What will society do to children in order to make them win? What should be sacrificed in the name of competition? How much pressure is too much? And how do we pick up the pieces when young athletes are pushed too far?
Your patient is 15 years old. Legally, they cannot smoke, they cannot drink, they cannot drive or make decisions for themselves. But they are pressured to take a cocktail of drugs, vitamins, and supplements, limit their diets, wear skin-tight costumes, and compete under a global microscope. There, the whole world watches them shine…or delights in their failures. What do you advise your patient and their family caregivers?
Kamila Valieva is a 15-year-old Olympic figure skater who competed for the Russian Olympic Committee (ROC) in the 2022 Olympic Winter Games, held in Beijing. During the team event, Valieva became the first woman ever to land a quadruple jump on Olympic ice. Days later, reports of a failed drug test came to light.1
She tested positive for trimetazidine, a banned substance according to the rules of the World Anti- Doping Agency. Trimetazidine, a drug used for treating angina, is believed to improve an athlete’s endurance. There was talk of banning Valieva from skating in the individual competition and stripping the ROC of the gold medal they won in the team event, which Valieva helped them earn.
On February 14, the Court of Arbitration for Sport determined that Valieva would be allowed to continue to skate, despite the failed drug test. Among the reasons for such: disqualifying her would cause Valieva “irreparable harm.”2 However, in allowing her to skate, perhaps the court caused just that: irreparable harm. The controversial clearing brought the youth to the center of attention—not for her ability, but out of anger at the injustice to other Olympian athletes. It also failed to address an important issue: What is the impact of the pressures being placed on these youth?
Danielle Kamis, MD, the backup sports psychiatrist for the 2022 Winter Olympics and Paralympics, urges observers to consider how substances can impact an athlete’s outlook, mood, and performance.
“Athletes train many hours, days, and years in order to perform at their peak at competition, which can last for only minutes at a time during their time to perform. There is no banned substance that is worthwhile to put all of this time, energy, and training all at risk,” Kamis told Psychiatric Times™. “If an athlete abuses a banned substance, the player now not only has to balance the stress of competition and training, but also the feelings of guilt and secrecy in hiding a substance that was abused.”
Valieva’s story raises many provocative questions. To start, what will society do to children in order to make them win? What should be sacrificed in the name of competition? How much pressure is too much? And how do we pick up the pieces when young athletes are pushed too far?
Suicide: Breaking the Stigma
Discussing suicide with young athletes is crucial, now more than ever.
Harry Miller, a former offensive lineman on Ohio State University’s football team, recently announced his retirement after struggles with suicidal ideation.3 In a 2-page letter posted on Twitter, Miller admitted he “would rather be dead than a coward,” referring to his fear of seeking help due to the potential reaction. He credits his retirement decision to the guidance from his coach, Ohio State head coach Ryan Day, arguably among the most important people in his life as an athlete.
“We frequently observe media portrayals, social media commentary, coaches, and even parents, who view mental health difficulties as a sign of weakness,” said Wilsa M.S. Charles Malveaux, MD, MA, a sports psychiatrist in Los Angeles, California, and the CEO of WCM Sports Psych. “Changing the dialogue around mental illness and being more open about challenges can help to decrease this stigma.”
This could have helped Katie Meyer, the star goalkeeper and captain of Stanford University’s women’s soccer team, who died from suicide in March 2022. Following her death, her mother said: “There’s so much pressure I think on athletes…especially at that high level balancing academics and a high competitive environment. And there is anxiety and there is stress to be perfect, to be the best, to be number 1.”4
Positive Effects on Psyche
Sports have been known for their positive impact on child and adolescent mental health. Young athletes do better academically. Sports provide exercise, a way to meet friends, and a place to learn skills like perseverance, teamwork, and problem-solving.5 These positive experiences can enhance their lives in important ways.
“Successful game play can increase self-esteem and confidence and improve [a child’s] overall self-image,” Birgit Amann, MD, medical director and founder of the Behavioral Medical Center in Troy, Michigan, told Psychiatric Times™. “They can learn the importance of developing and using patience and learn the value of practicing their sport.”
Research supports these conclusions. For example, a study examining sports participation found that it can also help protect against depression and suicidal ideation by boosting self-esteem and increasing social support. Results showed the odds of suffering from depression decreased by 25% and suicidal ideation decreased by 12% as sports participation increased.6
Results of another study indicated that boys who play sports during their early childhood are less likely to experience emotional stress, including depression and anxiety, later in life compared with boys who did not participate in sports.7
“Given the recent soaring rates of mental health challenges among children, adolescents, and their families, it is more important than ever to foster protective factors such as team sport involvement,” Hannah Simon, MD, a child and adolescent psychiatry fellow at NewYork-Presbyterian Hospital, told Psychiatric Times™.
Amann also noted the potential benefits of playing multiple sports, rather than specialization in a single sport. “Playing multiple sports can broaden their experiences,” she explained. “It can improve their overall athletic development, and because they are using different muscles for different sports they play, it can potentially prevent overuse injuries, which are more common when children play a single sport. It can also prevent burnout, which is more common when a child specializes in 1 sport.”
Increased pressure—particularly on high-level athletes—may contribute to the risk of depression or anxiety (Table 1).8
“Like a broken bone, anxiety and depression may require rest, support, and rehabilitation in the form of therapy, and in some cases, even medications in order to heal. I emphasize that improving and preserving mental health requires hard work and practice, analogous to the way we gain mastery in any sport,” Simon commented.
In a study of elite Canadian swimmers, it was found that 68% of the surveyed athletes met criteria for a major depressive episode, with 34% meeting diagnostic criteria and 26% self-reporting mild to moderate symptoms of depression post competition. The depression prevalence doubled among the top 25% of athletes. Female athletes in particular are at risk for depression, according to a study by the National Collegiate Athletic Association (NCAA) Division I, the NCAA’s most competitive division.9 One study found “many student-athletes report higher levels of negative emotional states than non-student athlete adolescents.”10
“When you are told that your body represents a value out of 10, that is a problem. If your body is the vehicle in which you can achieve physical excellence, that’s another story,” Warren Y.K. Ng, MD, MPH, president of the American Academy of Child and Adolescent Psychiatry, told Psychiatric Times™. “We have to think about the values, the messages, and the culture related to the sport and the messages that we are giving young people about their bodies.”
Framing and focus, stressed Ng, is crucial. If the adults—parents, coaches, supporters—frame an Olympic or elite-level competition as a once-in-a-lifetime opportunity to showcase the youth’s abilities, but also focus on how the event is not their entire life, the youth can have a positive mindset. “We need to be respective of their age and humanity,” Ng commented.
Although some degree of pressure can be healthy for kids, it is important to gauge when pressure goes too far.
“Athletic pressures can teach kids how to navigate stressful life events and build resilience in the face of defeat,” Simon explained. “[They] can improve kids’ self-esteem by providing a sense of mastery as they learn a new skillset and feel empowered to overcome their own insecurities. However, if the pressure to perform results in significant impairment in personal functioning—as evidenced by problems with sleep or appetite, significant weight loss or weight gain, decline in grades, distressing anxiety or mood symptoms—then it may be time to reconsider whether continuing the sport is healthy for this child.”
Table 2 lists tips to share with young athletes and their families to prevent and reduce anxiety.11,12
Injuries, Performance Enhancers
Injuries are often a catalyst for anxiety, depression, and substance abuse among athletes. Many athletes may also show signs of posttraumatic stress disorder following a traumatic injury.13 When a young athlete’s identity and sense of self-worth is closely tied up in their sport, injury can leave them feeling lost and alone.14
“An injury can have a significant negative impact on children, emotionally,” said Amann. “They can become more depressed and anxious, and even feel frustrated and angry. They can become more disengaged with family and friends and become withdrawn. The longer the recovery takes, the greater the risk for these emotional issues.”
In a study of NCAA Division I football players, 33% of injured athletes reported high levels of depressive symptoms compared with 27% of noninjured athletes, measured using the Center for Epidemiological Studies Depression scale.15 Although emotional responses of sadness or loss from injury are normal, coaches and parents should be cognizant of problematic emotional responses (Table 3).16
Concussion and traumatic brain injuries can be particularly challenging for student athletes, as there is no defined timeline for recovery and return to play.17 Further, concussion management necessitates cognitive and physical rest, which can be hard for an athlete who is used to much activity.
Performance-enhancing drugs, unproven supplements, and extreme dieting can lead to severe mental health consequences, yet these strategies—often offered by trusted adults—are a reality for many athletes.
In the case of Valieva and other Russian figure skaters, they may delay puberty by eating only “powdered nutrients” or by taking leuprorelin (Lupron), a puberty blocker known to induce menopause. They are also said to restrict their eating to stay light enough for complicated jumps, and to use “smelling salts” to help them perform while injured.18
Figure skating is not the only culprit. The NCAA reported the number of student athletes testing positive for stimulant medications has increased 3-fold in recent years.19 Cortisone injections, prescription opioids, and blood doping are common ways to perform despite pain.20
Is Winning Everything?
Performance failure is significantly associated with depression: If an athlete does not win or at least do extraordinarily well in their competition, they feel increasingly depressed.21
According to research, as many as 70% of young athletes stop playing organized sports by age 13. The increased pressure to specialize in a single, high-level sport—and win—may be a driving factor in the lower participation rates of adolescents in organized sports.22
“We know why kids drop out of youth sports,” said Mark Hyman, JD, George Solomon Endowed Chair in Sports Journalism at the University of Maryland. “They’re not having fun anymore. They’re weary of the pressure. They’re tired of being yelled at by coaches and, sometimes, by their parents. The most talented players sometimes are forced to quit because they’ve been playing competitively for so long that they’re hurt…But those for whom winning is the most important thing can unravel a child’s devotion to a team and a sport quickly.”23
Simone Biles, considered the greatest gymnast of all time and winner of 4 Olympic gold medals, recently spoke out about deeming mental health more valuable than competing, after she withdrew from the US women’s gymnastics team final in the Summer Olympic Games held in Tokyo in 2021.
“Put mental health first, because if you don’t, then you’re not going to enjoy your sport and you’re not going to succeed as much as you want to,” Biles said. “It’s OK sometimes to even sit out the big competitions to focus on yourself, because it shows how strong of a competitor you really are, rather than just battle through it.”24
Rashmi Parmar, MD, a psychiatrist with Mindpath Health, applauds Biles’ strength. “She definitely paved the way for future aspiring young athletes to advocate for their emotional well-being in face of stressful situations,” Parmar shared with Psychiatric Times™. “In general, there is a huge taboo among younger athletes about seeking help for their mental health, followed by low awareness and denial of the ‘need to seek help.’ Many embrace the ‘perfect’ or ‘superhuman’ identity as a normal part of their lives.”
Young athletes and their mental health are in crisis. Dr Kamis offers the following advice for caring for young elite athletes: “Be grateful to have the opportunity to work with such talented and driven people. Show them the compassion that perhaps they do not take the time to show themselves.”
1. Ryan M. Kamila Valieva will continue to compete in Olympics, panel rules. Popsugar. February 13, 2022. Accessed February 18, 2022. https://www.popsugar.com/fitness/kamila-valieva-tests-positive-trimetazidine-2022-olympics-48712618
2. The CAS ad hoc division declines to impose a provisional suspension on the Russian figure skater Kamila Valieva. Court of Arbitration for Sport. News release. February 14, 2022. Accessed February 18, 2022. https://www.tas-cas.org/fileadmin/user_upload/CAS_Ad_Hoc_Media_Release_Beijing_8.pdf
3. Harry Miller: Ohio State offensive lineman says he is medically retiring from football, citing mental health struggles. CNN. March 11, 2022. Accessed March 14, 2022. https://www.cnn.com/2022/03/11/sport/ohio-state-harry-miller-medically-retiring-spt-intl/index.html
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5. Benefits of sports for adolescents. University of Missouri Health Care. Accessed March 3, 2022. https://www.muhealth.org/conditions-treatments/pediatrics/adolescent-medicine/benefits-of-sports\
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8. Depression and anxiety in sports. American Medical Society for Sports Medicine. Accessed March 3, 2022. https://www.sportsmedtoday.com/depression-and-anxiety-in-sports-va-245.htm
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10. Neal TL, Diamond AB, Goldman S, et al. Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement. J Athl Train. 2015;50(3):231-249.
11. Tucker LV. How sports psychiatry benefits athletes. Lawrence Tucker, MD. October 16, 2016. Accessed March 14, 2022. http://drlawrencetucker.com/how-sports-psychiatry-benefits-athletes/
12. Pok-Him Tam J, Sahni M. Mental health of elite young athletes: spot and support them before it’s too late. British Journal of Sports Medicine blog. August 14, 2017. Accessed March 14, 2022. https://blogs.bmj.com/bjsm/2017/08/14/mental-health-elite-young-athletes-spot-support-late/
13. Specialized care supports athletes’ unique mental health needs. The Ohio State University Wexner Medical Center. News release. February 7, 2022. Accessed March 14, 2022. http://osuwmc.multimedia-newsroom.com/index.php/2022/02/07/specialized-care-supports-athletes-unique-mental-health-needs/
14. Flanagan L. Why are so many teen athletes struggling with depression? The Atlantic. April 17, 2019. Accessed March 14, 2022. https://www.theatlantic.com/education/archive/2019/04/teen-athletes-mental-illness/586720/
15. Brewer BW, Petrie TA. A comparison between injured and uninjured football players on selected psychological variables. Acad Athl J. 1995;10:11-18.
16. American College of Sports Medicine; American Academy of Family Physicians; American Academy of Orthopaedic Surgeons, et al. Psychological issues related to injury in athletes and the team physician: a consensus statement. Med Sci Sports Exerc. 2006;38(11):2030-2034.
17. Putukian M. The psychological response to injury in student athletes: a narrative review with a focus on mental health. Br J Sports Med. 2016;50(3):145-148.
18. Wenxin Wang R. The culture of child abuse that’s poisoning figure skating. Slate. February 16, 2022. Accessed March 14, 2022. https://slate.com/culture/2022/02/kamila-valieva-coach-eteri-tutberidze-abuse-russia-doping.html
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20. NIDA Blog Team. Crossing the line: athletes risk their health when using performance-enhancing drugs. National Institute on Drug Abuse. December 11, 2014. Accessed March 14, 2022. https://archives.drugabuse.gov/blog/post/athletes-risk-their-health-when-using-performance-enhancing-drugs
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23. Hyman M. Keep sports fun. The New York Times. Updated October 21, 2014. Accessed March 3, 2022. https://www.nytimes.com/roomfordebate/2013/10/10/childrens-sportslife-balance/keep-sports-fun-3
24. Silva D. ‘We’re human, too’: Simone Biles highlights importance of mental health in Olympics withdrawal. NBC News. July 27, 2021. Accessed March 3, 2022. https://www.nbcnews.com/news/olympics/we-re-human-too-simone-biles-highlights-importance-mental-health-n1275224 ❒