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W2145672109 abstract "During the 2012–2013 academic year, 7.7 million secondary school students took part in organized interscholastic sports, compared with just 4 million participants during the 1971–1972 year.1 Many student-athletes define themselves by their identities as athletes.2 Threats to that identity may come in the form of struggling performance; a chronic, career-ending, or time-loss injury; conflicts with coaches and teammates; or simply losing the passion for playing their sport.3–5 These challenges and associated factors may put the student-athlete in a position to experience a psychological concern or to exacerbate an existing mental health concern.2The types, severities, and percentages of mental illnesses are growing in young adults aged 18 to 25 years, an age group a little older than secondary school student-athletes.6 Given that mental illnesses being reported in the 18- to 25-year-old age group may well start before or during adolescence and given the overall numbers of student-athletes at the secondary school level, clinicians are certain to encounter student-athletes with psychological concerns. The goal of this consensus statement is to provide recommendations for developing a plan to address the psychological concerns of student-athletes at the secondary school level. The recommendations will discuss education on mental disorders in young adults, stressors unique to being a student-athlete at the secondary school level, recognition of behaviors to monitor, special circumstances faced by student-athletes that may affect their psychological health, collaborating with secondary school professionals to assist student-athletes with psychological concerns, and legal considerations. Also addressed are educational efforts for student-athletes, coaches, and parents, as well as practical steps to consider when proposing a psychological-concerns plan to administration. The interassociation work group that developed these recommendations included representatives from 8 national organizations and an attorney experienced in sports medicine and health-related litigation; all members had a special interest in and experience with psychological concerns in student-athletes. This multidisciplinary group of professionals included experts in athletic training, general medicine, psychology, psychiatry, pediatrics, secondary school counseling, sport psychology, critical-incident stress management, and law.Recommendations of the consensus statement are directed at the athletic health care team, athletic department administration and staff, and secondary school administration. This includes athletic trainers (ATs); team physicians; coaches; athletic department administrators; administrators such as principals and superintendents; secondary school nurses; and secondary school counselors. It is imperative to remember that the student-athlete is first and foremost a student of the school district and in most cases a minor child; therefore, collaboration with secondary school departments is a must.Two points about this consensus statement are critical. First, the terms psychological concern and mental disorder are used instead of mental illness because only credentialed mental health care professionals have the legal authority to diagnose a mental illness. Suspecting a mental illness in a student-athlete that affects the student-athlete's psychological health is a concern that noncredentialed mental health care professionals have. Thus, we selected psychological concerns for the title, although that term and mental disorder are interchangeable within the statement. Second, only credentialed, licensed mental health care professionals are to legally evaluate, diagnose, treat, and classify a student-athlete with a mental illness. The credentialed mental health care professional should perform that medical-legal duty and not a noncredentialed individual, no matter how caring that person may be. This consensus statement was produced to inform ATs about developing a plan to recognize potential psychological concerns in secondary school student-athletes and to establish an effective mechanism for referring the student-athlete into the mental health care system for assessment and treatment by a credentialed mental health care professional. This consensus statement does not make recommendations regarding mental illness evaluation or care. Rather, our intent was to assist the AT, in collaboration with the athletic department and secondary school administration, in facilitating the evaluation and care of the student-athlete suspected of a psychological concern by credentialed mental health care professionals. Throughout this statement, the terms psychological and mental are used; various authors in both the text and in literature citations chose to use one or the other. Although the terms are synonymous, the focus of the statement is recognition and referral, not treatment; treatment is left to the credentialed mental health care professional. Additionally, in this statement, the term secondary school is interchangeable with high school as found in the literature.This statement mirrors the 2013 document “Interassociation Recommendations for Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns at the Collegiate Level: An Executive Summary of a Consensus Statement.”2 That statement was designed for use by the AT practicing at the intercollegiate level. The current statement is designed for use by ATs practicing at the secondary school level, or in the absence of an AT at a particular secondary school, administrators may use this statement to develop a plan to address their student-athletes' psychological concerns. Ideally, a certified AT will help to develop and implement the recommendations of this consensus statement. The information contained in the collegiate and high school statements is similar but is targeted for each audience, and each statement is to be regarded as a stand-alone document for the indicated setting.The purpose of this consensus statement is for the reader to take the information provided and develop an appropriate plan for his or her institution to address the psychological concerns of student-athletes as part of a comprehensive sports medicine health care program. Specific goals of the statement are toThis consensus statement is organized as follows:The recommendations in this consensus statement use the Strength of Recommendation Taxonomy (SORT) criterion scale proposed by the American Academy of Family Physicians,7 which are based on the highest quality of evidence available. Each letter designation characterizes the quality, quantity, and consistency of evidence in the available literature to support a recommendation.Although this consensus statement uses SORT level C evidence for best practices, the educational component of mental illness in young adults is based on SORT level A evidence.Category: ACategory: ACategories: B, CCategories: A, BCategories: B, CCategory: CSimilar to physical injuries, psychological concerns can range from mild to severe, with varying effects on the life of the adolescent. In addition, some of these conditions can be lifelong, whereas others may be short-lived. Normal adolescence is a period of great change and maturation, during which emotional and behavioral difficulties are commonplace; however, the incidence of diagnosed mental health conditions remains consistent across studies, and psychological concerns must be appropriately recognized and treated.In 2001, the US Surgeon General10 defined mental health as “the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity.” Approximately 1 in every 4 to 5 youths in this country experiences impairment during his or her lifetime as a result of a mental health disorder.11 The prevalence of many emotional and behavioral disorders in children and adolescents is higher than that of some well-known physical ailments, such as asthma and diabetes.11The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),8 states that “a mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning.” The definition8 further states that mental disorders are “usually associated with significant distress or disability in social, occupational, or other important activities.” It is important to note that classifying a mental disorder only describes the mental disorder an individual has; it does not describe the individual.8 Thus, labeling a student-athlete as a “maniac” or a “druggie” further stigmatizes individuals with mental disorders. The diagnosis of a mental disorder should also have clinical utility, meaning it should assist clinicians in determining the treatment plan and prognosis for the patient. Having the diagnosis of a mental disorder is not equivalent to needing treatment.8Most DSM-5 disorders have a numeric International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code, and the DSM-5 disorders are grouped into 22 major diagnostic classes, categorizing hundreds of mental disorders.8 The DSM-5 diagnosis is applied to an individual's current presentation, not to a previous diagnosis.8 It is imperative that the DSM-5 not be applied by untrained individuals. Only those with appropriate clinical training and diagnostic skills may diagnose an individual with a mental disorder. The criteria in the DSM-5 serve as a guideline for the mental health care professional to form a clinical judgment and are not merely a recipe to follow.8In a recent study, nearly 1 in 3 adolescents (31.9%) met the criteria for anxiety disorder, 19.1% were affected by behavioral disorders, 14.3% experienced mood disorders, and 11.4% had substance-use disorders.11 The early onset of major classes of mental disorders has been documented.6 Of the affected adolescents,11 half experienced symptoms of their anxiety disorder by age 6, of their behavioral disorder by age 11, of their mood disorder by age 13, and of their substance-use disorder by age 15. Comorbidity rates of affected individuals have been reported at 40%, and 22.2% described having a mental disorder with severe impairment or distress that interfered with daily life.11The average age of onset for major depression and dysthymia is between 11 and 14 years of age.12 The rate of outpatient treatment for depression13 increased markedly in the United States between 1987 and 1997, with 75.3% of those individuals being treated with antidepressant medication in 2007.The US Substance Abuse and Mental Health Services Administration6 reported in 2012 that 45.9 million American adults aged 18 or older, 20% of the survey population, experienced a mental illness in 2010. Of those aged 12 to 17 years, 8% (1.9 million) had experienced a major depressive episode in 2010, which was defined as having a depressed mood or loss of interest in daily activities that lasted at least 2 weeks.6Most seriously impairing and persistent mental disorders found in adults are associated with onset during childhood or adolescence and have high comorbidity.14 Of adolescents aged 13 to 17 years who had experienced childhood adversity (ie, parental loss, parental maltreatment, parental maladjustment, or economic hardship), 58.3% reported at least 1 childhood adversity and 59.7% reported multiple childhood adversities; childhood adversities were strongly associated with the onset of psychiatric disorders. The prevalence ranged from 15.7% with fear disorders to 40.7% with behavioral disorders. A total of 28.2% of all onsets of psychiatric disorders were associated with 1 or more childhood adversities.15 Disorder onset was somewhat predictable and provides clues to the best times for intervention. The median age of disorder onset was 6 years for anxiety, 11 years for behavior, 13 years for mood, and 15 years for substance use.16Epidemiologic surveys estimate that as many as 30% of the adult population in the United States meet the criteria for a year-long DSM mental disorder.17,18 Fewer than half of individuals diagnosed with a mental disorder receive treatment.19,20 Mental disorders are widespread, with serious cases concentrated in a relatively small proportion of patients with high comorbidity.21Anxiety disorders are reported often in mental-disorder surveys21 and appear to exact significant and independent tolls on health-related quality of life.22Mental health care professionals are discovering more information on various mental health disorders. For example, intermittent explosive disorder is much more common than previously recognized.23 The typical onset is at age 14 years, with significant comorbidity of mental disorders that have later ages of onset. Only 28.8% of patients ever received treatment for their anger.23Anxiety disorders, such as panic disorders and social phobia, were the most common conditions, affecting 31.9% of teens. Next were behavioral disorders, including ADHD, which affect 19.1% of teens. Mood disorders, including major depressive disorder, were third at 14.3% and substance-use disorders were fourth at 11.4%.2 Comorbidity is also a significant concern within this age group, given that nearly 40% of patients with 1 class of disorder also met the criteria for a second class of disorder at some point in their lives.In a landmark study funded by the National Institute of Mental Health, the prevalence of a broad range of mental disorders in a nationally representative sample of US adolescents was examined. Participants in the National Comorbidity Survey Replication–Adolescent Supplement consisted of youths aged 13 to 18 years. One in 10 children had a serious emotional disturbance that interfered with daily activities. In addition, few affected youths received adequate mental health care. Mood disorders affected 14.3% of teens, including twice as many girls as boys. The prevalence of these disorders increased with age: a nearly 2-fold increase between age 13 to 14 years and age 17 to 18 years. One in 3 adolescents (31.9%) met the criteria for an anxiety disorder, ranging from 2.2% for generalized anxiety disorder to 19.3% for a specific phobia. These disorders are more common in girls.11Concerns about adolescent mental health are shared by many countries. In a review24 of community survey studies from around the world, approximately one-fourth of youths experienced a mental disorder during the past year and about one-third did so across their lifetimes.The incidence of depression increases with age. It is 1% to 2% at age 13, climbs to 3% to 7% at age 15, and continues to increase throughout early adulthood. Results are mixed when it comes to the effects of social class, race, and ethnicity.11 Although rare in children, the prevalence of bipolar disorder (mania and hypomania) ranges from 0% to 0.9% in those aged 14 to 18 and from 0% to 2.1% over a lifetime. As far as comorbidity, both major depressive disorder and bipolar disorder are associated with multiple other conditions, including ADHD, anxiety disorder, oppositional defiant disorder, and conduct disorder.25,26 Half of all adult mental disorders have their onset during adolescence, and suicide is the third leading cause of death among adolescents.27Data from the National Health and Nutrition Examination Survey28 revealed the following regarding adolescent medication use for psychological concerns:By 2020, it is estimated that psychiatric and neurologic conditions will account for 15% of the total burden (in terms of both prevalence and financial costs) of all diseases. Identified gaps in resources for childhood mental health that can be targeted for improvement can be categorized as economic, staffing, training, and policy.24 Approximately 25% of affected youth will have a second mental health disorder. This incidence actually increases 1.6 times for each additional year from age 2 (18.2%) to age 5 (49.7%). In addition, children with a physical illness are more likely to develop depression and those with an emotional disorder have an increased risk of developing physical disorders.29,30Considering the number of student-athletes within secondary school athletic departments and the statistical data on mental disorders in the United States, particularly those affecting adolescents, there is a high probability that most secondary school athletic teams include student-athletes who experience 1 or more psychological concerns. The AT, in collaboration with the athletic department and secondary school administration, should develop a plan to recognize student-athletes with psychological concerns and facilitate an effective referral system to mental health care professionals for evaluation and treatment.To maintain a competitive advantage, universities may recruit increasingly younger players, which affects secondary school coaches, student-athletes, and their families. Many student-athletes report higher levels of negative emotional states than non–student-athlete adolescents and have been identified as having higher incidence rates for sleep disturbances, loss of appetite, mood disturbances, short tempers, decreased interest in training and competition, decreased self-confidence, and inability to concentrate.Some of these changes in mood can also be related to overtraining.31,32 Due to pressures to win, competitions for athletic scholarships, and the adoption of professional training methods to ensure these outcomes, overtraining has become a way of life for many of our young athletes. They may compete year-round, often with multiple teams, and both train and compete multiple times each week. However, an emphasis on work without time for rest and recovery can lead to physical and psychological staleness and burnout.33–35Student-athletes often exhibit sport identity foreclosure,36 and the greater this rigid identification, the more negative the psychological reaction can be when real and perceived barriers arise in their sporting lives. Stressors of athletic participation may include being cut from a team, dealing with injury, performance challenges, mistakes in play, dealing with success, pressure to overspecialize or overtrain, and early termination from sport.37–39Demands and stressors on the student-athlete can be physical (eg, physical conditioning, injuries, environmental conditions), mental (eg, game strategy, meeting coaches' expectations, attention from media and fellow students, time spent in sport, community-service requirements, and less personal and family time), and academic (eg, classes, study time, projects, papers, examinations, attaining and maintaining the required grade point average to remain on the team, and earning and maintaining a collegiate or academic scholarship). These stressors place numerous expectations on a student-athlete.40Pressure on a student-athlete is common when there is no off-season and training continues throughout the year. The student-athlete is exposed to a predictable pattern of lack of sleep and underrecovery, putting him or her at risk for anxiety and depression.41–53 Recovery is closely related to well-being and performance, yet many student-athletes are mired in persistent cycles of chronic fatigue.46 For student-athletes, the complex combination of long-term training and uncontrollable life variables often leads to overtraining, putting them at risk for physical, mental, and emotional health problems.All too often, athletes are portrayed as superhuman, larger than life, and unaffected by stress or concerns of a clinical nature.54–58 Although many individuals are equipped to meet these physical and mental expectations, a segment of the student-athlete population will have difficulty. The stressors of being a student-athlete can trigger a new psychological concern, exacerbate an existing concern, or cause a past concern to resurface. Triggering events and stressors to be aware of are described in Table 1.The AT, team 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 secondary.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.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 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.62Student-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 psychological problem.63The 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.70Total US prevalence11 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.73Despite 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 problems associated with it. Significant correlations were found between reported alcohol abuse and self-reported depression and psychiatric symptoms.72Health 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 (depression, anxiety, bipolar disorder, or ADHD) makes it more likely that student-athletes will use substances or alcohol.74In 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.Diagnosing ADHD in children and adolescents can be challenging. Therefore, it is important that all the 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 affect females twice as often as males, but the incidence in both sexes increases with age. Total prevalence11 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-IV85 criteria for eating disorders of anorexia nervosa or bulimia nervosa fall into a classification of eating disorder not otherwise specified (EDNOS). In the clinical setting, EDNOS tends to be diagnosed more frequently than either anorexia nervosa or bulimia nervosa.85–87For some athletes, the focus on weight management becomes obsessive, and disordered-eating behaviors develop. 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 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.90A young person can be a bully, a victim, or both. Bullying can take place via physical, verbal, or social 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.”91,92Studies on bullying91,93 revealed thatWarning signs that a student is being bullied include the following:Warning signs that a student might be bullying others include the following: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 prope" @default.
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W2145672109 title "Interassociation Recommendations for Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns at the Secondary School Level: A Consensus Statement" @default.
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