Mental Health & Wellness

Like most other mental illnesses, depression probably occurs in athletes at the same rate as in the general population.  Symptoms of depression include (and note a person does not need ALL of these symptoms in order to have depression):

1. Feeling sad, down, hopeless, or tearful on most days
2. Feeling irritable on most days (this can be especially common in adolescent depression)
3. Not looking forward to or enjoying things that used to make the person happy
4. Feeling worthless
5. Lower energy than usual
6. Worse concentration than usual
7. Appetite changes (either much lower or much higher than usual)
8. Sleep changes (either trouble falling or staying asleep or sleeping more than usual)
9. Thoughts of death or dying, including suicidal thoughts

On rare occasion, someone who has times of feeling depressed may have a condition called bipolar disorder.  This is a disorder in which they not only may have times of depression, but they also have times of abnormally elevated mood (called mania or hypomania). In mania or hypomania, they have multiple days or weeks on end of feeling euphoric, not needing very much sleep and still feeling rested and very energetic (this is different than simple insomnia in which they wish they could sleep but can’t), feelings of being better than everyone around them, talking much more quickly than usual, engaging in uncharacteristically risky behaviors without thinking through the consequences, engaging in much more activity than usual, seeming more sexual than usual, and reckless spending of relatively large amounts of money (note a person does not need ALL of these symptoms in order to have mania or hypomania).  Importantly, this is not just feeling better than they feel compared to when they are depressed. It is a dramatic state of elevated mood in which people around them notice they are not their usual selves, and the behaviors and symptoms create problems in their lives.

Student-athletes with depression, bipolar disorder, or any number of other psychiatric disorders may be at risk for suicide.  High school student-athletes do no appear to be at any greater risk of suicide than their non-athlete peers. 

Anxiety may also occur in student-athletes at the same rates as in the general population.  Some symptoms of anxiety are similar to those of depression.  It is possible that athletes can have both depression and anxiety.  Symptoms of anxiety may include (and note a person does not need ALL of these symptoms in order to have anxiety):

1. Worry about many things (for example, sports, school, friends, family, day to day obligations) in a way that feels difficult to control and happening on most days
2. Trouble sleeping (especially falling asleep)
3. Lower energy than usual
4. Worse concentration than usual
5. Muscle tension
6. Feeling fidgety or restless
7. Feeling irritable much of the time

There are also specific types of anxiety that can occur, including:

Social anxiety disorder:  This is a condition in which someone has significant fear and anxiety about being negatively judged and evaluated by others.  People with this condition may be viewed as extremely shy or unfriendly, but in actuality, these people would like to be able to make friends.  They dislike being the center of attention and being observed while doing something, and this can make it hard for some people to participate in certain sports, especially individual sports.

Panic disorder:  This is a condition in which someone has sudden, severe attacks of intense anxiety and fear lasting several minutes. They usually involve physical symptoms such as feeling short of breath, feeling one’s heart beat hard in the chest, or feeling dizzy.  Sometimes the symptoms can feel similar to how people feel when they exercise intensely, and that can make an athlete with panic disorder start to avoid their sport out of fear that exercise will bring on an actual panic attack.

Obsessive-compulsive disorder (OCD):  This is a condition in which someone has repeated, unwanted thoughts that come into their mind that they have difficulty controlling (obsessions) and/or physical or mental behaviors that they feel must be performed over and over (compulsions).  Examples include intense fear of germs and associated washing of hands over and over, or ordering things “just so” or symmetrically to an extreme degree.  OCD is different than superstitious rituals, which are usually harmless.  Rituals are common among athletes, and examples include wearing the same pair of socks for every game or eating the same meal before each race. Full-blown OCD may be more common in athletes than in non-athletes.

Post-traumatic stress disorder:  This is a condition in which someone has suffered any sort of trauma (for example, physical, verbal, or sexual abuse, assault, major accidents or illnesses).  Associated with that trauma, they have symptoms that may include:  nightmares or flashbacks about it, avoidance of anything that reminds them of the trauma, increased startle response, and any of a number of symptoms of depression and anxiety.  Traumas unique to athletes may include “out of the ordinary” sport-specific adverse events, such as severe injuries (especially if they involve threats to physical integrity), witnessing of lethal accidents, loss of a crucial game where the athlete feels they are to blame, public cheating scandal, or teammate suicide. The more a student identifies themselves as "athlete" to the exclusion of other sources of identity, the more traumatic a major injury may feel to them.

Signs & Symptoms of Disordered Eating in Student-Athletes

• Significant or sudden weight loss, gain, or fluctuations (or failure to gain expected weight in a child/adolescent who is still growing). Importantly, student-athletes with eating disorders can present in all sizes.
• Fatigue
• Cold intolerance
• Unexpected athletic performance decline
• Bowel changes (constipation or diarrhea)
• Trouble concentrating (e.g., on school work or coaches’ instructions)
• Dizziness
• Chest pain or heart palpitations

Disordered eating in student-athletes includes a wide range of eating concerns.  These range from the student-athlete who inadvertently is not eating enough to fuel their body for sport simply out of not realizing how high their caloric needs are, all the way to the extreme of a full blown eating disorder and associated complications.  Eating disorders include anorexia nervosa (being significantly underweight with distorted body image and intense fear of gaining weight) and bulimia nervosa (recurrent episodes of binging--rapidly eating very large amounts of food well beyond the point of comforably full and in a manner that feels out of control--and purging--self-induced vomiting, laxative or diuretic use, excessive exercise beyond that recommended by coaches in order to compensate for food eaten, or times of fasting to compensate for binges).  Student-athletes may underfuel because of wanting to try to achieve a competitive advantage in sport, meet appearance standards for sport or for society, or for other reasons.  Ultimately, underfueling is not a sustainable way to achieve success in sport, and athletic performance will suffer if disordered eating continues.  Student-athletes may find themselves on a slippery slope in which a desire to “eat healthy” turns into food restriction and rigid dieting in the hopes of improving athletic performance. 

Note that some people reference the term “Female Athlete Triad”, which is becoming outdated. However, the idea still applies that the three elements of the Triad, disordered eating, menstrual cycle changes, and lowered bone mineral density, can occur in athletes who are not eating enough calories to fuel their activity levels. A newer term being used is RED-S (Relative Energy Deficiency in Sport). The International Olympic Committee has used the “RED-S” terminology since 2014. This term is preferred over Female Athlete Triad in recognition of the fact that student-athletes across genders can suffer from inadequate intake, disordered eating, or full-blown eating disorders (though it is a more common problem in females). Additionally, the RED-S term conveys that there are more than just three issues when it comes to underfueling in sport.

Risk Factors

• Participation in sports in which lean body physique is felt by some to be advantageous (e.g., cross country, track)
• Participation in sports in which artistic quality, in addition to technical skill, is felt to be important (e.g., gymnastics)
• Anxiety or depression
• Family members with disordered eating
• Perfectionism

Complications

• Changes in menstrual cycles (either not starting menstruation at all by the expected age, no longer getting menstrual cycles, or getting menstrual cycles less often, lighter, or for a shorter duration than usual)
• Low bone mineral density, which can result in stress fractures or other bone stress injuries and eventual osteoporosis
• Abnormal levels of electrolytes such as potassium
• Dehydration
• Problems with the cardiovascular system (heart and blood vessels)
• Mental health conditions and suicide
• Weakened immune system
• Changes in metabolism

Treatment

The ultimate treatment for disordered eating in sport is increased caloric intake.  Any athlete suffering from signs and symptoms of disordered eating should be referred for professional help to a sports medicine physician, pediatrician, family medicine physician, internal medicine physician, psychiatrist, psychologist/therapist/counselor, and/or registered dietician.  Disordered eating is a serious concern that can have life-threatening consequences if unaddressed. In the mean time, parents and coaches can be helpful via the following:

• Educate athletes on the energy demands of their sport.
• Create an environment that supports eating at least three meals and one to two snacks daily.  Talk about having a regular breakfast, full lunch at school, and a pre-practice snack to provide energy for training.

Resources

Sample Training Day Menus

NCAA Resources - Disordered Eating

Disordered Eating Scenarios

Question: One of our top athletes looks like she lost quite a bit of weight.  She’s not having any problems with the training but I think she might be having a problem with food.  She rarely eats at our team functions and I hear from some of her teammates that she skips school lunch. How should I approach this?

Answer:   Have a private meeting with the athlete and discuss your observations and concern for the athlete’s health.  Discuss how under-fueling (i.e., dieting) can lead to drops in performance, injury, and health problems such as irregular menstruation, anemia, and low bone density.   Ask the athlete what she typically eats on a training day.  Many athletes will report eating a “healthy diet” by avoiding “junk food”, soda, and drinking “lots of water” but do not know how much food/fuel their bodies need to support their training.  Sometimes this can result in eating very small portions or skipping meals because there is nothing “healthy to eat”.  This is a frequent excuse for avoiding school lunch or fast food meals.  Also, drinking water to excess can be a concern.  Excessive water intake can result in eating small portions causing low calorie intake, can mask hunger, or can cover up food avoidance.  Share a sample training day menu based on the athlete’s weight (MENU HERE) and point out areas for improvement.

Question:  Last season we had several girls injured with stress fractures.  This year at our team meeting we talked about preventing stress fractures and how not having a period can be a warning sign.   Today one of my athletes told she has not had a period for a few months.   In addition to suggesting she see her physician, is there anything else I can do?

Answer:  One of the risk factors for irregular periods is not eating enough calories to meet the demands of training. You can discuss with her what and how much she normally eats on a training day.  Key fueling times are the 3 meals and a pre/post workout snack.  Some athletes eat healthy, but not enough.  Share the sample training day menu posted on the WIAA website  (MENU HERE) for an example of what, when, and how much she needs to eat to fuel her training.

Question: I am concerned about one of my athletes, who has lost quite a bit of weight and has stopped getting her period.  I sent her to a doctor, but the doctor was not concerned and said the athlete could continue competing.  Is there anything else I should do?

Answer:  Some professionals are not sufficiently educated about disordered eating to fully understand the seriousness of its long-term consequences.  You should have your athlete see a different provider who is knowledgeable about disordered eating. Types of professionals to whom you should consider sending your athlete include:  physicians (family medicine, internal medicine, pediatrics, sports medicine, or psychiatry), registered dieticians, psychologists or other licensed therapists, school counselors, and athletic trainers.  Additionally, the coach is the one who determines the athlete’s workouts.  Thus, the coach can cut back on the amount of training the athlete does, even if she is officially ‘cleared’ to return to sport.

Question:  I am concerned about an athlete that I coach, but she and her parents refuse to get help.  How can I convince them, and what else should I do? 

Answer:  Talk about the potential negative consequences of disordered eating with the athlete and her parents.  Explain that the athlete could develop life-long struggles with eating disorders and other mental health problems.  The sooner disordered eating is addressed, the more likely it is to permanently resolve.  Also, explain that irreversible bone loss and osteoporosis are more likely to occur the longer insufficient calorie intake goes on.  Additionally, you should insist that she see a professional prior to her continuing to participate on the team. Further video examples of athletes who have struggled with disordered eating are available on the International Olympic Committee website here: http://www.olympic.org/hbi.  Feel free to share these with your athletes and their parents.   

Common Myths

MYTH: Runners are the only athletes who develop eating disorders.

FACT:  It is true that athletes in sports in which leanness is emphasized (e.g., cross country, track and field, gymnastics, figure skating, diving, swimming) are more likely to develop eating disorders.  However, we see athletes in any and all sports develop eating disorders.

MYTH: Only girls develop eating disorders. 

FACT:  Athletes across genders develop eating disorders. Eating disorders in boys often happen in sports such as wrestling, cross country, and track and field, but it can happen to athletes of any gender in any sport.

MYTH: If an athlete’s performance has not started suffering, then they must not have a problem.  

FACT:  Even if an athlete’s performance has not started to suffer yet, it eventually will.  Not taking in enough calories to match activity level is not sustainable in the long-run.

MYTH: It is normal for female athletes to stop menstruating. 

FACT:  It is never normal for an athlete with a uterus to stop menstruating, and it often means that the athlete is not taking in enough calories to match her activity level.  There are serious health risks, especially bone loss, to not menstruating.  Research shows that after three years of not menstruating, bone loss is likely to be permanent.  Loss of future reproductive function could also occur.  Any athlete who has been without a menstrual period for three months should be referred to a physician for an evaluation.

MYTH: It is normal for female athletes to have changes in their menstrual patterns when exercising heavily. 

FACT:  It is NOT normal for athletes to stop menstruating or to have lighter menstruation or lighter flow, even during heavy training.  

MYTH:  If athletes are not losing weight, they are probably eating enough.

FACT:  Weight loss does not always happen when an athlete under-eats.  The body can compensate by slowing down metabolism.   Fifty percent of the time when an athlete restricts calories, menstrual cycle changes are the first symptoms to appear. Thus, discussions with athletes about the menstrual cycle are extremely important.  

MYTH: If an athlete who loses their period goes on the birth control pill to start menstruating, her bones will be protected.  

FACT:  An athlete is likely to start menstruating again by going on the birth control pill, but if she has not started eating more, then this is just treating the symptoms and not the underlying problem.  No medication, including birth control, has been shown to restore bone loss.  

MYTH: If an athlete is not eating enough to match activity level, they are aware of what they are doing.  

FACT:  Denial is powerful.  Athletes will very often feel that they are being as healthy as possible, and that meticulous attention to diet is a sign of dedication to sport.  Coaches, parents, and professionals will need to help the athlete see the problems with the behaviors.  It will probably take time, education, and convincing for the athlete to see there is a problem.

MYTH: An athlete who eats “healthy,” is a top performer on the team, and excels in class is unlikely to have an eating disorder.

FACT: Traits that are desirable in an athlete can make them more at risk of developing an eating disorder.  Mental toughness, pursuit of excellence, performance despite pain, commitment to training, and being a team player  are very similar to excessive exercise, perfectionism, denial of discomfort, asceticism, over-compliance, and  being self-less.   What looks like a “good athlete” may also be a person with a serious eating problem.

The National Federation defines hazing as any humiliating or dangerous activity expected of a student to belong to a group, regardless of their willingness to participate.

Some practices associated with high school hazing carry the potential for serious bodily harm or even death. These practices may include: tattooing, piercing, head-shaving, branding, sleep deprivation, physical punishment (paddling and "red-bellying"), "kidnapping," consuming unreasonable/unacceptable foods or beverages, being deprived of personal hygiene and/or inappropriate sexual behavior. Coerced sexual activity, in addition to being classified as sexual assault and/or rape, is another form of hazing. Such activity puts victims at risk for injuries, sexually transmitted diseases, and pregnancy. Alcohol abuse is another significant factor in hazing incidents that feature forced consumption of large amounts of alcohol.

Wisconsin Hazing Law

948.51 Hazing.

(1) In this section "forced activity" means any activity which is a condition of initiation or admission into or affiliation with an organization, regardless of a student's willingness to participate in the activity.

(2) No person may intentionally or recklessly engage in acts which endanger the physical health or safety of a student for the purpose of initiation or admission into or affiliation with any organization operating in connection with a school, college or university. Under those circumstances, prohibited acts may include any brutality of a physical nature, such as whipping, beating, branding, forced consumption of any food, liquor, drug or other substance, forced confinement or any other forced activity which endangers the physical health or safety of the student.

(3) Whoever violates sub. (2) is guilty of: 

(a) A Class A misdemeanor if the act results in or is likely to result in bodily harm to another.

(b) A Class E felony if the act results in great bodily harm or death to another.

What to do about Hazing?

• Become thoroughly familiar with your school's policies on hazing. If you're an administrator, check out your state DPI guidelines. Look for language in the policy that prohibits hazing both on and off school property and during or after regular school hours.
• Talk to your students about what constitutes hazing, the consequences of hazing, and your unwillingness to tolerate any form of hazing on your team or group. Make sure all students and parents are familiar with the hazing policy, and know what behaviors are appropriate and inappropriate. Take many opportunities to prevent hazing by promoting respect, teamwork, and fair play.
• Include the hazing policy in the athletic/activity code of conduct. Have all parents and students sign this code before the student is allowed to participate in athletic and/or activities.
• Use pre-season meetings with students and parents as an opportunity to review your school's philosophy about hazing and the rules and consequences for hazing.
• Make sure students and parents know that whether or not a person voluntarily participates in a hazing activity does not matter.

Keep a log of all activities you have done to prevent hazing. Your own reputation and that of your school's may depend on your ability to demonstrate that you have done what you can to prevent hazing. You cannot always control the actions of your students, but you must be able to demonstrate that you have done what you can to protect the safety of all students.

Reminder: WIAA Season Regulations and State Law (9175.22) prohibits use of cell phones (and other image-recording devices) in locker rooms except in emergency situations.

Resources

• Wis DPI Bullying Guidelines
• NFHS Hazing Information
• Alfred University Study
• NCAA Hazing Prevention Handbook
• Stop Hazing

High school athletes should get 8–10 hours of sleep per night. Sleep is important for their health and performance because it helps with: 

• Recovery: Sleep helps the body recover from exercise and daily activities.
• Injury avoidance:  Getting enough sleep decreases the risk of sport injury in high school athletes.   
• Energy: Sleep helps athletes have the energy to perform their best. 
• Stress management: Sleep helps athletes manage stress. 
• Academic performance: Sleep helps athletes concentrate and perform well in school.
• Sport Performance: Lack of sleep negatively impacts strength, speed, and reaction time.

Here are some tips to help high school athletes get enough sleep: 

• Avoid screens before bed: Minimize screen time before bed (at least one hour) to improve sleep quality. 
• Create a bedtime routine: Develop a relaxing bedtime routine to reduce stress and to get your brain and body ready for sleep. 
• Stick to a sleep schedule: Try to stick to a regular sleep schedule (as consistent a bed time and wake time as possible), even on weekends and when traveling. 
• Keep your bedroom cool, dark, and quiet: Use a fan or low-level white noise machine to block out sounds if necessary.
• Avoid caffeine, especially in the afternoon and evening.
• Evaluate your mattress and pillows: Make sure your mattress and pillows are comfortable.