Current Opinion in Psychiatry:
CHILD AND ADOLESCENT PSYCHIATRY: Edited by Richard Williams and Philip Hazell
Adolescent athletes: psychosocial challenges and clinical concerns
Tamminen, Katherine A.a; Holt, Nicholas L.b; Crocker, Peter R.E.a
aSchool of Kinesiology, The University of British Columbia, Vancouver, British Columbia
bFaculty of Physical Education and Recreation, University of Alberta, Edmonton, Alberta, Canada
Correspondence to Katherine A. Tamminen, PhD, Exercise and Sport Psychology Lab, School of Kinesiology, The University of British Columbia, 210 - 6081 University Boulevard, Vancouver, BC, V6T 1Z1, Canada. Tel: +1 604 822 9192; e-mail: firstname.lastname@example.org
Purpose of review: To review the recent literature (over the past 18 months) regarding psychosocial challenges and clinical concerns among adolescent athletes, and to address the advances made in understanding adolescent athletes’ coping processes.
Recent findings: Coping research has moved from identifying discrete stressors and coping strategies to examining the processes of coping over time. Parents and coaches play an important role in young athletes’ sport experiences and athletes’ use and development of coping strategies. In terms of clinical concerns, findings regarding the prevalence of disordered eating have been equivocal. However, disordered eating may be of greater concern among athletes participating in ‘leanness’ sports. Sport participation may contribute to increased alcohol consumption among adolescent athletes but decreased use of drugs and smoking cigarettes, while steroid use appears to be relatively rare compared with athletes’ use of alcohol and cigarettes.
Summary: The reviewed studies have implications for future research by identifying opportunities for intervention and education regarding clinical and nonclinical psychosocial challenges. Researchers have emphasized the importance of athletes’ social context and relationships in coping with psychosocial challenges in sport. One concern is that adolescent athletes’ disordered eating and substance use may reflect maladaptive coping. Experimental and intervention research is limited; however, incorporating members of athletes’ social network into future research and interventions may be a practical avenue to achieving positive outcomes among adolescent athletes.
Sport participation can improve motor skills, physical and mental health, and psychosocial development [1–3,4▪]. However, youth report both positive and negative experiences associated with competitive sport participation . In this review, we examine psychosocial challenges and coping in sport, with particular attention paid to the role of parents and coaches, followed by a review of clinical concerns among adolescent athletes (disordered eating and substance abuse).
PSYCHOSOCIAL CHALLENGES AND COPING AMONG ADOLESCENT ATHLETES
Early research in this area focussed on the identification of psychosocial challenges or stressors associated with sport participation and the ways in which athletes attempt to cope with these demands [6,7]. Lazarus's  transactional approach has been most widely used to study stressors and coping among adolescent athletes [9,10]. From this perspective, stressors are subjective appraisals influenced by the strength of an individual's goal commitment and values concerning his or her sport participation and competition. Adolescent athletes report a number of stressors, including making physical or mental errors, parent, teammate, and coach criticism, pressure to perform, fear of injury, viewing opponents cheating or performing well, official and referee decisions, and organizational stressors, including time management, travel, and balancing sport with school demands [11–14]. Coping is defined as on-going conscious and deliberate attempts to manage specific external and internal demands that are appraised as taxing or exceeding the resources of the person [8,15]. Coping is important for achieving subjectively and objectively successful sport performances , and in preventing sport withdrawal or dropout [17,18].
Some studies have examined variability in stressors and coping over short periods of time (e.g., over the course of one competition) [19,20], whereas others have examined coping over longer periods, such as an entire season . These studies showed that stressors fluctuate over time and stressor appraisals also appear to change with development. In a longitudinal study among early and middle adolescent competitive soccer players , athletes (mean age = 14.48 years) reported differences in both the nature and frequency of stressor appraisals depending on age; early adolescents reported a higher mean stressor frequency than middle adolescents over the entire season. Furthermore, early adolescents reported more stressors in the early part of the season, whereas middle adolescents reported more stressors in the mid-season to late season. Both early and middle adolescents frequently reported stressors which included making a physical or mental error and receiving a wrong decision from an official. However, some stressors early adolescents reported more frequently than middle adolescents included observing an opponent cheat and observing another player perform well, whereas the types of stressors middle adolescents reported more frequently included injury and criticism from coaches, parents, and other players. The differences in early and middle adolescent athletes’ stressor appraisals may reflect different developmental stages as well as contextual changes associated with middle adolescents playing at higher competitive levels. Thus, the use of longitudinal designs in sport coping research has drawn attention to the fluctuating nature and frequency of stressor appraisals within athletes’ social environment, as well as the changing demands athletes face over the course of a season.
Studies examining the effect of gender on coping have produced equivocal results [6,21,22]. However, a limitation of these studies is that they have generally examined stressors as generic events at a ‘macro level’, without fully examining the subjective appraisal processes associated with specific stressors. An examination of stressors and coping which takes into account stressors appraisals and stressor sources may explain some differences in male and female athletes’ coping . One recent study helped produce a more refined understanding of gender differences in stressors and coping. Hoar et al. had 524 male and female adolescent team sport athletes (n = 274 male, n = 250 female, mean age = 13.1 years) complete measures of coping with interpersonal stressors in sport. There were no significant differences in the amount of coping strategies male and female athletes used overall. However, there were gender differences across different sources of interpersonal stress. Female athletes used more instances of seeking social support in the context of stressors related to coach and personal social behaviour than male athletes. Female athletes also reported using more cognitive reappraisal than male athletes, but only in the context of referee stressors. These findings draw attention to the differences between male and female athletes’ relationships and social connectedness goals; however, this study only focussed on gender differences in coping with interpersonal stressors. It remains unclear how gender differences would emerge in relation to other competitive stressors in sport.
Few experimental or intervention studies have examined ways to improve coping among adolescent athletes. One exception was a theoretically driven small-scale intervention among five male soccer players (mean age = 13.6 years) [25▪]. Using a coping effectiveness training program, the authors found that athletes’ coping self-efficacy improved, whereas coping effectiveness and performance showed some improvements in effect sizes compared with baseline, but not all athletes reported improvements. Interestingly, athletes’ perceptions of coping effectiveness peaked following the intervention session on problem-focussed coping, which has been reported as most effective in dealing with stressors in sport contexts . This intervention was conducted among a small sample, and researchers have called for more studies which evaluate the effectiveness of interventions to improve athletes’ coping, achievement, and well being in a sport context [27▪].
Role of parents and coaches
Parents help their children understand and interpret their experiences in sport by acting as role models of behaviours, beliefs, and attitudes . However, some young athletes report parental pressure as a stressor associated with sport participation . Recent research has focussed on identifying those parental behaviours which affect young athletes’ experiences in sport and athletes’ perceptions about parental behaviours. Interviews with elite tennis players and their coaches and parents revealed positive parental behaviours included providing social support, positive communication, providing motivation, developing psychological and social skills, and keeping sport in perspective . Negative parental behaviours included being pushy or placing too much pressure on the athlete, yelling or criticizing the athlete, over-involvement and controlling behaviours, ineffective or negative communication, and an overemphasis on winning. Mindful of the potential negative effects parents may have on adolescent athletes, researchers continue to focus on understanding the athlete–parent relationships to optimize parental involvement in sport.
Researchers have sought adolescent athletes’ perspectives to determine their preferences for parental behaviours. Athletes’ specific preferences for parental involvement in sport include making comments on effort and attitude (not performance), providing practical advice, and wanting parents to match supportive comments with nonverbal behaviours . Athletes also preferred specific behaviours before, during, and after competition . Prior to competitions, athletes wanted parents to help them prepare physically and mentally (e.g., ensuring proper hydration and helping the athlete to relax). During competitions, athletes wanted parents to encourage the entire team, focus on athletes’ effort rather than on the outcome of the competition, interact positively with athletes, and athletes wanted parents to maintain control of their emotions. Athletes did not want parents to coach from the sidelines, argue with officials, or engage in behaviours which might draw attention to themselves or the athlete. After competitions, athletes wanted parents to provide positive and realistic postgame feedback. These findings offer some promising guidelines for parental behaviour, but to our knowledge there is no recent research which has adopted an intervention approach to target parental behaviour and to examine whether optimizing parental behaviours results in more positive sport experiences or performance outcomes among athletes.
Nicolas et al.[27▪] examined the perceptions of supportive coaching behaviours, coping, and sport achievement among 80 individual sport athletes (mean age = 18.46 years) to investigate the influence of coaches on athletes’ coping. Task-oriented coping (i.e., thought control, mental imagery, relaxation, logical analysis, seeking social support, and effort expenditure) was associated with improved sport achievement, whereas distraction-oriented coping (e.g., disengagement and resignation, venting of unpleasant emotions) was associated with decreased sport achievement. Perceptions of unsupportive coach behaviours prior to competition were associated with disengagement-oriented coping during competition, whereas supportive coach behaviours were significantly associated with task-oriented coping during competition and sport achievement. Further analyses indicated perceptions of supportive coaching had a prospective influence on athletes’ sport achievement during competition via the initiation of task-oriented coping strategies. These findings suggest that perceptions of coaches as either supportive or unsupportive may represent a factor in the use of adaptive or maladaptive coping strategies among adolescent athletes.
Researchers have recently begun to examine the ways in which parents and coaches influence adolescent athletes’ development of coping strategies. Extending this line of research, Tamminen and Holt [33▪] developed a grounded theory of the ways in which young athletes learn to cope with stressors in sport and the role of parents and coaches in this process. This study sampled 17 athletes (mean age = 15.6 years), 10 parents (six mothers and four fathers), and seven male coaches to qualitatively investigate the development of adolescent athletes’ coping. Findings suggested that athletes’ learning about coping was an experiential process facilitated by exposure to multiple sport experiences and by reflecting on one's coping. Parents and coaches played an important role in helping athletes to learn about coping by creating a supportive context for learning and by using a number of specific strategies to help athletes learn about coping, including questioning and reminding athletes about effective coping strategies, providing perspective, sharing their own experiences, dosing or structuring potentially stressful experiences for athletes, initiating informal conversations about coping, creating learning opportunities, and direct instruction about coping. This study suggested ways in which adolescent athletes’ coping may be supported and guided by members of their social networks, providing targets for intervention. However, this qualitative study was limited to team sport athletes, and the interviews were retrospective in nature. Future longitudinal research could examine the correspondence between athletes’ day-to-day (short-term) coping and its influence on long-term psychosocial outcomes.
Clinical sport psychology has recently emerged as a distinct discipline separate from applied sport psychology or performance enhancement. As such, little research to date has specifically investigated clinical issues among adolescent athletes, particularly within the past 18 months. More broadly, researchers have found that the prevalence of psychological problems among high-performance athletes (e.g., generalized anxiety disorder, depression, panic disorders) is not higher than in the general population, although specific social or environmental stressors associated with competitive contexts may contribute to the development of certain disorders . Consequently, two clinical issues have emerged as significant areas of interest in the past 18 months among researchers and practitioners: disordered eating and alcohol and drug abuse.
Researchers’ use of varying definitions and measures of disordered eating has created some conceptual confusion in the literature. Some researchers have made distinctions between anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified (EDNOS, e.g., when some but not all criteria are met for diagnosis of anorexia nervosa or bulimia nervosa), and subclinical conditions such as problematic eating behaviours and attitudes which do not meet the diagnostic criteria for disordered eating but are still associated with severe physical, psychological, and behavioural disturbances . Other researchers have made distinctions between diagnoses of ‘eating disordered’ (including anorexia nervosa, bulimia nervosa, EDNOS, and binge eating disorder), ‘symptomatic’ (individuals report disordered eating but not at a threshold for diagnosis), or ‘nonsymptomatic’ (individuals do not report any criteria for diagnosis) . Additional diagnoses pertinent to athletic populations include anorexia athletica (characterized by reduced body mass or weight cycling for performance, dieting and excessive exercise), exercise dependence, body dysmorphic disorder (a preoccupation with perceived defects in appearance) , and the female athlete triad (the co-occurrence of disordered eating, amenorrhea, and osteoporosis) . The age of onset for athletes’ disordered eating has been suggested to occur during adolescence; however, the prevalence of adolescent athletes’ disordered eating is not well established [38,39].
To date, most research examining disordered eating in sport has focussed on elite adult athletes; however, there is cause for concern regarding young athletes’ disordered eating. Adolescent athletes experience physical changes associated with maturation, including gains in height, weight, and body fat; these changes may affect athletes’ perceptions of their physical appearance and physical ability, potentially contributing to restrictive eating practices [38,40,41]. Disordered eating is more prevalent among adolescent athletes participating in ‘leanness’ sports (e.g., dance, gymnastics, swimming, etc.) versus ‘non-leanness’ sports (e.g., alpine skiing, soccer, basketball, etc.) . Krentz and Warschburger [43▪] conducted a prospective study among 65 male and female adolescent athletes (mean age = 14.0 years) participating in aesthetic or ‘leanness’ sports. Boys reported significantly lower levels of disordered eating at 1-year follow-up, whereas girls’ disordered eating remained stable. Overall, athletes’ desire to be leaner in order to improve sport performance was predictive of disordered eating, and not vice versa, which supports the notion that athletes’ beliefs about leanness as being important for sport performance contribute to a higher prevalence of eating disorders . However, this study did not describe specific diagnoses of anorexia nervosa, bulimia nervosa, etc., but rather it examined athletes’ levels of disordered eating which included subclinical conditions. In another recent study of adolescent aesthetic athletes (52 female and 16 male athletes aged 11–21), Van Durme et al. used three separate measures to assess disordered eating pathologies and psychological characteristics related to eating disorders (drive for thinness, bulimia, body dissatisfaction, perfectionism, and interpersonal distrust). Female aesthetic sport athletes reported significantly higher drives for thinness and more features of bulimia, engaged in more dieting behaviours, and had greater concerns about their weight and body shape compared with a female adolescent control group. Competitive state anxiety (e.g., feelings of nervousness or worry prior to competition) , age, and eating concerns accounted for a significant amount of variance in dieting behaviour among aesthetic sport athletes. Thus, cognitive concerns regarding one's body and competition are important as core features of adolescent athletes’ disordered eating.
There are some contradictory findings despite the studies reported above. Martinsen et al.[47▪] examined dieting and disordered eating among 15–16-year-old elite athletes (n = 606) and nonathlete controls (n = 355). Disordered eating was examined through the assessment of athletes’ drive for thinness and body dissatisfaction, attempts to lose weight, pathogenic weight control, or self-reported menstrual dysfunction. Martinsen et al.[47▪] classified athletes on the basis of having one or more symptoms of disordered eating, under the assumption that it is important to measure subclinical eating disorders in addition to clinical eating disorders. The non-athlete controls reported a higher incidence of dieting and disordered eating than elite athletes. Furthermore, there was no difference in the prevalence of self-reported dieting or disordered eating between athletes participating in leanness and non-leanness sports. One possible explanation for this finding is that young athletes under-report disordered eating symptoms, and disordered eating may appear and be diagnosed more frequently among older athletes in leanness sports because of a longer period of involvement in sport and extended exposure to leanness requirements.
Generally, disordered eating has been investigated to a greater extent among older adolescents and adult athletes [48–50]. Clinical and subclinical disordered eating is more prevalent among elite athletes compared with the general population, is higher among female athletes compared with male athletes, and is higher among athletes participating in leanness sports than those participating in nonleanness sports . On the balance of evidence, young athletes participating in ‘leanness’ sport may be at risk for developing disordered eating. But, given that some findings have been contradictory, further research is required to understand the development and trajectory of disordered eating among athletes throughout adolescence and into adulthood.
Alcohol and drug abuse
Another clinical issue of concern is adolescent athletes’ alcohol and drug abuse. A recent review reported that sport participation was related to higher alcohol use among athletes but lower levels of cigarette smoking and use of illicit drugs . In a longitudinal survey using data from a national cohort of 11 741 American adolescents, Terry-McElrath and O’Malley [53▪] examined graduating high school students’ sport and exercise participation and its relationship to substance use, conducting four follow-up measurements at 1-year intervals. Findings indicated that adolescents who initially (at age 18) participated in team sports reported higher alcohol use, and higher initial frequency of alcohol use was related to significantly higher frequency of use throughout young adulthood. However, initial sport participation was also associated with decreased cigarette and drug use, and decreased drug use at age 18 was associated with decreased drug use through adulthood. Terry-McElrath and O’Malley's longitudinal study corroborates findings which suggest that sport participation may contribute to alcohol consumption; however, participation in sport may also protect against smoking and drug use .
Current research is focussed on identifying the factors which contribute to alcohol and drug use among athletes. Male and female adolescent athletes may have different intentions to consume alcohol. Davies and Foxall  found that young men involved in sport were more likely to consume alcohol to the extent of getting drunk compared with their nonathletic male peers; however, findings were not significant for women. Parental and peer subjective norms regarding drinking were also significant predictors of male and female athletes’ intentions to consume alcohol. Although peer and parental norms have been found to predict athletes’ intention to consume alcohol , greater drives for muscularity and thinness have been found to predict stronger intentions to use doping substances, regardless of level of sport involvement . Understanding the psychological and social contributors to alcohol and drug use as well as disordered eating continues to be an important area of research.
Researchers have raised concerns about young athletes’ use of performance-enhancing substances and anabolic–androgenic steroids [56▪]. A number of studies have examined the prevalence [57▪,58▪,59] and predictors [55,56▪] of adolescents’ use of performance-enhancing substances. Findings from studies within the past 18 months suggest that the prevalence of high school students’ steroid use is low, ranging from 0.9 [58▪] to 4% [57▪] of surveyed adolescents, and the relationship between adolescent athletes’ sport participation and steroid use is not clear. In one study, sport participation was not significantly related to Icelandic high school students’ steroid use (n = 10 918, 48.2% men, mean age = 17.7 years), although steroid use was associated with participation in informal physical fitness activities (e.g., exercise outside formally organized sports; weightlifting, etc.). Conversely, according to analysis of national data from the Youth Risk Behavior Surveillance System, participation in multiple sports was associated with a higher probability of male athletes’ steroid use [57▪]. Generally speaking, it appears the prevalence of steroid use ‘is not rampant among high school students’ and ‘compared to smoking and drinking, steroid use is relatively rare’ ([57▪], p. 211). Adolescent athletes’ steroid use may be relatively low compared with alcohol and cigarette use [57▪]; however, steroid use could be part of a broader experimentation with substances [58▪,59] or part of adolescents’ motivation to secure a position on an elite team or to gain athletic scholarships [56▪,57▪]. More research is needed to investigate young athletes’ motivation and perceived incentives for steroid use, although adolescent athletes’ alcohol use appears to be a more pressing issue.
Researchers have focussed on establishing the prevalence of disordered eating and alcohol and drug use, as well as psychological and social factors which contribute to these issues. However, to date there is little published research adopting intervention approaches which target adolescents’ disordered eating or alcohol and drug use in sport contexts, which would be a valuable addition to the current research addressing clinical concerns among adolescent athletes.
Sport is viewed as a context for adolescents’ positive development; however, there is a large body of literature revealing psychosocial challenges and clinical concerns associated with youth sport participation. Recent research has examined how young athletes cope with challenges in sport contexts and the process by which athletes learn to cope, with parents and coaches being implicated as important social agents in athletes’ coping. This line of research may provide valuable information about adolescents’ coping in other contexts, particularly in achievement contexts such as school and academic settings. For example, task-oriented coping (e.g., logical analysis, seeking social support, effort expenditure) is associated with improvements in sport achievement [27▪], and athletes’ perceptions of coping effectiveness increased following educational sessions dealing with problem-focussed coping [25▪]. Educating athletes about task-oriented and problem-focussed coping may be useful in helping athletes to deal with competitive demands, as well as demands in other achievement contexts (i.e., school). There is abundant research in recent years examining the development of life skills and the potential for the transfer of life skills learned in sport to other contexts [60,61]. Despite these advances, there is little research examining the transfer of the coping skills athletes gain in sport contexts to other areas of their lives.
Why do some adolescent athletes develop eating disorders? Researchers have identified the importance of cognitive concerns as core features of adolescent aesthetic sport athletes’ disordered eating. It would appear that cognitive concerns regarding body weight and competitive anxiety about performance contribute to the development of disordered eating . Thus, perceptions that striving for a thin body ideal will be beneficial for performance may put athletes at risk for developing disordered eating [45,47▪]. Although disordered eating is suggested to develop as a result of young athletes’ desire to be leaner to improve performance [43▪,47▪], research among adolescent athletes is limited in scope and has provided equivocal results. It may be the case that disordered eating is diagnosed more often in contexts which emphasize aesthetics and weight management. It should also be noted that most research examining athletes’ disordered eating has been conducted with older, elite populations. Nonetheless, eating disorders diagnosed among adult elite athletes may begin during adolescence, particularly if pressures to perform contribute to young athletes’ cognitive concerns regarding their body shape and weight. Further longitudinal research which examines the trajectory of development of disordered eating is warranted.
The definitions and diagnoses of clinical versus subclinical eating disorders is an important issue to be addressed. Subclinical eating disorders are those which are not considered diagnosable as a clinical eating disorder; yet, the athlete still presents symptoms of disordered eating and may experience severe physical, psychological, and behavioural disturbances as a result . It is not entirely clear how subclinical eating disorders are different from ‘eating disorders not otherwise specified’ (e.g. when some but not all criteria are met for diagnosis of anorexia nervosa or bulimia nervosa), and it is also not clear how practitioners and researchers understand and apply these different definitions and diagnoses. Petrie and Greenleaf  have previously drawn attention to this issue, and we agree that greater clarity and consistency surrounding these definitions and diagnoses are needed.
Why do young athletes drink alcohol? Several reasons have been offered to account for adolescent athletes’ alcohol use. Young athletes’ increased social standing and pressure to maintain academic and sport performances may create increased demands, and socialization processes may encourage the association between sports and alcohol consumption [52,54]. Therefore, perceptions of increased demands or greater difficulty in managing challenges, along with a ‘normalization’ of drinking, may contribute to an increase in adolescent athletes’ alcohol consumption. Peer group influence and parental norms are important in predicting adolescent athletes’ alcohol use, which suggest key opportunities for intervention and education . Parent communication and modelling of appropriate behaviours may be a viable avenue for decreasing adolescent athletes’ alcohol consumption. Researchers may wish to examine the efficacy of team and parental interventions to examine the short-term and long-term effects on adolescent athletes’ alcohol use.
Over the past 18 months, researchers have established evidence for psychosocial challenges and clinical concerns among adolescent athletes; however, one limitation is a lack of studies adopting intervention or experimental studies designed to target these issues among young athletes. There is a need for studies which evaluate the effectiveness of educational or preventive programmes regarding disordered eating or substance abuse, to improve parental involvement in sport, and to enhance coping among adolescent athletes. Moving forward, it would be worthwhile for researchers to consider intervention research aimed at adolescent athletes as well as members of their social network to promote psychosocial well being and lifelong sport participation.
Sport may serve as a context for youth development; however, there are demands and pressures inherent in competitive contexts which may be stressful and potentially overwhelming for adolescent athletes. Athletes’ coping in sport contexts may be valuable for learning to deal with stressors, but in some extreme cases athletes may engage in maladaptive behaviours such as disordered eating, substance abuse, and steroid use to deal with the demands of sport. Progress is being made in understanding how athletes perceive psychosocial challenges in sport and how interventions can equip young athletes with the necessary coping skills to manage their demands in an adaptive manner.
During the preparation of this manuscript K.A.T. was supported by a postdoctoral fellowship from the Social Sciences and Humanities Research Council of Canada.
P.R.E.C. was supported by a standard research grant from the Social Sciences and Humanities Research Council of Canada.
Conflicts of interest
There are no conflicts of interest.
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Although most research has been cross-sectional, this was a longitudinal study examining sport-related variables which may contribute to disordered eating among young athletes. Social pressure to be thin increased at 1-year follow up among women but not among men; findings suggest that athletes may be at risk for developing disordered eating if they believe it will help improve performance.
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Findings suggest that dieting and weight control are more prevalent among controls than athletes; however, athletes’ motivations to diet and engage in disordered eating include losing weight and improving performance, whereas controls’ motivations concerned improving appearance. Interventions to reduce disordered eating should target specific motivations in athletic and nonathletic populations.
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coach; coping; disordered eating; parent; sport; stressors; substance abuse
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