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Special Populations: Section Articles

Safeguarding the Child and Adolescent Athlete

Lamb, Micah DO1; Kuhn, Andrew W. BA2; LaBotz, Michele MD, FAAP3; Diamond, Alex B. DO, MPH, FAAP4,5

Author Information
Current Sports Medicine Reports: December 2018 - Volume 17 - Issue 12 - p 419-424
doi: 10.1249/JSR.0000000000000538
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Abstract

Introduction

Youth athletics have long been touted for their ability to cultivate many of the physical and psychological values we ascribe to well-adjusted adults. And until recently, sports have been relatively free from scrutiny over the ways they put their youngest participants at risk.

While it was often disregarded in early childhood research, athletics emerged as an avenue of child abuse in the 1980s (1). Individual cases reporting maltreatment of children participating in sports certainly existed, but these were felt to be single instances and not sentinel events. By the 1990s a small body of research had been established showing a pattern of abuse (2), spurring sporting organizations and governing bodies to assess their own policies and produce rough standards for safeguarding children against abuse.

Around the same time, many high-profile cases of large-scale abuses were reported in the media casting the topic into the international spotlight. In 2010, the UNICEF Innocenti Research Center published their review and recommendations on protecting children from violence in sports (3). In addition to establishing the issue on a global level, their efforts led to a drastic increase in safeguarding practices within national bodies and culminated with the creation of a document titled “International Safeguards for Children in Sport.” The document laid out evidence-based safeguards for individuals and organizations to strive for in preventing abuse in sports (4).

In the United States, to help meet these ends, the US Olympic Committee (USOC) started to develop consensus statements both on the general health and well-being of the young athlete (5), and then specifically on safeguarding practices (6). They ultimately created the US Center for SafeSport in March 2017 which serves to provide training and resources, and to respond to allegations of abuse within the entirety of the USOC’s Olympic and Paralympic population.

While multiple strides have been taken, there still exist questions and gaps in knowledge surrounding abuse of child and adolescent athletes. This includes but is not limited to: scope and prevalence of abuse, definitions and what ultimately constitutes “abuse,” unique aspects of abuse in sport, and recognition and preventative efforts.

Scope and Prevalence

Although high-profile isolated events exposing the abuse of elite athletes have recently grabbed the attention of the nation and catalyzed a response (7), the true prevalence of harassment and abuse of athletes remains relatively unknown. Studies from across the world have attempted to elucidate these figures through retrospective questionnaires (8–16). However, to date, few have examined trends in larger and perhaps more vulnerable populations, including child and adolescent athletes.

One of the most difficult aspects in determining the scope of abuse in sports lies in defining the abuse itself. While there are more obvious forms, such as physical and sexual abuse, subtle psychological abuses are significant as well. Furthermore, multiple researchers have noted types of mistreatment that do not rise to the level of what is commonly considered abuse, but still have negative effects on the child (8). To this end, the scope and prevalence is most easily discussed within the context of each individual subset of abuse.

Definition of Abuse

In its 2010 review on child violence in sports, UNICEF proposed an intentionally broad definition of abuse (3). The definition stems from article 19 of the UN Convention on the Rights of the Child, where abuse is defined as “all forms of physical or mental violence, injury, and abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse.” Endorsing a broad definition is important to encompass all forms of abuse which researchers have separated into acts of physical, sexual, and psychological abuse. Within each category, there are an ever-changing number of ways in which abuses occur.

Sexual abuse

Sexual violence is the most widely studied area of child abuse in sports (2,7,10,14,16–19). The scope of sexual mistreatment is relatively broad and includes everything from frank sexual abuse and sexual harassment to lewd behavior. Although data are limited, 2% to 22% of children and teens are victims of sexual misconduct through sport (7). Sexual abuse can be perpetrated by anyone who interacts with the athlete (coaches, parents, officials, medical staff, or other players). Ninety-eight percent of cases of abuse are committed by adults in positions of power while peer athletes are far more likely than adults to be perpetrators of sexual harassment (6,7).

In a recent retrospective study by Vertommen and colleagues, more than 4000 individuals in the Netherlands and Belgium were asked to recall violence they had been subjected to while playing sports as children. A total of 14.3% of these respondents noted that they were exposed to some level of sexual violence (8). This finding affirms data in a study by Parent et al. of more than 8000 individuals with a reported 8.8% prevalence rate of sexual abuse among athletes between ages 14 and 19 years (9).

The Vertommen and Parent studies found that females were over 1.6 and 4.3 times more likely to report sexual abuse, respectively. This further supports prior studies demonstrating similar gender differences with regard to sexual harassment and abuse (10,12,14,16). However, as Parent and Bannon note, research on the sexual harassment and abuse of males in sport also is warranted (20), as is understanding the increased prevalence rates of sexual violence sustained by child and adolescent athlete minority groups (immigrant, LGBTQ, disabled).

Of particular interest within the subject of sexual abuse in sports, is the idea of “grooming.” Jim Clemente, a former FBI investigator asked to review the recent high-profile case of abuses at Penn State, defines grooming as, a “dynamic process using a constellation of seemingly innocent behaviors aimed at gaining the cooperation of the child to achieve sexual gratification for the offender” (21). The preferential treatment exhibited as part of the grooming behavior also can sometimes be directed at the parents in efforts to further gain favor and trust. Unfortunately, sports are uniquely positioned to put kids at risk for this kind of abuse. Both the power imbalance and the associated celebrity relative or otherwise, allow predators access to a near constant stream of victims. In one study, 3% of coaches admitted to having intimate relations with an athlete under the age of 18 (22).

Psychological abuse

Psychological abuse covers a broad spectrum of behavior that inflicts any type of psychological or emotional harm. While previously not well documented, psychological abuse is now considered the most prevalent form of abuse experienced by young athletes, and is the core around which all other forms of maltreatment are built (6). The Vertommen study demonstrated that 37.6% of respondents reported having been the recipient of some form of psychological violence (8). Even more astounding were results published by Yabe et al. (23) who polled 1283 coaches in Japan and found that 64.7% had themselves experienced verbal abuse as a player.

The scope of psychological maltreatment is incredibly varied. Examples of abuse include name-calling, intimidation, threatening, and other overt verbal abuses. There also are much more subtle abuses such as blaming, scapegoating, rejecting, isolating, and ignoring (11,18,24–27).

Neglect is a form of abuse that is increasingly recognized within youth sports. It results when a player’s best interests are placed below that of other parties. Neglect can have multiple physical and psychological consequences, such as failure to implement safety measures, or to protect from injury. With so many competing interests, all too often the rights of the child athlete do not take priority.

Physical abuse

Physical abuses also are extremely varied and can be as simple as excessive physical training as a punishment for poor play, or as clear as laying hands on players. The established baseline physicality in sport can make physical abuse particularly difficult to define. Physical contact that is often deemed acceptable within the confines of the playing field is often not acceptable in almost any other arena.

With regard to the prevalence of physical abuse, rates are understandably varied. Vertommen’s work reports an 11% overall prevalence of physical abuse (8) while Yabe’s study reported 6.2% (23).

Consequences of Abuse

Apart from the well-known issues associated with physical and sexual abuse, the more subtle abuses described above are not without consequence. Small semistructured interviews with former athletes demonstrate that emotional abuse in the context of the coach-athlete relationship during adolescence, has psychological effects (low mood and self-efficacy, anger, anxiety), training effects (reduced motivation and enjoyment, impaired focus, difficulty with skill acquisition), gameplay effects (performance decrements), and even impacts their willingness to report incidents of maltreatment (26,27).

The long-term effects of harassment and abuse in children and adolescent athletes also are concerning (28). A recent extension to the Vertommen study showed that experiencing severe sexual, physical, and psychological childhood violence was associated with psychological distress and reduced quality of life as an adult. Victims who had experienced all three types of abuse reported the most psychological complications as adults, followed by those who had experienced only one or two of the forms of abuse. Respondents who reported at least one instance of violence described as “severe” also were more likely to endorse lasting psychological issues.

Given the potential short- and long-term effects of abuse in young athletes, sports medicine professionals need to be adept at understanding not only the types of violence that can affect these children (29), but also be aware of the risk factors for, signs of, and physical and psychological consequences of harassment and abuse (19).

Unique Aspects of Sports

Sports are in many ways uniquely conducive to abuse. They place the young athlete in relationships and physical environments that are not seen anywhere else. The idea that relationships play a major role in the abuse of young athletes is not new. In 2009, Stirling attempted to create a definition of sport-related abuse based specifically on whether or not they take place within a “critical relationship” (30). She proposed looking at abuses depending on whether they occur between the athlete and someone in whom there is “safety, trust, and fulfillment of needs.” These relationships therefore include most of the commonly implicated abusers (coaches, peers, family members, and health care personnel). Within each of these groups, there are unique aspects of their interactions with young athletes that can potentiate offenses.

Coaches

Coaches have been a well-studied and often cited source of abuse of children in sports (7,11,23,26,27). Sports are unique in that they necessitate an imbalance of power. By definition, sports are a form of competitive physical activity within a specified set of rules, and as relative experts, coaches are given an immense amount of power over their players. This power, coupled with limited oversight, has been implicated in many of the recent instances of sexual abuses by coaches on players.

While one study found that almost 5% of former athletes experienced coach-inflicted physical violence before the age of 18 years (8), less overt forms of physical abuse are far more common. Coaches are often given a lot of leeway in what is appropriate in the name of developing physical and mental strength. Coaches maintain power and control over the level and intensity of practices and games. Unfortunately, the physicality and training strategies used in many sports may blur the line between abuse and simply what is needed for optimal performance. Punishment is often doled out in the form of added physical activity which can place struggling players at risk for physical and emotional injury, and this too can easily cross the border into maltreatment. Practice environments that include unsafe weather or environmental conditions or poor attention to other safety issues (particularly in contact sport) may constitute maltreatment.

Coaches also have been known to fall short when it comes to the care of injured athletes. It is relatively well understood that child athletes suffer emotionally after injuries (31). Unfortunately, coaches can often add to the psychological burden of returning from an injury through pressure to return sooner than indicated, or not emotionally supporting an athlete who is struggling to return from an injury. Athletes can be notoriously strong-willed and will often overlook their own well-being if encouraged. When injuries are potentially career-ending or threaten long-term disability, such as recurrent concussions, coaches are often guilty of emboldening athlete’s misguided understanding of their long-term risk (32). However, coaches that are in tune to their player’s needs may actually decrease injury rates (33).

Coaches are given extensive license with regard to what they say to and about players. Verbal abuse also is often cloaked in the guise of player development, and in many settings verbal abuse of athletes by coaches has been normalized (23,24,34). However, recent research demonstrates that even seemingly harmless comments and actions can have lasting implications on a player’s future well-being (28). Recognition of the potential harms of verbal abuse requires a shift in the current common perception of this as an acceptable coaching technique.

Peers

Peer pressure and encouragement of risky behaviors is a well-defined concern within adolescent sports teams, but abuse between peers is receiving increased recognition. Many articles have shown increased rates of alcohol and illicit drug use by teens participating in sports (24,28,35), and this may foster environments conducive to interpersonal abuse. Hazing in particular has been portrayed relatively frequently over the past 10 years (36). Often ignored by coaches and parents, as a rite of passage. Both the severity and prevalence of hazing incidents are of growing concern. Rates of middle school hazing in sport have been shown to range from 5% to 17.4%, while high school rates are higher at 17.4% to 48% (37,38).

Cyberbullying is an emerging threat of special concern due to its ubiquitous nature, the permanence of the online reputation created, and the difficulty in detection by authority figures limiting their ability to recognize and respond to it. As such, many of the same abuses seen in the locker room are now being brought into the home.

Family

The interaction between parents and their child athletes can be a fragile one. The current climate of youth sports can strain the family unit. In their thorough review, Bean et al. reviewed not only the stress that competitive sports puts on the athlete, but also on their siblings and parents. They highlighted the sport-related financial and time commitments of families, as well as the feelings of competition between siblings, which can often make homelife less hospitable (24). In all, the weakening of traditionally held support systems in the name of sport was shown to have significant ramifications.

Medical personnel

In light of more recent events, the health care provider’s role in the abuse of the young athlete needs to be further examined. Athletes are expected to perform and put their inherent trust in any number of health care professionals to help them stay physically and mentally prepared for their sport. This, in combination with the often sensitive nature of concerns and strict confidentiality afforded to protect the athlete’s privacy, put them in precarious positions. Athletes may commonly find themselves alone with a provider who holds some authority over them.

Apart from gross physical and sexual offenses, there are much more subtle infractions of providers’ responsibility to put patient well-being above all else. This again can be seen in clearing players from injury prior to full recovery (39) or encouraging medications or supplements not ultimately in the best interest of the athlete’s health. Examples of this were recently discussed by Tscholl et al. (40) in a review of the excessive prescription of painkillers in elite level youth soccer players.

Contextual concerns

With regard to the general environment in which sports occur, young athletes are often placed in physical situations that make them vulnerable to various forms of abuse. Whether it is in a locker room, team bus, or travel to away sporting events, there are many times where children are placed in the temporary guardianship of someone other than their parents.

This is no more evident than in the locker room where children are exposed in the most fundamental way. Whether it is with an adult teacher, coach, or peers, being in a place intended for privacy and devoid of general traffic, facilitates maltreatment. Sexual misconduct is relatively commonplace in the locker room, where supervision is often sparse. This exposure extends beyond physical abuse and includes “locker-room talk” as a form of unwanted verbal abuse as well. Discrimination by gender, sexual orientation, and religion, on top of explicit, and threatening language, are often chalked up to harmless banter within the confines of a team. Similar level of risk can be attributed to “one-on-one” training sessions where the athlete is without the support and watchful eyes of their teammates or other observers.

The prevalence of sexual abuse appears to be higher in elite level athletes (19,41). It is unclear whether this is due to intrinsic changes in the athlete-coach relationship, or reflects greater exposure to high-risk situations (7,42,43). For the preelite athlete, there is often a heightened level of stress and dependence on coaches and staff, which in turn may leave the athlete more vulnerable to predation. The preelite athlete also is more likely to tolerate inappropriate behaviors rather than compromise pending achievement (44). In addition, athletes who specialize at a younger age, particularly around puberty, have been found to be highly vulnerable to sexual abuse (2).

Institutional concerns

Sports by nature are competitive, which has proved problematic for a host of reasons (45). In addition to the impacts of injury, overtraining, and burnout, at its simplest, competition marginalizes the mediocre athlete. While sports are intended to garner a sense of pride and accomplishment among all participants, it very frequently does the opposite in those not considered high performers.

Athletics also brings notoriety and is financially lucrative for many institutions. With fame and money as the motivator, children’s rights are often cast aside. Priorities can be misguided in attempts to produce and accumulate the best athletes and facilities possible. Organizations may essentially use young talented participants as “employees” working for the benefit of the team, rather than as children whose athletic development should be individualized and fostered over the long term. Less commonly seen in western countries, but child trafficking, age forgery, and child labor violations are all common practices in the name of sports in developing countries (46).

Recognition and Response

Abuse, whether in the context of sports or not, is an extremely difficult diagnosis for any provider to make. While there can be suspicion, the implications of abuse claims are such that providers often look to accept any other reasonable explanation for findings. Recent advances in child abuse research have provided for some increased diagnostic certainty for certain types of physical and sexual abuse. However, as discussed previously, within sports-related abuses, there are countless subversive forms of abuses that occur daily, often without notice.

For physicians, a general recommendation is to follow the American Academy of Pediatrics (AAP) Bright Futures Guidelines regarding assessing an adolescent’s psychosocial and behavioral well-being at each annual visit. Within these discussions, be very specific in asking young athletes about extracurricular activities, their level of comfort and safety within these activities, and any concerns for abuse. Physicians also should be encouraged to think of sports and sport-related abuses as being a part of any symptoms encountered on annual depression screening in their adolescents.

Maltreatment in sport also should be considered when encountering patterns of preventable or recurrent injuries, or when there is pressure to subvert clinical decision making regarding a child’s ability to return to play. Regardless of whether that pressure is from a coach, parents, or the player themselves, it should be a red flag whenever a provider is asked to set aside their objectivity.

Health care providers should be on alert if a child or teen presents with various nonspecific and recurrent medical and somaticizing concerns including headaches, lethargy, sleep disturbances, bed wetting, acting out or engagement in risky behaviors, self-harm, weight fluctuations, and poorer general health satisfaction (19). In addition, specific to athletes, signs of abuse also may include the excessive taking of risk within their sport, loss of confidence, lack of concentration during participation, declining performance, skipping training sessions or self-injurious behaviors to avoid having to participate in sport, early dropout, excessive training to cope which leads to burnout, and unexplained injuries that do not make sense or never seem to resolve (47).

In discussions with the child athlete, it is important to encourage open disclosure and avoid any suggestive, directing, or leading questions. It is essential to consider that the victim may be experiencing feelings of shame, guilt and/or fear (19,43). Be an active listener and create a safe and supportive environment for them to share their concerns. Reinforce that the abuse is not their fault and acknowledge the courage it required for them to speak about an issue that may implicate teammates, coaches, or other seemingly respected members of the community.

It is imperative that if a child athlete discloses an incident of alleged abuse, it be believed in full and reported to the necessary authorities (be aware of your local statutes). Prompt referrals also should be made to all relevant medical and mental health colleagues. Ensure accurate record completion and documentation.

Prevention

Given the damage inflicted by any episode of abuse, and the difficulty in recognizing those cases that do occur, prevention needs to be the cornerstone of efforts in this area. Although these conversations are often difficult, health care providers should foster discussion between patients, providers, and parents regarding the current issues surrounding sport-related abuses. Providers also should encourage parents to be advocates for their child’s well-being in sport and have frank and honest discussions with their children regarding appropriate behavior when they are under the care of another adult. Parents should raise awareness of potentially risky situations and highlight their avoidance ad nauseam. Open lines of communication that are free of judgment and without secrecy should exist across the board. All adult-child interactions, including medical examinations, should be visible by others or employ the use of adult chaperones who will unequivocally act on the child’s behalf.

Over the course of the last 5 years, more large-scale attempts at prevention also have been underway. There has been a dramatic increase in safeguard recommendations at all levels of youth sports. The most complete set of recommendations continues to be UNICEFs International Safeguards for Children. Initially created in 2014, it is a published set of the following eight evidence-based safeguards (4):

  1. Develop a policy
  2. Develop a system for responding to safeguarding concerns
  3. Offer advice and support for children
  4. Attempt to minimize the risk to children
  5. Establish guidelines on behavior
  6. Train staff and volunteers
  7. Use partnering institutions
  8. Monitor and evaluate how the safeguards are performing.

Individually, many of the safeguards are seemingly obvious, but as a whole, they represent the strongest evidence-based guidelines for preventing future instances of child abuse and form a template for development of more specific policy. Rhind (17) gave further support for these safeguards when they published a review of more than 650 reports of safeguarding in the UK. By using a government-sponsored reporting system, they were able to evaluate for certain patterns and nature of abuses as well as the identity of perpetrators (17). Since their production, these safeguards have been employed by close to 50 institutions as a pilot study. Rhind et al. also recently reviewed what made for successful implementation of safeguards within a section of these pilot institutions. Thematic analysis established “8 key pillars” (48) on which organizations can successfully develop and implement these safeguards globally.

Families and caregivers should seek out organizations that implement and adhere to policies that safeguard young athletes. Currently, in many communities, parents may need to advocate for development of such policies. A good resource for this and sample policies can be found at: https://www.cdc.gov/violenceprevention/pdf/preventingchildsexualabuse-a.pdf.

Resources for Families, Coaches, and Health Care Providers

Any individual with concerns of any abuse of a child should, without question, bring this to the attention of local authorities. Beyond this, as discussed above, the US Center for SafeSport does have a system in place for reporting and investigating concerns of abuse that occur within any of the USOC’s participating Olympic or Paralympic sports federations. This includes any child participating in sport through their national governing body (NGB). The US Center for SafeSport also has resources for organizations outside the Olympic movement hoping to develop a more robust system of safeguards within their own community (https://safesport.org/files/index/category/education-outreach), and even offers consultation services.

Lastly, parents also should actively engage with coaches and form a triad between them and the young athlete. With so many of the abuses mentioned above happening under the care of a coach acting as guardian, it is vital that parents make what they deem appropriate known.

Conclusions

A leading pioneer in the research of abuse of children in sports, the late Dr. Cecilia Breckenridge pointed out that, “each major stakeholder… has different interests related to their different mission” (1). Each organization (sports federations, NGOs, government bodies) has a different interest in sport but equal responsibility to the young athlete and thereby a unique vantage point for addressing abuse-related concerns. While early recognition of abuse is crucial, prevention of abuse is paramount. Health care providers contribute to this effort by educating patients and their families, as well as advocating for programmatic and culture changes that protect young athletes.

The authors declare no conflict of interest and do not have any financial disclosures.

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