulty sleeping
frequent headaches
complaints of stomach discomfort
faking illness or injuries
Warning signs that a student might be bullying others
include the following:
frequently getting into verbal or physical fights
having unexplained money or belongings
increasing aggressi on
having friends who are antagonistic
being overly conce rned with popularity
displaying exclusivity in their associates
Best practices would suggest that the AT who suspects a
student is either bullying or being bullied first contact the
head coach and then the school counselor. The response to
this problem is similar to the response required if an AT
suspects that an athlete is experiencing a mental health
concern. The AT is not expected to directly address the
problem with the student and engage in a therapeutic
relationship. However, making a referral to the head coach
and school counselor ensures that the AT has taken the
proper steps to ensure that a school professional has been
notified and will address the concern appropriately. It is
then the responsibility of the coach and counselor to take
the proper steps to investigate and remediate the problem.
Hazing of team members can be viewed as a rite of
passage on athletic teams. However, hazing can also be
viewed as a part of the bullying spectrum. Hazing is defined
as any humiliating or dangerous activity expected of a
student who wants to belong to a group, regardless of his or
her willingness to participate.
94
Studies on hazing in American high schools
95–97
revealed
that
Of students who belonged to groups, 48% were subjected to
hazing activities.
A total of 43% were subjected to humiliating activities.
Potentially illegal acts were performed by 30%.
The first hazing experience took place before age 13 in
25%.
Dangerous hazing activities were just as prevalent in high
school (22%) as in college (21%).
Hazing associated with substance abuse increased with age,
from 23% in high school to 51% in college.
Males hazed more than females, but both groups described
high levels of hazing.
Hazing would not be reported by 36% because there was no
one to tell.
Hazing would not be reported by 27% because adults would
not handle it correctly.
Hazing resulted in negative consequ ences for 71%.
Consequences included getting into fights; being injured;
fighting with parents; doing poorly in school; hurting other
people; having difficulty eating, sleeping, or concentrating;
and feeling angry, confused, embarrassed, or guilty.
Hazing rituals are frequently dangerous and can often harm
relationships among team members. They are not harmless
rites of passage used to build closeness or earn respect
within the group. These incidents can negatively affect both
the victims and the perpetrators. Common feelings that
result from hazing include apathy, mistrust, anxiety,
depression and isolation, loss of self-esteem and self-
confidence, increase in stress levels, and risk of posttrau-
matic stress disorder.
98
REFERRAL OF THE STUDENT-ATHLETE FOR
PSYCHOLOGICAL EVALUATION AND CARE
Team Approach
It is useful to have a team in place to address the
psycholo gical concerns of student-athletes. This team
includes the team physician(s), ATs, school nurses, school
counselors, and community-based mental health care
professionals (cli nical psycholo gists and psychiatrists).
Physicians practicing sports medicine frequently encounter
psychological concerns in student-athletes. Physicians also
discuss psychological issues with injured student-athletes
fairly frequently, although their comfort and perceived
competence vary widely.
99
School counselors can be an excellent source of
information for the AT. If a student has permitted the
school counselor to discuss personal information with the
AT, as dictated by the local and district policies, the AT can
use that information to best serve the student. The AT
should meet with the school counseling staff early in the
year to obtain information that could be critical in working
with student-athletes. Also, in the case of emergent referrals
for mental health problems, the AT can obtain the contact
information for the local crisis intervention specialists.
Also, the AT should meet with the school counselors and
school nurse to educate them regarding the symptoms of
concussions and postconcussion sequelae. If the school
counselors are aware that a student-athlete has sustained a
Journal of Athletic Training 239
concussion, they can notify the student-athlete’s teachers to
consider making academic adjustments.
The AT should establish a network within the secondary
school and school district:
Make connections and become oriented with the school
nurse and school counselor.
Learn the district’s policies and procedures for referrals.
Discuss a plan of action should a referral be warranted.
Include the nurse and counselor in the referral plan
(introducing them if necessary). Ask for their input and
feedback on various scenarios. This is no different than the
process of creating a required Emergency Action Plan.
The AT must determine what resources are available on
campus and when. Many districts provide school nurses
and counselors only on certain days of the week and at
certain times of the day. An early meeting between the AT
and the school-based health team facilitates efficient
communication protocols. Knowing when, where, and
how to access the school nurse and c ounselor is essential
for the AT to execute a plan of action. In addition, the
school nurse and counselor can advise the AT regarding
legal limitations, confidentiality considerations, and the
school’s current plan of action. They will also be able to
identify youth mental health resources within the com-
munity. The AT and school health team can then expand
the plan of action to incorporate t he AT’s scope of care,
protocols for after-school hours, procedures for contacting
parents, and district policy regarding contracted employ-
ees, as needed. The school health team can also advise the
AT regarding situations in which a parent may be the
source of the problem or a barrier to the child’s access to
mental health care. Given that until children reach age 18,
legal guardians have the authority to make decisions on
virtually all aspects of their health care, relying on the
school administration for this type of intervention will be
critical.
Depending on the hiring model for the secondary school
AT, his or her scope of responsibility may differ. For
instance, if the AT is employed by the school or district
directly, the role may be different in an on-campus
emergency than if the AT is a contracted employee, or
vendor, of the school. District a dministration may need to
be consulted for delineation as to what the AT should or
should not do in the event of a mental health emergency.
This would also be related to mandated-reporter guide-
lines a nd whether psychological concerns are included in
the list of c ircumstances for which reporting is required.
Consideration should also be given to a game situation
versus a practice day. If the AT does not have any
assistant ATs (by far the most common scenario), then he
or she may need to request assistance from other
responsible adults. If a psychological concern occurs
during a game, the AT may be unable to continue to
maintain the f ocus on the field or court and may be
unavailable to care f or an injured player. Identifying an
appropriate, qualified, and responsible adult to either
handle the mental health emergency or monitor the game
for injuries is suggested. In a practice situation, an
assistant coach may be able to provide assistance.
Team or family physicians may be called upon to meet
with and evaluate a student-athlete for a reported
psychological concern. Some physicians prescribe medica-
tions to student-athletes for mental disorders and encourage
the referral for counseling by a mental health care
professional. In many cases, the physician is seeing a
student-athlete for a psychological concern on the recom-
mendation of the AT, coach, school nurse, school
counselor, or parent. When evaluating and managing a
student-athlete with a psychological concern, physicians
should rely on their experience but recognize their limits.
Physicians collaborating with mental health care profes-
sionals can develop the plan of care, including counseling
and medication as needed, appropriate for the student-
athlete.
In 2010, ATs were surveyed on student-athlete mental
health issues.
59
Highlights of the survey relative to ATs’
comfort in managing student-athlete mental health concerns
are provided in Table 7. This consensus statement
recommends that each athletic training program consider
exploring more educational opportunities in psychology,
communication, and critical thinking to enhance the ability
of ATs to recognize and refer student-athletes for
psychological concerns.
100,101
The Preparticipation Physical Examination and the
Student-Athlete’s Psychological History
The preparticipation physical examination is an optimal
time to ask about a history of mental health problems and to
screen for common mental health conditions such as
depression, anxiety, learning disabilities, and eating
disorders. Questions related to nutrition, weight, perfor-
mance, learning disabilities, eating disorders, and other
mental disorders should be included in the health history.
The preparticipation physical examination offers an
opportunity to ask open-ended questions, demonstrate
openness, and destigmatize mental health concerns by
including mental health as an important aspect of overall
health. Suggestions for mental health questions during the
preparticipation physical examination are found in Table 8.
Any affirmative answers to the mental health questions of
the preparticipation physical examination should be
brought to the attention of the physician for a discussion
with the student-athlete to ascertain whether follow-up
evaluation, care, or medication is required. The vast
majority of secondary school student-athletes are minors;
therefore, parental notification of discussions and referrals
is recommended.
Table 7. National Collegiate Athletic Association: Managing
Student-Athletes Mental Health Concerns
59
Almost 85% of athletic trainers indicated that anxiety disorders
affected their student-athletes
83% indicated that eating disorders and disordered eating were
concerns
Mood disorders (77%), substance-related disorders (69%), and
management and treatment (46%) were concerns
87% were engaged in campus counseling, 71% engaged other
athletics personnel, and 66% sought off-campus help
60% engaged coaches and 23% referred to the 2012–13 NCAA
Sports Medicine Handbook
3
Adapted with permission from the National Collegiate Athletic
Association.
240 Volume 50
Number 3
March 2015
Approaching the Student-Athlete With a Potential
Psychological Concern
Approaching a student-athlete with a concern about
mental well-being can be an uncomfortable experience.
However, the health and wellness of the student-athlete is
paramount. Before arranging a private meeting with the
student-athlete, it is important to have accurate facts, with
context, relative to the behavior of concern. The conver-
sation should focus on the student-athlete as a person, not
as an athlete. Listening empathetically and encouraging the
student-athlete to talk about what is happening are
essential. A list of open-ended questions to consider asking
the student-athlete to encourage discussion of the situation
is shown in Table 9.
Encouraging a student-athlete to consider a mental health
evaluation can be challenging, given the stigma that is still
sometimes attached to receiving mental health care.
103
Student-athletes experience as much or more psychological
distress as nonathletes; however, they use professional
mental health services less than nonathletes.
104
Pointing out that mental health is as important as physical
health is one line of reasoning that may persuade the
reticent student-athlete to seek help for a psychological
concern. Assisting the student-athlete in accessing the
mental health care system at the secondary school or
community through prearranged services eases the transi-
tion from deciding to seek help to meeting a mental health
care professional.
Confidentiality
In approaching student-athletes with questions of con-
cern, it is important to notify them of the limits of
confidentiality. Those ATs who have established a rapport
with their athletes may be successful in making a student
feel comfortable enough to discuss personal problems.
However, it is important for the AT to explain the limits of
confidentiality during the conversation. If a student
discusses a personal concern that becomes an emergent
psychological concern, then the AT is mandated by state
law to follow the procedures set forth by the secondary
school district.
Once the student-athlete has been approached and agrees
to go for a psychological evaluation or self-reports wanting
to be evaluated for a psychological concern, he or she
should be referred as soon as possible. In most cases, unless
there is an imminent risk of harm to themselves or others or
a code-of-conduct violation ha s ta ken place, student-
athletes cannot be compelled to report for a mental health
evaluation. When a student-athlete is reticent to undergo a
mental health evaluation, the AT may make the following
suggestions:
Express confidence in the mental health profession.
Clarify what counseling is and how it could help the
student-athlete’s overall health.
Emphasize the confidential nature of mental health care and
referral.
The question of whether to inform the student-athlete’s
parents or coach invariably arises. The AT should
emphasize that parents and coaches are concerned about
the w elfare of the student-athlete and t hat informing them
about psychological health is no different than informing
them about physical health. The AT should e ncourage the
disclosure but not insist. Due to the minor age of most
secondary school student-athletes, secondary school
districts must develop referral protocols for psyc hological
concerns to ensure compliancewithstatelawregarding
the care of minor children. This includes emergent mental
health care evaluations in the event of a threat or actual
incident of self-harm, harm to others, or destruction of
property.
Suicide in Student- Athletes
Approximately 4700 young people between the ages of
14 and 24 die by suicide annually in the United States.
105
In addition, 1 in 6 high school students seriously consider
attempting suicide, and 1 in 13 high school students
attempt suicide 1 or more times.
105
Suicide facts and
figures (Table 10), suicide risk and protective f actors
(Table 11), suicide symptoms and danger signs (Table 12),
steps to take when fearing that a person may take his or
her life ( Table 13), and information on surviving the loss
of a loved one to suicide (Table 14) are supplied to assist
in developing a plan.
Emergencies and Catastrophic Incidents in Student-
Athletes With Psychological Concerns
Although psychological concerns in student-athletes
rarely result in a medic al emergency (ie, injury to
Table 8. Student-Athlete Preparticipation Medical History: Mental
Health-Related Item
102
Statement Yes/No
I often have trouble sleeping
I wish I had more energy most days of the week
I think about things over and over
I feel anxious and nervous much of the time
I often feel sad or depressed
I struggle with being confident
I don’t feel hopeful about the future
I have a hard time managing my emotions (frustration, anger,
impatience)
I have feelings of hurting myself or others
Adapted with permission from Alcoholism Treatment Quarterly.
Table 9. Approaching the Student-Athlete With a Potential Mental
Health Concern: Questions to Ask
59
‘‘ How are things going for you?’’
‘‘ Tell me what is going on.’’
‘‘ Your behavior [mention the incident or incidents] has me concerned
for you. Can you tell me what is going on, or is there something I
need to know to understand why this incident happened?’’
‘‘ Tell me more [about the incident].’’
‘‘ How do you feel about this [the incident or the facts presented]?’’
‘‘ Tell me how those cuts [or other wounds] got there.’’
‘‘ Perhaps you would like to talk to someone about this issue?’’
‘‘ I want to help you, but this type of issue is beyond my scope as
[coach, athletic trainer, administrator]. I know how to refer you to
someone who can help.’’
Adapted with permission from the National Collegiate Athletic
Association.
Journal of Athletic Training 241
themselves or others) or a catastrophic event (ie, suicide,
homicide, permanent disability), it is prudent to plan for
such circumstances.
The following guidelines may be included in the emergent
mental health emergency response plan (as approved by the
school district):
Respond with empath y and support
Enact the school crisis response plan
Notify the student crisis team
Identify the level of intervention or referral needed
(emergent, urgent, less urgent, or nonurgent) and remember
that not all mental health concerns require referral
Ensure safety and err on the side of safety
Collaborate with colleagues
Mobilize the student’s support system (including family)
Connect immediately with the appropriate resources
Follow up on the referral
In the event of a medical emergency resulting from an
injury to the student-athlete with a psychological concern
or to others, the Emergency Action Plan for that venue
should be implemented immediately. The ‘‘ National
Athletic Trainers’ Association Position Statement: Emer-
gency Planning in Athletics’’
9
should be c onsulted when
developing an athletic department Emergen cy Action
Plan.
Crisis Counseling for Student-Athletes
Traumatic events have the potential to simultaneously
evoke both human resilience and distress.
107–109
Student-
athletes may be exposed to a variety of potential traumatic
stressors in the course of their athletic pursuits as well as in
the course of their daily lives. Examples of traumatic events
common to students include death of or injury to friends or
family members, exposure to suicide in the community,
significant motor vehicle crashes involving the athlete or
friends, exposure to violence, and significant injury during
athletic events. These examples illustrate the variety of
events that can cause a traumatic stress reaction (including
grief), even if th e student-athle te was not directly
affected.
110
Stress reactions to a traumatic event are typically normal
human reactions. Many, if not most, of these reactions are
self-limiting and will resolve with support, time, and
natural resilience. Recognition that an individual needs
formal assistance is based on the level of distress that the
student-athlete experiences and, most important, the degree
to which that distress impairs his or her ability to function
in any domain (eg, school performance, athletic perfor-
mance, relationships). Initial reactions are often limited,
Table 10. Suicide Facts and Figures
Suicide is a preventable public health problem and a leading cause of
death in the United States. More investment in suicide prevention,
education, and research will prevent the untimely deaths of
thousands of Americans each year.
General
An American dies by suicide every 12.95 minutes.
Americans attempt suicide an estimated 1 000 000 times annually.
90% of people who die by suicide have a diagnosable psychiatric
disorder at the time of their death.
In 2012, firearms were the most common method of death by
suicide, accounting for 50.9% of all suicide deaths, followed by
suffocation (including hangings) at 24.8% and poisoning at 16.7%.
For every woman who dies by suicide, 4 men die by suicide, but
women are 3 times more likely to attempt suicide.
Over 40 000 Americans die by suicide every year.
Suicide is the tenth leading cause of death in the United States.
The combined medical and work loss costs of suicide in the
United States each year are $44 billion.
More than 1.5 million years of life are lost annually to suicide.
50% to 75% of all people who attempt suicide tell someone about
their intention.
Suicide rates tend to be highest in the spring months, peaking in
April.
In 2010, suicide took more lives than war, murder, and natural
disasters.
90% of those who attempt suicide do not go on to die by suicide.
Youth
Suicide is the second leading cause of death for ages 10–24.
The suicide rate among American Indian/Alaska Native
adolescents and young adults ages 15–24 is 1.8 times the
national average.
Adapted with permission from the American Foundation for Suicide
Prevention.
Table 11. Suicide: Risk and Protective Factors
106
A combination of individual, relational, community, and societal factors
contribute to the risk of suicide. Risk factors are those
characteristics associated with suicide; they may or may not be
direct causes.
Risk factors
Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (eg, belief that suicide is the noble
resolution of a personal dilemma)
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Barriers to accessing mental health treatment
Loss (relational, social, work, or financial)
Physical illness
Easy access to lethal methods
Unwillingness to seek help due to the stigma attached to mental
health and substance abuse disorders or to suicidal thoughts
Protective factors buffer individuals from suicidal thoughts and
behavior. To date, protective factors have not been studied as
extensively or rigorously as risk factors. Identifying and
understanding protective factors are, however, as important as
researching risk factors.
Protective factors
Effective clinical care for mental, physical, and substance abuse
disorders
Easy access to a variety of clinical interventions and support for
help-seeking
Family and community support (connectedness)
Support from ongoing medical and mental health care relationships
Skills in problem solving, conflict resolution, and nonviolent ways
of handling disputes
Cultural and religious beliefs that discourage suicide and support
instincts for self-preservation
242 Volume 50
Number 3
March 2015
and it is normal to experience temporary disruptions in
daily functioning during times of traumatic stress. Howev-
er, when a reaction persists, referral for mental health
support is indicated. Early intervention with mental health
care is more effective in resolving traumatic stress than a
prolonged period of waiting.
110
In the first days to weeks after a traumatic event, common
reactions are intrusive thoughts and images of the event;
periods of emotional numbing alternating with periods of
heightened emotions; and anxiety symptoms including
trouble sleeping, irritability, changes in appetite, fatigue,
and an increase in general tension. Individuals differ in
their rate of recovery from these initial signs of distress.
Reactions that warrant immediate referral for evaluation
include significant use of alcohol or substances to manage
distress, suicidal thinking, thoughts of harming others, and
severe panic.
111
Severe physical stress reactions (ie,
repeated fainting, chest pain, difficulty breathing, persis-
tent vomiting, severe persistent insomnia) are not common,
and student-athletes with these problems should be
immediately referred to a medical professional.
The AT is in a unique position to be helpful during and
after a traumatic incident. The AT’s relationship with the
student-athlete offers the opportunity to provide support
and recognition of the need for referral to formal mental
health support. The traumatic stress literature has identified
several actions that can be taken to support those who have
suffered a traumatic event.
110
Hobfoll e t al
111
outlined the essential elements of
psychological first aid: (1) promote a sense of safety, (2)
promote calming, (3) promote self-efficacy and collective
efficacy, (4) promote connectedness, and (5) promote hope.
These 5 elements can be accomplished through active
listening and crisis support, along with knowledge of the
available resources for referral.
Referral resources after a traumatic event should be used
for students of concern. These personnel should be trained
in traumatic stress counseling as well as grief management
to provide the studen t with appropriate professional
support. Ideally, the resources available for student-athletes
after traumatic events should be identified in advance to
allow for more effective referral in a crisis.
Legal Considerations in Developing a Plan for
Psychological Concerns in Student-Athletes
The majority of student-athletes at the secondary school
level are below the legal age of 18. This means that the
secondary school student-athlete must be considered of
minor age, and therefore, appropriate measures must be
practiced to comply with state laws. Legal considerations
promote the idea that an interdisciplinary approach,
including individuals in various positions within secondary
schools, and when necessary, outside resources, should be a
goal in confronting the complex subject of mental health
and the student-athlete.
Legal liabilities vary from state to state, and health care
providers, including ATs, should apprise themselves of the
applicable state laws. The AT has the duty to conform to
Table 12. Suicide Warning Signs
Warning signs of suicide:
Talking about wanting to die.
Looking for a way to kill oneself.
Talking about feeling hopeless or having no purpose.
Talking about feeling trapped or in unbearable pain.
Talking about being a burden to others.
Increasing the use of alcohol or drugs.
Acting anxious, agitated, or recklessly.
Sleeping too little or too much.
Withdrawing or feeling isolated.
Showing rage or talking about seeking revenge.
Displaying extreme mood swings.
The more of these signs a person shows, the greater the risk.
Warning signs are associated with suicide but may not be what
cause a suicide.
What to do:
If someone you know exhibits warning signs of suicide
Do not leave the person alone.
Remove any firearms, alcohol, drugs or sharp objects that could
be used in a suicide attempt.
Call the US National Suicide Prevention Lifeline at 800-273-TALK
(8255).
Take the person to an emergency room or seek help from a
medical or mental health professional.
The National Suicide Prevention Lifeline: 800-273-TALK (8255)
A free, 24/7 service that can provide suicidal persons or those around
them with support, information and local resources.
Adapted with permission from the American Foundation for Suicide
Prevention.
Table 13. How to Talk to Someone Who May Be Struggling With
Depression or Anxiety
Don’t assume someone will reach out. Only 1 in 5 seeks help. You
can encourage them to make that critical first step.
1. Ask if you can talk in private.
2. Ask questions to open up the conversation.
How are you doing?
You haven’t seemed yourself lately. Is everything okay?
Is anything bothering you?
3. Listen to their story, and express concern and caring.
4. Ask if they have thought about hurting themselves or ending their
life.
5. Encourage them to seek mental health services. Tell them
seeking help can take courage, but it’s the smart thing to do.
Avoid:
Minimizing feelings.
Advice to fix it.
Debating on the value of life.
Offering clich
´
es.
Do:
Listen.
Express concern and caring.
Ask open-ended questions.
Talk about suicide openly and directly.
If they are considering suicide:
Take the person seriously.
Tell them to call the National Suicide Prevention Lifeline: 800-273-
TALK (8255).
Help them remove lethal means.
Escort them to an emergency room, counseling service, or
psychiatrist.
Adapted with permission from the American Foundation for Suicide
Prevention.
Journal of Athletic Training 243
the standard of care required of the profession by exercising
reasonable care for the health and safety of student-athletes.
Although state laws may be stricter than federal laws
about reporting emergencies, consideration needs to be
given in an emergency, when there is an imminent risk to
the student-athlete or others, to going to the nearest hospital
emergency department. Assessing the level of risk is a
judgment that has become known as a threat assessment.
The US Department of Education’s Office for Civil Rights
has described ‘‘ a significant risk to the health or safety of
the student or others’’ as follows: ‘‘ a significant risk
constitutes a high probability of substantial harm, not just
slightly increased, speculative or remote risk.’’
112
Such
considerations should be described and defined in the
secondary school plan, so that individuals have guidance in
operating during emergency situations to protect the health
and safety of the student-athlete, as well as others.
Finally, even if a student-athlete refuses to sign a waiver
for release of confidential information, state law may
mandate notification. Secondary school district policy must
be followed.
Education
Providing education on stress, stress-management strat-
egies, and services available to the student-athlete to
better manage stressors and improve his or her ability to
function, both on and off the field, is as beneficial as
information on hydration, nutrition, and sleep to improve
performance. Any threat to the student-athlete’s identity
as an athlete because of an injury, poor performance, or
strife with the coach or teammates may trigger a new
psychological concern or exacerbate an existing one.
Mental health literacy is a problem among school-aged
students. Many do not recognize when they are experi-
encing symptoms.
113
An educational component on psychological health
should be developed for presentation to student-athletes,
coaches, and parents. This educational component may
include information from this consensus statement regard-
ing the prevalence of psychological concerns in adoles-
cents, stressors unique to secondary school student-athletes,
behaviors to monitor, and the school district’s policy on
referring s tudents for psychological evaluation. This
educational component will help to destigmatize psycho-
logical concerns, encourage student-athletes to seek help,
and inform the coach and parents of the procedure to follow
when a psychological evaluation seems appropriate, in
order to assist the student-athlete with psychological health
and well-being.
Building a Plan for Recognition and Referral of
Student-Athletes With Psychological Concerns
The primary purpose of this consensus statement was to
offer recommendations to the AT, working in collaboration
with the athletic department and institutional administra-
tion, about developing a plan to recognize and refer
student-athletes with psychological concerns. Ideally, an
AT practicing full time in a secondary school district will
be the ‘‘ point person ’’ in developing the plan and leading
the collaborative efforts to implement it. However, if no AT
is employed to provide athletic training services at the
secondary school, this plan can be developed by the school
district and modified accordingly.
To summarize, the following are considerations in
building a plan for the recognition and referral of student-
athletes with psychological concerns:
1. Establish the need for a plan to recognize and refer
student-athletes with psychological concerns. Use the
data provided in this c onsensus statement to prepare a
memorandum to the secondary school administration
outlining t he prevalence of mental disorders in adoles-
cents, the stressors found in student-athletes, and t he
availability of mental health care in the community. Once
the decision has been made to start this process, draft a
document.
Table 14. Helping Survivors of Suicide
107
The loss of a loved one by suicide is often shocking, painful, and
unexpected. The grief that ensues can be intense, complex, and
long term. Grief and bereavement is an extremely individual and
unique process.
There is no given duration to being bereaved by suicide. Survivors of
suicide are not looking for their lives to return to their prior state
because things can never go back to how they were. Survivors aim
to adjust to life without their loved one.
Common emotions experienced with grief are
Shock
Pain
Anger
Despair
Depression
Sadness
Rejection
Abandonment
Denial
Numbness
Shame
Disbelief
Stress
Guilt
Loneliness
Anxiety
The single most important and helpful thing you can do is listen. Let
them talk at their own pace; they will share with you when (and
what) they are ready to. Be patient. Repetition is a part of healing,
and as such, you may hear the same story multiple times.
Repetition is part of the healing process, and survivors need to tell
their stories as many times as necessary. You may not know what
to say, and that’s okay. Your presence and unconditional listening
are what a survivor is looking for.
Survivors of suicide support groups are helpful to survivors to express
their feelings, tell their stories, and share with others who have
experienced a similar event. These groups are good resources for
the healing process, and many survivors find them helpful. Please
consult our Web site (www.suicidology.org) for a listing of support
groups in or near your community.
Additional resources
Survivors of Suicide (www.survivorsofsuicide.com)
Suicide Awareness: Voices of Education (SAVE; www.save.org)
American Foundation of Suicide Prevention (AFSP; www.afsp.org)
Adapted with permission from the American Association of
Suicidology.
244 Volume 50
Number 3
March 2015
2. Draft the plan. Consider including the following sections:
introduction; education on mental health issues facing the
adolescent student (based on the data in this statement and
consisting of a backgr ound section, stressors, and triggers)
to raise the awareness of school nurses, school counselors,
coaches, administrators, and staff; behaviors to monitor;
special needs of the student-athlete; and the secondary
school district’s procedure for referral. Information about
confidentiality should also be provided. Be sure to make
clear that when personnel are unsure of what to do, they
should call the appropriate secondary school entity (for
example the principal or superintendent’s office) for
direction.
3. Once the draft of the document is finished, share it with the
secondary school nurse, school counselor, and administra-
tion for review. Sharing a copy of this consensus statement
for all parties to review as the plan is being developed may
be helpful. Having preexisting relationships with these
personnel will provide an easier path for introdu ction and
discussion of the plan. Have all departments review,
amend, and approve the plan for legal and procedural
purposes. Remember, this document contains consider-
ations of what to do, rather than hard rules. No single plan
can contain guidance for every situation. Each secondary
school can have its own vers ion based on the specific
resources available.
4. Once the plan has been approved by all parties, send it to
all sports medicine staff, physicians, school nurses, school
counselors, coaches, and administrators. Be sure each
professional has easy access to the document; no one can
tell when a student-athlete may need assistance, and having
a readily accessible plan for help navigating the process is
helpful.
5. Review and update the plan annually or as necessary.
The information contained in this consensus statement,
along with practical considerations in developing a school-
specific plan for recognizing and referring student-athletes
for psychological concerns, will assist in developing a plan
and assisting student-athletes in need. Variables such as
institutional human resource guidelines, state or federal
laws, statutes, rules, and regulations may affect the
development and implementation of these recommenda-
tions.
CONCLUSIONS
The most important factors in helping a student-athlete
with a psychological concern are education, early recogni-
tion of a potential problem, and effective referral to the
mental health system. The athletic community is in a
unique position to observe and interact with student-
athletes. By raising the awareness of the prevalence of
mental disorders in adolescent students, understanding the
stressors placed on student-athletes, observing behavior,
and facilitating evaluation and care through referral of the
student-athlete to mental health care professionals for
assistance, the AT, physician, nurse, school counselor,
coach, or administrator may make a difference in the life of
a student-athlete. Developing a plan to address psycholog-
ical concerns will make the recognition and referral of
student-athletes with psychological concerns more effec-
tive, while minimizing the risk to the athletic department
and secondary school district.
REFERENCES
1. Comstock RD, Collins CL, Currie DW. Summary report: national
high school sports-related injury surveillance study: 2012–2013
year. Center for Injury Research & Policy. The University of
Colorado at Denver Web site. http://www.ucdenver.edu/academics/
colleges/PublicHealth/research/ResearchProjects/piper/projects/
RIO/Documents/2012-13.pdf. Accessed October 6, 2014.
2. Neal TL, Diamond AB, Goldma n S, et al. Inter-association
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. J Athl Train. 2013;
48(5):716–720.
3. Guideline 2o: Mental health: interventions for intercolleg iate
athletics. In: Klossner D, ed. 2012–13 NCAA Sports Medicine
Handbook. 23rd ed. Indianapolis, IN: The National Collegiate
Athletic Association; 2012:77–83.
4. Neal TL. Recognizing the signs. Train Condition. 2012;22(3):36–
43.
5. Neal TL. Game changers: mental-health issues can impair a student-
athlete’s performance, so support is critical. Adv Phys Ther Rehab
Med. 2010:21(25):32–33.
6. Results from the 2010 National Survey on Drug Use and Health:
Mental Health Findings. NSDUH Series H-42, HHS Publication
No. (SMA) 11–4667. Rockville, MD: Substance Abuse and Mental
Health Services Administration; 2012. http://www.samhsa.gov/data/
nsduh/2k10MH_Findings/2k10MHResults.pdf. Accessed October
6, 2014.
7. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation
taxonomy (SORT): a patient-centered approach to grading evidence
in the medical literature. Am Fam Physician. 2004;69(3):548–556.
8. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 5th ed. Arlington, VA: American
Psychiatric Association; 2013.
9. Anderson JC, Courson RW, Kleiner DM, McLoda TA. National
Athletic Trai ners’ Association position statement: emergency
planning in athletics. J Athl Train. 2002;37(1):99–104.
10. Office of the Surgeon General; Center for Mental Health Services;
National Institute of Mental Health. Mental Health: Culture, Race,
and Ethnicity: A Supplement to Mental Health. A Report of the
Surgeon General. Rockville, MD: Substance Abuse and Mental
Health Services Administration; 2001.
11. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of
mental disorders in US adolescents: results from the National
Comorbidity Survey Replication–Adolescent Supplement (NCS-A).
J Am Acad Child Adolesc Psychiatry. 2010;49(10):980–989.
12. Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in
older adolescents: prevalence, risk factors, and clinical implications.
Clin Psychol Rev. 1998;18(7):765–794.
13. Marcus SC, Olfson M. National trends in the treatment for
depression from 1998 to 2007. Arch Gen Psychiatry. 2010;67(12):
1265–1273.
14. Kessler RC, Wang PS. The descriptive epidemiology of commonly
occurring mental disorders in the United States. Annu Rev Public
Health. 2008;29:115–129.
15. McLaughlin KA, Greif Green J, Gruber MJ, Sampson NA,
Zaslavsky AM, Kessler RC. Childhood adversities and first onset
of psychiatric disorders in a national sample of US adolescents.
Arch Gen Psychiatry. 2012;69(11):1151–1160.
16. Kessler RC, Avenevoli S, McLaughlin KA, et al. Lifetime co-
morbidity of DSM-IV disorders in the US National Comorbidity
Survey Replication–Adolescent Supplement (NCS-A). Psychol
Med. 2012;42(9):1997–2010.
17. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month
prevalence of DSM-III-R psychiatric disorders in the United States:
Journal of Athletic Training 245
results from the National Comorbidity Survey. Arch Gen Psychi-
atry. 1994;51(1):8–19.
18. Regier DA, Kaelber CT, Rae DS, et al. Limitations of diagnostic
criteria and assessment instruments for mental disorders: implica-
tions for research and policy. Arch Gen Psychiatry. 1998;55(2):
109–115.
19. Kessler RC, Berglund PA, Bruce ML, et al. The prevalence and
correlates of untreated serious mental illness. Health Serv Res.
2001;36(6, pt 1):987–1007.
20. Kessler RC, Zhao S, Katz SJ, et al. Past-year use of outpatient
services for psychiatric problems in the National Comorbidity
Survey. Am J Psychiatry. 1999;156(1):115–123.
21. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE.
Prevalence, se verity, and comorbidity of 12-month DSM-IV
disorders in the National Comorbidity Survey Replication. Arch
Gen Psychiatry. 2005;62(6):617–627.
22. Comer JS, Blanco C, Hasin DS, et al. Health-related quality of life
across the anxiety disorders: results from the National Epidemio-
logical Survey on Alcohol and Related Conditions (NESARC). J
Clin Psychiatry. 2011;72(1):43–50.
23. Kessler RC, Coccaro EF, Fava M, Jaeger S, Jin R, Walters E. The
prevalence and correlates of DSM-IV intermittent explosive disorder
in the National Comorbidity Survey Replication. Arch Gen
Psychiatry. 2006;63(6):669–678.
24. Merikangas KR, Nakamura EF, Kessler RC. Epidemiology of
mental disorders in children and adolescents. Dialogues Clin
Neurosci. 2009;11(1):7–20.
25. Lewinsohn PM, Moerk KC, Klein DN. Epidemiology of adolescent
depression. Econ Neurosci. 2000;2:52–68.
26. Lewinsohn PM, Duncan EM, Stanton AK, et al. Age at first onset
for nonbipolar depression. J Abnorm Psychol. 1986;95(4):378–383.
27. Belfer ML. Child and adolescent mental disorders: the magnitude of
the problem across the globe. J Child Psychol Psychiatry. 2008;
49(3):226–236.
28. Jonas BS, Gu Q, Albertorio-Diaz JR. Psychotropic medication use
among adolescents: United States, 2005–2010. NCHS Data Brief.
2013;(135):1–8.
29. Cohen P, Pine DS, Must A, et al. Prospective associations between
somatic illness and mental illness from childhood to adulthood. Am
J Epidemiol. 1998;147(3):232–239.
30. Parry-Langdon N, Clements A, Fletcher D, et al. Three Years On:
Survey of the Development and Emotional Well-Being of Children
and Young People. Newport, UK: Office for National Statistics;
2008.
31. Meeusen R, Duclos M, Foster C, et al. Prevention, diagnosis, and
treatment of the overtraining syndrome: joint consensus statement
of the European College of Sport Science and the American College
of Sports Medicine. Med Sci Sports Exerc. 2013;45(1):186–205.
32. Winsley R, Matos N. Overtraining and elite young athletes. Med
Sport Sci. 2011;56:97–105.
33. Armstrong LE, VanHeest JL. The unknown mechanism of the
overtraining syndrome: clues from depression and psychoneuroim-
munology. Sports Med. 2002;32(3):185–209.
34. Meeusen R, Piacentini MF, Busschaert B, Buyse L, De Schutter G,
Stray-Gundersen J. Hormonal responses in athletes: the use of a two
bout exercise protocol to detect subtle differences in (over) training
status. Eur J Appl Physiol. 2004;91(2–3):140–146.
35. Rechel JA, Yard EE, Comstock RD. An epidemiologic comparison
of high school sports injuries sustained in practice and competition.
J Athl Train. 2008;43(2):197–204.
36. Good AJ, Brewer BW, Petitpas AJ, Van Raalte JL, Mahar MT.
Identity foreclosure, athletic identity, and college sport participa-
tion. Acad Athl J. 1993;8:1–12.
37. Baillie PH, Danish SJ. Understanding the career transition of
athletes. Sport Psychol. 1992;6(1):77–98.
38. McPherson BD. Retirement from professional sport: the process and
problems of occupational and psychological adjustment.
Sociol
Symp. 1980;30:126–143.
39. Linville PW. Self-complexity as a cognitive buffer against stress-
related illness and depression. J Pers Soc Psychol. 1987;52(4):663–
676.
40. Etzel EF, Ferrante AP, Pinkney JW. Counseling College Student-
Athletes: Issues and Interventions. 2nd ed. Morgantown, WV:
Fitness Information Technology; 1996.
41. Derman W, Schwellnus MP, Lambert MI, et al. The ‘‘ worn-out
athlete’’ : a clinical approach to chronic fatigue in athletes. J Sports
Sci. 1997;15(3):341–351.
42. Gould D. Personal motivation gone awry: burnout in competitive
athletes. Quest. 1996;48(3):275–289.
43. Gould D, Dieffenbach K. Overtraining, under-recovery, and burnout
in sport. In: Kellmann M, ed. Enhancing Recovery: Preventing
Underperformance in Athletes. Champaign, IL: Human Kinetics;
2002:25–35.
44. Hanin Y. Individually optimal recovery in sports: an application of
the IZOF model. In: Kellmann M, ed. Enhancing Recovery:
Preventing Underperformance in Athletes. Champaign, IL: Human
Kinetics; 2002:199–217.
45. Kellmann M, Kallus KW. Mood, recovery-stress state, and
regeneration. In: Lehmann M, Foster C, Gastmann U, Keizer H,
Steinacker JM, eds. Overload, Performance Incompetence, and
Regeneration in Sport. New York, NY: Plenum; 1999:101–117.
46. Kellmann M. Psychological assessment of under-recovery. In:
Kellmann M, ed. Enhancing Recovery: Preventing Underperform-
ance in Athletes. Champaign, IL: Human Kinetics; 2002:37–55.
47. Puffer JC, McShane JM. Depression and chronic fatigue in athletes.
Clin Sport Med. 1992;11(2):327–338.
48. Raedeke TD. Is athlete burnout more than just stress? A sport
commitment perspective. J Sport Exerc Psychol. 1997;19(4):396–
417.
49. Shuer ML, Dietrich MS. Psychological effects of chronic injury in
elite athletes. West J Med. 1997;166(2):104–109.
50. Silva JM. An analysis of the training stress syndrome in competitive
athletics. J Appl Sport Psychol. 1990;2(1):5–20.
51. Tsuno N, Besset A, Ritchie K. Sleep and depression. J Clin
Psychiatry. 2005:66(10):1254–1269.
52. Voelker R. Stress, sleep loss, and substance abuse create potent
recipe for college depression. JAMA. 2004;291(18):2177–2179.
53. Yang J, Peek-Asa C, Corlette JD, Cheng G, Foster DT, Albright J.
Prevalence of and risk factors associated with symptoms of
depression in competitive collegiate student athletes. Clin J Sport
Med. 2007;17(6):481–487.
54. Andersen MB, Denson EL, Brewer BW, Van Raalte JL. Disorders
of personality and mood in athletes: recognition and referral. J Appl
Sport Psychol. 1994;6(2):168–184.
55. Armstrong S, Oomen-Early J. Social connectedness, self-esteem,
and depression symptomatology among collegiate athletes versus
nonathletes. J Am Coll Health. 2009;57(5):521–526.
56. Broshek DK, Freeman JR. Psychiatric and neuropsychological
issues in sport medicine. Clin Sports Med. 2005;24(3):663–679.
57. Davis H. Neurophysiologic consequences of competitive upset: an
MRI and CBT study. Paper presented at: Annual Meeting of the
Association for the Advancement of Applied Sport Psychology;
October 2005; Vancouver, British Columbia, Canada.
58. Donohue B, Covass in D, Lancer K, et al. Exami nation of
psychiatric symptoms in student-athletes. J Gen Psychol. 2004;
131(1):29–35.
59. Managing student-athletes’ mental health issues. National Colle-
giate Athletic Association Web site. http://www.NCAA.org/health-
safety. Accessed October 7, 2014.
246 Volume 50
Number 3
March 2015
60. Signs and symptoms of depression. National Institute of Mental
Health Web site. http://www.nimh.nih.gov/health/topics/depression/
men-and-depres sion/signs-and-symptoms- of-depression/index.
shtml. Accessed December 22, 2014.
61. Diseases and conditions: anxiety. Mayo Clinic Web site. http://
www.mayoclinic.org/diseases-conditions/anxiety/basics/symptoms/
con-20026282. Accessed December 22, 2014.
62. Ray R, Wiese-Bjornstal DM. Counseling in Sports Medicine.
Champaign, IL: Human Kinetics; 1999.
63. Ardern CL, Taylor NF, Feller JA, Webster KE. A systematic review
of the psychological factors associated with returning to sport
following injury. Br J Sports Med. 2001;45(7):596–606.
64. Giza CC, Hoyda DA. The neurometabolic cascade of concussion. J
Athl Train. 2001;36(3):228–235.
65. Schoenhuber R, Gentilini M. Anxiety and depression after mild
head injury: a case control study. J Neurol Neurosurg Psychiatry.
1988;51:722–724.
66. Guskiewicz KM, Marshall SW, Bailes J, et al. Association
between recurre nt concussion and late-life cognitive im pairment
in retired professional football p lay ers. Neurosurgery. 2 005;57(4 ):
719–726.
67. Karzmark P, Hall K, Englander J. Late-onset post-concussion
symptoms after mild brain injury: the role of premorbid, injury-
related, environmental, and personality factors. Brain Inj. 1995;
9(1):21–26.
68. Kerr ZY, Marshall SW, Harding HP, Guskiewicz KM. Nine-year
risk of depression diagnosis increases with increasing self-reported
concussions in retired professional football players. Am J Sports
Med. 2012;40(10):2206–2212.
69. Chen JK, Johnston KM, Petrides M, Ptito A. Neural substrates of
symptoms of depression following concussion in male athletes with
persisting post-concussion symptoms. Arch Gen Psychiatry. 2008;
65(1):81–89.
70. Pennington N. Head injuries in children. J Sch Nurs. 2010;26(1):
26–32.
71. Johnston LD, O’Malley PM, Bac hman JG, Schulenberg JE.
Monitoring the Future National Results on Adolescent Drug Use:
Overview of Key Findings. Bethesda, MD: National Institute on
Drug Abuse; 2007.
72. Miller BE, Miller MN, Verhegge R, Linville HH, Pumariega AJ.
Alcohol misuse among college athletes: self-medication for
psychiatric symptoms? J Drug Educ. 2002;32(1):41–52.
73. Johnson T, Shapiro R. National Survey on American Attitudes on
Substance Abuse XVII: Teens. The National Center on Addiction
and Substance Abuse at Columbia University Web site. http://www.
casacolumbia.org/addiction-research/reports/national-survey-
american-attitudes-substance-abuse-teens-2012. Accessed October
7, 2012.
74. DrugFacts: comorbidity. Addiction and other mental disorders.
National Institute on Drug Abuse Web site. http://www.drugabuse.
gov/publications/drugfacts/comorbidity-addiction-other-mental-
disorders. Accessed December 22, 2014.
75. Putukian M, Kreher J, Coppel D, Glazer J, McKeag D, White R.
Attention hyperactivity disorder and the athlete: an American
Medical Society for Sports Medicine position statement. Clin J
Sport Med. 2011;21(5):392–401.
76. Perrin AE, Jotwani VM. Addressing the unique issues of student
athletes with ADHD. J Fam Pract. 2014;63(5):E1–E9.
77. Preti A, Girolamo G, Vilagut G, et al. The epidemiology of eating
disorders in six European countries: results of the ESEMeD-WMH
project. J Psychiatr Res. 2009;43(14):1125–1132.
78. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and
correlates of eating disorders in the National Comorbidity Survey
Replication. Biol Psychiatry. 2007;61(3):348–358.
79. Garfinkel PE, Lin E, Goering P, et al. Should amenorrhea be
necessary for the diagnosis of anorexia nervosa? Evidence from a
Canadian community sample. Br J Psychiatry. 1996;168(4):500–
506.
80. Walters EE, Kendler KS. Anorexia nervosa and anorexia-like
syndromes in a population-based female twin sample. Am J
Psychiatry
. 1995;152(1):64–71.
81. Bijl RV, Ravelli A, van Zessen G. Prevalence of psychiatric
disorder in the general population: results of the Netherlands Mental
Health Survey and Incidence Study (NEMESIS). Soc Psychiatry
Psychiatr Epidemiol. 1998:33(12):587–595.
82. Bushnell JA, Wells JE, Hornblow AR, Oakley-Browne MA, Joyce
P. Prevalence of three bulimia syndromes in the general population.
Psychol Med. 1990:20(3):671–680.
83. Kendler KS, MacLean C, Neale M, Kessler R, Heath A, Eaves L.
The genetic epidemiology of bulimia nervosa. Am J Psychiatry.
1991;148(12):1627–1637.
84. Garfinkel PE, Lin E, Goering P, et al. Bulimia nervosa in a
Canadian c ommunity sample: prevale nce and comparis on of
subgroups. Am J Psychiatry. 1995;152(7):1052–1058.
85. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 4th ed. Arlington, VA: American
Psychiatric Association; 1994.
86. Eddy KT, Celio Doyle A, Hoste RR, Herzog DB, le Grange D.
Eating disorder not otherwise specified in adolescents. J Am Acad
Child Adolesc Psychiatry. 2008;47(2):156–164.
87. Fairburn CG, Bohn K. Eating disorder NOS (EDNOS): an example
of the troublesome ‘‘ not otherwise specified’’ (NOS) category in
DSM-IV. Behav Res Ther. 2005;43(6):691–701.
88. Turner H, Brant-Waugh R. Eating disorder not otherwise specified
(EDNOS): profiles of clients presenting at a community eating
disorder service. Eur Eat Disord Rev. 2004;12(1):18–26.
89. Currie A, Morse ED. Eating disorders in athletes: managing the
risks. Clin Sports Med. 2005;24(4):871–883.
90. Eating disorders. National Institute of Mental Health Web site.
http://www.nimh.nih.gov/health/topics/eating-disorders/index.
shtml#part3. Accessed December 22, 2014.
91. Youth risk behavior surveillance: United States, 2011. Centers for
Disease Control and Prevention Web site. http://www.cdc.gov/
MMWR/PDF/SS/SS6104.PDF. Accessed October 7, 2014.
92. Gladden RM, Vivolo-Kantor AM, Hamburger ME, Lumpkin CD.
Bullying surveillance among youths: uniform definitions for public
health and recommended data elements, version 1.0. Centers for
Disease Control and Prevention Web site. http://www.cdc.gov/
violenceprevention/pdf/bullying-definitions-final-a.pdf. Published
2014. Accessed October 7, 2014.
93. Robers S, Kemp J, Truman J, Snyder TD. Indicators of school crime
and safety: 2012. The National Center for Education Statistics Web
site. http://nces.e d.gov/pubs2013/201 3036.pdf. Published 2013.
Accessed October 7, 2014.
94. Lesyk JJ, Kornspan AS. Coaches’ expectations and belie fs
regarding benefits of youth sport participation. Percept Mot Skills.
2000;90(2):399–402.
95. Batsche GM, Knoff HM. Bullies and their victims: understanding a
pervasive problem in the schools. Sch Psychol Rev. 1994;23(2):
165–174.
96. Who is at risk? Warning signs. US Department of Health and
Human Services Web site. http://www.stopbullying.gov/at-risk/
warning-signs/index.html. Accessed October 7, 2014.
97. Hoover NC, Pollard NJ. Initiation rites in American high schools: a
national survey. Alfred University Web site. http://www.alfred.edu/
hs_hazing/. Accessed October 7, 2014.
98. Hazing. National Federation of State High School Associations
Web site. http://www.nfhs.org/hazing.aspx. Accessed October 7,
2014.
Journal of Athletic Training 247
99. Mann BJ, Grana WA, Indelicato PA, O’Neill DF, George SZ. A
survey of sports medicine physicians regarding psychological issues
in patient-athletes. Am J Sports Med. 2007;35(12):2140–2147.
100. Stiller-Ostrowski JL, Ostrowski JA. Recently certified athletic
trainer’s undergraduate educational preparation in psychosocial
intervention and referral. J Athl Train. 2009;44(1):67–75.
101. Misasi SP, Davis CF, Morin GE, Stockman D. Academic
preparation of athletic trainers as counselors. J Athl Train. 1996;
31(1):39–42.
102. Carroll JFX, McGinley JJ. A screening form for identifying mental
health problems in alcohol/other drug dependent persons. Alcohol
Treat Q. 2001;19(4):33–47.
103. Schwenk TL. The stigmatization and denial of mental illness in
athletes. Br J Sports Med. 2000;34(1):4–5.
104. Pinkerton RS, Hinz LD, Barrow JC. The college student-athlete:
psychological considerations and interventions. J Am Coll Health.
1989;37(5):218–226.
105. Kann L, Kinchen S, Shanklin SL, et al. Youth risk behavior
surveillance: US, 2013. MMWR Morbid Mortal Wkly Rep. 2013;
63(SS04):1–168.
106. Suicide: risk and protective factors. Centers for Disease Control and
Prevention Web site. http://www.cdc.gov/violenceprevention/
suicide/riskprotectivefactors.html. Accessed December 22, 2014.
107. Helping survivors of suicide : what can you do? American
Association of Suicidology Web site. http://www.suicidology.org/
Portals/14/docs/Survivors/Loss%20Survivors/Hepling-Survivors-
of-Suicide_What-Can-You-Do.pdf. Accessed December 22, 2014.
108. Bonanno GA. Loss, trauma, and human resilience: have we
under estimated the human capacity to thrive after extremely
aversive events? Am Psychol. 2004;59(1):20–28.
109. Everly GS, Jr, Welzant V, Jacobson JM. Resistance and resilience:
the final frontier in traumatic stress management. Int J Emerg Ment
Health. 2008;10(4):261–270.
110. Everly GS, Mitchell JT. Integrative Crisis Intervention and Disaster
Mental Health. Ellicott City, MD: Chevron; 2008.
111. Hobfoll SE, Watson P, Bell C, et al. Five essential elements of
immediat e and mid-term mass trauma intervention: empirical
evidence. Psychiatry. 2007;70(4):283–315.
112. Student mental health and the law. The Jed Foundation Web site.
https://www.jedfoundation.org/professionals/programs-and-
research/legal-resource. Accessed October 7, 2014.
113. Skre I, Friborg O, Breivik C, Johnsen LI, Arnesen Y, Wang CE. A
school intervention for mental health literacy in adolescents: effects
of a non-randomized cluster controlled trial. BMC Public Health.
2013;13:873.
Address correspondence to Timothy L. Neal, MS, ATC, TLN Consulting, 8285 Dampier Circle, Liverpool, NY 13090. Address e-mail to
248 Volume 50
Number 3
March 2015
Appendix. Interassociation Writing Group: Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns at the
Secondary School Level. Participating National Organizations and Endorsing National Societies
Chair Organization
Timothy L. Neal, MS, ATC National Athletic Trainers’ Association
President, TLN Consulting
Liverpool, NY
Kembra Mathis, MEd, ATC
Sports Medicine Instructor
Bentonville High School, AR
Stacey J. Ritter, MS, ATC
Director of Sports Medicine and Athletic Training
San Luis Sports Therapy
San Luis Obispo, CA
Alex B. Diamond, DO, MPH American Academy of Pediatrics
Assistant Professor of Orthopedics and Rehabilitation
Assistant Professor of Pediatrics
Vanderbilt University School of Medicine
Nashville, TN
Scott Goldman, PhD, CC-AASP Association of Applied Sport Psychiatry
Director of Athletic Counseling
University of Michigan, Ann Arbor
Karl D. Liedtka, MS American School Counselor Association
Supervisor, K–12 Counseling Program
Lebanon High School, PA
Eric D. Morse, MD, DFAPA International Society of Sports Psychiatry
Carolina Performance
Raleigh, NC
Margot Putukian, MD, FACSM American Medical Society for Sports Medicine
Director of Athletic Medicine
Princeton University, NJ
Eric Quandt, JD
Scharf Banks Marmor, LLC
Chicago, IL
John P. Sullivan, PsyD American Psychological Association, Division 47: Exercise and Sport Psychology
Founder/CEO
Clinical & Sports Consulting Services
Providence, RI
Victor Welzant, PsyD International Critical Incident Stress Foundation
Director of Education and Training
The International Critical Incident Stress Foundation, Inc
Ellicott City, MD
Journal of Athletic Training 249
