PT SPORTS MOD 2:
PSYCHOSOCIAL ASPECTS OF YOUTH SPORTS
PRIORITIES THAT PHYSICIANS, ATHLETIC
TRAINERS, AND SPORTS PHYSICAL THERAPISTS
MUST SET IN CARING FOR YOUNG ATHLETES
 Ensure overall emotional and cognitive development,
in addition to physical development, are crucial
factors for the athlete’s well-being now and later in
life.
 Shield the young athlete from the increased
pressures and demands to perform and achieve at an
earlier age than athletes of the past. These pressures
appear to leave young athletes more vulnerable to
injury and emotional burnout.
 All health providers, regardless of their area of
expertise or specialty, need to focus on their
patient, recognizing that the child and sometimes the
parent will lose perspective and consider the next
game as “make it or break it” the child’s career.
HEALTH FOCUS OF YOUTH SPORTS
 Youth sport should lead to physical health,
psychosocial development and lifelong recreational
or elite sport participation.
BALYI AND HAMILTON MODEL OF LONG-TERM
ATHLETIC DEVELOPMENT
 Promoted as the basis of the national framework
for coaching healthy and successful sports
participation and achievement in Canada and UK
 Stresses the importance of recognizing the physical
and emotional capabilities and needs of the
developing young athletes
 The model makes allowances for differences
between early specialization sports (e.g., diving,
figure skating, gymnastics) and late specialization
sports (most team sports as well as cycling, rowing,
and racquet
 Emphasis early on for the young athlete is to have
fun and learn overall motor skills (6-10 yrs is the
“FUNdamental” stage).
 Children aged 10-12 (with variation for gender
differences), the emphasis shifts to building the
widest range of fundamental sport skills
(“Learning to Train” stage).
 “Training to Train” stage at ages 12-16 yrs, aim
should be to build the athlete’s aerobic base and
improve strength toward the end of the phase while
further developing sport-specific skills.
 “Training to Compete” stage (approx. 15-18 yrs
and beyond), athletes progress toward refining
more specialized skills and tactics in their primary
sport.
 This model allows for the gifted athlete who will go on
to elite competition while also promoting lifelong
fitness and athletic participation for all throughout
childhood.
BALYI’S LONG-TERM ATHLETIC ACHIEVEMENT MOODEL
Early specialization model Late specialization model
1. Training to train stage 1. FUNdamental stage
2. Training to compete 2. Learning to train
3. Training to win 3. Training to train
4. Retirement/retainment 4. Training to compete
5. Training to win
6. Retirement/retainment
ERICSON MODEL
 10 yrs or 10,000 hrs of practice are required to
reach an expert or elite level of performance
 “10,000 hr practice rule” holds true in a wide range of
athletic endeavors (e.g., cites data supportive of the
hypothesis for swimmers and marathon runners)
APPROACH MOST CONSISTENTLY SUPPORTED BY
RESEARCH
 Adults involved in youth sports and parents of
athletes from ages 6 to 12 need to encourage fun,
friendship, and fitness as the true measures of their
children’s sporting success
 Children in this age range should sample many sport
experiences in which the emphasis is on enjoyment
and gradually improving fitness and overall athletic
skill.
 As children enter adolescence, they are generally
capable of being introduced to more intense
competition as well as a more vigorous development
of specific sport skill and competencies
 Parents and coaches best serve their teen athletes by
promoting, in order of importance, character,
camaraderie, and athletic competence.
 Talent without good coaching will necessarily
underperform
KEY PSYCHOSOCIAL COMPONENTS TO SUCCESS
IN SPORT
Winning
 A child or teenager engages the deeply wired “fight or
flight” response in many of the competitive sports
activities.
 Experience of the fear, passion, and stress of
competition also helps to fuel the sense of pleasure
and release that comes with winning.
 Competition biologically stimulates the physiological
state of parents and coaches, as well as young
players.
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 PT SPORTS MOD 2:
PSYCHOSOCIAL ASPECTS OF YOUTH SPORTS
 This biology is embedded in a family that may be Psychological Features of the Injured Athlete
under considerable pressure (e.g., time, finances, Following Injury
competing priorities)
 Athletes are likely to experience a characteristic
 Winning can be considered so special that it
cluster of emotions and behaviors. These include
overwhelms other values, priorities, and even
hyperaroused responses, intrusive effects, and
sportsmanship.
emotional withdrawal or avoidance.
 Evidence of undesirable behavior can be seen in
 Manifest an intense zeal “to do whatever it takes to
steroid use, undue pressure on or by the injured
get back on the field
athlete to return prematurely, undue privileges for the
gifted star athlete, and the not-so-subtle promotion of  There can be a grandiose self-perception that if the
a “win-at-all-costs” attitude. normal healing time is 8 weeks
 Athlete might also be susceptible to intrusive effects
Key Tools for Parents for Performance Enhancement that hinder the healing process and undermine his
in Children or her overall health

 Set goals
 Parents, coaches, and health care providers can
 Have a sports mission greatly help the injured athlete by monitoring the
 Know your child and his or her stage of physiological fundamentals of good health
and o Adequate physical and emotional rest;
emotional development o Proper hydration and diet
 Know yourself and your own personal “baggage” o Appropriate exercise that does not exacerbate
 Know the child’s sport environment the injury
 Know the sport’s culture o Avoidance of an obsessive focus on the injury
 Know how to deal with over-involved parents o Balanced approach to home life, academics, and
friendships
CONSIDERATIONS FOR DEALING WITH THE
INJURED ATHLETE Psychological Features of Recovery for the Injured
Athlete
Initial Psychological Response to Physical Injury
 A sense of emotional safety is a crucial psychological
 A cluster of overwhelming emotions may flood the
element in the recovery from trauma.
injured athlete.
 The desired outcome of the initial encounter with any
 The initial cognitive and emotional reaction to the
health care provider is that sense of recognition of the
shock of injury and trauma often involves fear, a
nature of the injury and course of treatment, but also
sense of disconnectedness or sense of things not
a sense of reassurance and even relief.
being real, and a sense of captivity or feelings of
 As the injured athlete gradually begins to trust the
being trapped.
healing process and builds a sense of trust with his or
 The injured athlete often experiences a high level of
her doctor, sport physical therapist, and athletic
anxiety and fear, which, in the case of serious
trainer, his or her feelings, comments, and behaviors
injuries such as broken bones or torn ligaments, can
should begin to reflect a sense that he or she is
become gut-wrenching and sickening terror.
adapting and adjusting to the process of recovery.
Event (initial Symptoms Recovery o Adjustment phase may include some behaviors
response to (following (recovery from that are similar to grieving. Comments or
injury) injury) injury) behaviors that reflect mourning for the lost
 Terror (fear in  Hyperarousal  Safety playing time or season are not uncommon.
mid- or post- (forced (predictable o There may be a lingering emotional avoidance
trauma) healing) outcome) and withdrawal from all contact with their sport
 Captivity (no  Intrusion  Adjustment o Rule of thumb is that people are entitled to grieve
quick fix) (preoccupied (dealing with in many ways.
 Disconnection with injury) limits)  If the recovery process has been successful, then
(protective  Emotional  Reconnection the athlete will enter a phase of reconnection to his or
denial) withdrawal (restoration of her previous athletic endeavors.
(depression/d health)
espair)

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 PT SPORTS MOD 2:
PSYCHOSOCIAL ASPECTS OF YOUTH SPORTS
BURNOUT, STALENESS, OR JUST A SLUMP
 Burnout, staleness, and slump fall under umbrella
term of maladaptive fatigue syndrome.
 Burnout: “state of mental, emotional and physical
exhaustion brought on by persistent devotion to a
goal whose achievement is dramatically opposed to
reality.
o Often occur in quiet, perfectionistic, highly
coachable athletes who work too hard and too
intensely for too long in unrewarding situations
o Burnout occurs when three basic psychological
needs: autonomy, competence, and relatedness
have been chronically frustrated.
 Staleness: early warning sign of possible burnout
characterized by diminishing physical and emotional
capabilities.
 Slump: diminished performance that may or may not
be a function of staleness or burnout
Factors that contribute to staleness or burnout
 Length of the season
 Monotony of training
 Lack of positive reinforcement
 Abusive coaches
 Overly stringent rules
 Player boredom
 Perception of low achievement
 Failure
 High levels of competitive stress
 Sense of being overloaded and helpless to effect
constructive change in the sporting environment
 Sense of being trapped in an untenable situation.
Treatment for Burnout and Staleness
 Appreciating the need for time away from the sport, a
mental and physical break or time out.
→ “The All Star break” is generally recognized as a
time that most players necessarily use to
recharge themselves emotionally and physically.
 The American Academy of Pediatrics outlines specific
recommendations that include limiting sporting
activity to a maximum of 5 days per week with at least
1 day completely free from organized physical
activity. Regularly scheduled breaks from training and
competition in any one sport, with time away every 2
to 3 months to cross-train or to focus on other
activities are also strongly recommended.
 Increased athlete input in decision-making and
control can increase motivation and morale and deter
burn out.
 Team captains
→ Improved management of post-competition
tension is also an important area for reducing
burnout, staleness, and team friction.
 Protecting athletes from overly emotional responses
to victory or defeat and reducing overall postgame
stimuli as well as overly critical individual, player-to-
player, and coach-to-player responses
BURNOUT AND DEPRESSION
 The burned-out athlete might be reacting to stressors
from a home environment and areas of life outside of
the sports domain, discerning where burnout ends
and major depression begins can be difficult.
→ Separating or divorcing parents.
 This social dilemma meets the criteria for potential
burnout with an untenable, unwinnable, trapped
situation in which the athlete in question cannot live
up to others’ expectations.
 Burnout certainly could result from such a scenario,
but so too could a reactive depression emerge if the
untenable situation exists in other areas of life and is
not addressed.
Eight symptoms for a major depression cued by the
mnemonic “SIGECAPS”
 Sleep (increase or decrease)
 Interest/pleasure (socially less active, reduced
libido)
 Guilt or ruminations (self-blame): possibly
manifested as irritability
 Energy (decreased/not motivated): indifference
 Concentration (cannot focus or make decisions)
 Appetite (increase or decrease)
 Psychomotor (agitation [adolescents] or lethargy)
 Suicide (thoughts and/or plans about death and
dying)
→ If the conditions of burnout have been addressed
and five of the eight symptoms have been
present for 2 weeks, then the athlete in question
should be referred to his or her physician and
then on to a mental health professional.
DEALING WITH ATHLETES WITH ATTENTION
DEFICIT DISORDER
 ADD/ADHD can be diagnosed by the presence of a
cluster of symptoms that include significantly elevated
levels of distractibility, inattentiveness, and cognitive
or behavioral impulsivity.
 Individuals with ADD/ADHD may be more prone to
engage in high-risk or thrill-seeking behaviors. This is
especially true for boys.
 Untreated ADD/ADHD may place the individual at risk
for addictive, self-medicating behaviors such as
substance abuse, sexual acting out, fighting, and
gambling.
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 PT SPORTS MOD 2:
PSYCHOSOCIAL ASPECTS OF YOUTH SPORTS
 Athletes as a group may manifest a much higher
incidence rate of ADD/ ADHD and the behaviors that
have come to be associated with the condition.
 ADD/ADHD pattern of inattentiveness, impulsivity,
risk-taking, and stubbornly rigid thinking or
hyperfocus leaves these athletes more vulnerable to
accident and injury.
Possible Risks Associated with ADD/ADHD in
Athletes Recovering from Injury
 Pattern of thrill-seeking or risk-taking behaviors
 Noncompliance or impatience with recovery (may
seek alternative
therapies)
 Increased substance use
 Increased irritability, oppositional defiance, or
fighting
 Increased addictive behaviors (e.g., sex, gambling,
video games)
 Increased depressive symptoms
 Decreased academic performance
 Recurring injury, accident, or other trauma
DEALING WITH THE CONCUSSION:
PSYCHOLOGICAL CONSIDERATIONS
 Concussions can occur without a loss of
consciousness, many researchers view these
numbers as a gross underestimate of the problem by
as much as 50%
 All sports related concussions should be viewed as
serious because they pose a threat to the young
athlete that only in recent years is being fully realized.
Young athletes appear more susceptible to second-
impact syndrome, a condition that results from a
second head injury before full recovery from an initial
concussion.
o can lead to acute and long-term neurological and
neuropsychological problems that in rare cases
have been fatal in athletes, especially athletes 18
and younger
 Because of the hidden nature of head injury, many
concussions are unseen, unrecognized, unreported,
and therefore undiagnosed and untreated. Because a
blow to the head might result in a dazed or confused
state, many athletes might not remember or
understand the importance of their symptoms.
Signs and Symptoms of Sports-Related Concussion
 Headache
 Dizziness
 Amnesia (retrograde or antegrade)
 Inability to recall plays, rules, assignments, date,
venue, score, or opponent
 Disorientation or confusion
 Drowsiness
 Irritability, sadness, or emotionality that does not
seem to fit the situation
 The burned-out athlete might be reacting to stress-
ors from a home environment and areas of life
outside of the sports domain, discerning where
burnout ends and major depression begins can be
difficult.
 Separating or divorcing parents.
 This social dilemma meets the criteria for potential
burnout with an untenable, unwinnable, trapped
situation in which the athlete in question cannot live
up to others’ expectations.
 Burnout certainly could result from such a scenario,
but so too could a reactive depression emerge if the
untenable situation exists in other areas of life and is
not addressed.
 A simple concussion is one in which symptoms are
resolved in 1 week to 10 days.
 No player should be cleared to play until all symptoms
have resolved completely
 The concussed athlete may manifest all of the
secondary psychological and emotional responses to
injury
 Strenuous cognitive activity like the academic
demands required of high school or college may need
to be avoided or curtailed.
 Failure by the clinician and family to provide the
necessary information and structure to implement a
slow-down in physical, cognitive, and academic
demand on the injured youngster can delay the
healing process and prolong the athlete’s suffering.
 Concussions are invisible. There is no cast or brace
that communicates the “real” nature of the injury.
SCREENING FOR SUBSTANCES ABUSE
 Alcohol is the most widely used drug and poses a
health risk for young athletes.
 It is widely acknowledged to increase thrill-seeking
and risk-taking behavior that can result in a number
of life-threatening situations such as drunk driving,
violence, and risky sexual practice.
 According to a study by Pate et.al, participation in
sports showed no effect on reducing the incidence of
binge drinking in the adolescent athlete
 Athletes need to be educated about the damaging
effects of alcohol or similar illegal substances on peak
athletic performance as well as the detrimental effect
substance abuse may have in the healing process.
CRAFFT” screening tool
 Score of 2 or more on this tool indicates that referral
for further assessment and treatment of substance
use is strongly indicated.
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 PT SPORTS MOD 2:
PSYCHOSOCIAL ASPECTS OF YOUTH SPORTS
C Have you ever ridden in a Car driven by
someone (including yourself) who was high or
had been using alcohol or drugs?
R Do you ever use alcohol or drugs to Relax, feel
better about yourself, or fit in?
A Do you ever use alcohol or drugs while you are
Alone?
F Do you ever Forget things you did while using
alcohol or drugs?
F Do your Family or Friends ever tell you that you
should cut down on your drinking or drug use?
T Have you ever gotten into Trouble while you
were using alcohol or drugs?
EATING DISORDERS
 Vulnerable adolescents may damage their bodies
through food restriction in a mistaken attempt to
improve appearance or, for a few, as the only
“acceptable” way out of what is experienced as a “no-
win” situation (e.g., conflict with parents, a coach, or
wanting to quit the sport)
 Eating disorders involving food restriction and binge
eating are more commonly expressed in girls who are
experiencing a combination of stresses stemming
from home life as well as school, athletic, and social
pressures
 Secrecy is common for eating disorders as part of the
syndrome.
 The most common ways orthopedic or primary care
physicians may detect an eating disorder in young
girls is when they observe repeated stress fractures,
for example, in track or cross country athletes.
 Female athlete triad: disordered eating,
amenorrhea (absence of menstruation), and
osteoporosis (weakening and thinning of bones)
MEDICAL COMPLICATIONS OF EATING DISORDERS
 Medical Complications of Eating Disorders
 For women—irregular periods, cessation of periods
(amenorrhea), reproductive complications
 Lowered metabolism
 Fatigue
 Weakness
 Muscle wasting (including heart tissue)
 Anemia
 Dehydration
 Electrolyte abnormalities: dizziness,
lightheadedness, weakness
 Fluid retention
 Delayed gastric emptying (i.e., bloating, early
fullness, indigestion)
 Constipation
 Diarrhea
 Hypoglycemia
 Stomach pain
 Esophageal tears
 Sore throat
 Dental erosion
 Parotid gland enlargement
 Rectal bleeding
 Frequent bruising
 Slow bone or wound healing
 Night blindness
 Dry skin and lips
 Dry, dull hair or significant hair loss
Two most common eating disorders
 Anorexia nervosa (restricted eating)
 Bulimia nervosa (binge eating followed by either
purging, extreme exercise, or medicines used to
prevent weight gain)
ANOREXIA NERVOSA
 Anorexic athletes are easier to detect because of their
extreme weight loss
 Also include tremendous fear of becoming fat and a
highly self-critical view of appearance.
 Her view of her body is so distorted that she is
completely detached from a reality regarding food,
body image, and weight, making her so vulnerable to
continued starvation that she may require emergent
care and hospitalization.
Abnormal Eating Patterns in Anorexia Nervosa
 Food intake is restricted and constant in content from
day-to-day.
 Hunger is controlled by high-bulk, low-calorie, calorie-
free, or strongly flavored food (e.g., lemon juice,
vinegar, pepper, mustard).
 Large amounts of caffeine or carbonated beverages,
chewing gum, or hard candy may be consumed to
control hunger.
 Fat-containing food is stringently avoided.
 Food may be prepared and eaten in a ritualistic
manner that may appear bizarre.
 Claims to be vegetarian may be a guise to avoid fat-
containing animal protein.
 There is often a complex interplay between calories
consumed, amount of hunger-suppressing foods
eaten, amount of exercise performed, and the amount
of strongly flavored foods eaten.
BULIMIA NERVOSA
 Harder to detect because they generally look quite
normal, as they may remain at normal weight and
typically hide their purging behaviors
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 PT SPORTS MOD 2:
PSYCHOSOCIAL ASPECTS OF YOUTH SPORTS
 Clinicians may notice other revealing symptoms in a
young woman such as broken blood vessels under
her eyes and scratches from her teeth on the back of
her fingers and knuckles from vomiting
 The stomach acid from vomiting may also cause
decay in the enamel of her teeth. She may experience
chronic chest pains and sore throats from vomiting
and at times look tired and even depressed.
 Clinicians may also notice that her skin is turning a
pale yellowish color from malnutrition
 Many female athletes are very thin secondary to their
body type and training. Clinicians must then be
sensitive to eating disorders and be ready to consult
others if they have a serious suspicion
Abnormal Eating Patterns in Bulimia Nervosa
 May have regular pattern, albeit restricted, of food
intake and regular binging and purging patterns.
 Food intake, binging, and purging patterns may be
chaotic.
 Often relies on similar hunger-suppressing foods and
substances as in anorexia nervosa.
 Late afternoon and evening are common time frames
for extreme hunger to override control and result in
binging and purging.
 Binging can last for minutes to hours before purging,
or there can be several binges and purges in
succession.
 Binges are highly variable in caloric content; 1200 to
11,500 kcal per episode have been reported.
 Fat-containing food is stringently avoided, and as in
anorexia nervosa, the individual may claim to be
vegetarian to avoid fat-containing animal protein.
TREATMENT FOR EATING DISORDERS
 Treatment requires a multidisciplinary team.
 Because of severe health risk from malnutrition,
electrolyte levels and weight need to be monitored by
a physician’s office.
 A nutritionist, athletic trainer, and mental health
counselor are also needed.
 Athletic trainers also play a key role in solidifying the
diagnosis, because it is frequently the case that other
members of her team may be discussing their
concerns informally. He/she may be the first clinician
to detect a problem. As the treatment progresses,
physicians can play a crucial role in setting limitations
on exercise and training while setting parameters for
health and weight before full return to play.
 Confronting an eating-disordered patient requires
great sensitivity and experience
 Changing disordered patterns of eating behavior is
very difficult for the young person, and the desire to
be strong and healthy for sports participation may be
one of the few incentives that may motivate change
 Because eating disorders are common among female
athletes, particularly in endurance sports, developing
a relationship with a local eating disorder specialist
may help facilitate the speed and sensitivity of more
effective detection and treatment
STEROID ABUSE
 Driven by the desire to increase strength and improve
performance in dramatically short periods to gain a
competitive edge much like the professional athletes,
young boys and girls are dangerously experimenting
with steroids despite significant risks to their minds
and bodies. Although steroid use is more commonly
associated with boys and men, there are reports that
girls and young women are also using steroids. Data
from the National Institute on Drug Use between the
years 1999 and 2003
 Drug use is frequently secretive and individuals, even
when asked anonymously, are less likely to reveal
their drug use and potentially illegal practices.
 Steroid use can interfere with normal growth (i.e.,
early closure of the epiphysis), including sexual
development and functioning, as well as trigger
severe acne and male baldness.
 10% of steroid users experience what is called “roid
rage,” terrifying violent outbursts that may surface
unpredictably
 Steroid users a susceptible to lower to lower levels of
self-esteem as well as elevated rates of depression
and suicide attempts
 Young male athletes are under increasing pressure to
“bulk up” and strengthen rapidly.
 The mindset of an adolescent male namely, the belief
that “I am bulletproof” makes health risks feel remote
and the potential benefits of getting stronger and
faster much more compelling.
 Sport nutritionists can advise youth and their families
about healthy eating and nutrition.
 Connecting young athletes with well-educated sport
physical therapists and athletic trainers can help
expose them to proper weight training regimens,
supervised by caring adults.
 Redirecting youth away from gyms where there is
unsupervised interaction with unqualified adults (who
are possibly using steroids) is also advisable
 A sports or clinical counselor may be appropriate if
the athlete has loss self esteem
 Team values may be assessed to note if the young
adult is pressured