Pediatric Annals

Feature Article 

Sport Psychology and the Adolescent Athlete

Aynsley M. Smith, RN, PhD; Andrew A. Link, BA

Abstract

Sport and exercise psychology is the scientific study of people and behavior in sport and exercise and the application of that information.1 People and their behavior affect sports and exercise. Some sports, such as gymnastics, specifically affect adolescent athletes. As pediatricians work with adolescent athlete patients and decide a sport psychology referral is appropriate, the following information will be helpful.

Who Practices Sport Psychology?

Abstract

Sport and exercise psychology is the scientific study of people and behavior in sport and exercise and the application of that information.1 People and their behavior affect sports and exercise. Some sports, such as gymnastics, specifically affect adolescent athletes. As pediatricians work with adolescent athlete patients and decide a sport psychology referral is appropriate, the following information will be helpful.

Who Practices Sport Psychology?

Aynsley M. Smith, RN, PhD, is Sports Psychology and Research Director, Sports Medicine Center, and Associate Professor of Orthopedics and PM&R, Mayo Clinic, Rochester, MN. Andrew A. Link, BA, is with the Sports Medicine Center, and will begin a Master’s Physician Assistant Program in the fall.

Dr. Smith and Mr. Link have disclosed no relevant financial relationships.

Address correspondence to: Aynsley M. Smith, RN, PhD, 200 First St. SW, Rochester, MN 55905; fax 507-2661803; e-mail smith.aynsley@mayo.edu.

Sport and exercise psychology is the scientific study of people and behavior in sport and exercise and the application of that information.1 People and their behavior affect sports and exercise. Some sports, such as gymnastics, specifically affect adolescent athletes. As pediatricians work with adolescent athlete patients and decide a sport psychology referral is appropriate, the following information will be helpful.

Who Practices Sport Psychology?

The first sport psychology consultant adolescent athletes see is often their physician, who will determine the needs of their patients. Although most sport psychology consultants conduct research, teach, and consult, their primary focus is either educational sport and exercise psychology or clinical sport and exercise psychology. Both types of practitioners are certified after meeting the competency and ethical standards of the Association for Applied Sport Psychology (AASP). Pediatricians may choose to match patients with sport psychology consultants most expert in one of the two domains.2 In addition to their sport psychology expertise, educational sport and exercise psychology consultants are competent in sport science (ie, biomechanics, exercise physiology, motor learning and control, sport medicine, pedagogy, team cohesion, and sociology of sport). Clinical sport psychology consultants are competent in abnormal, developmental, experimental and personality psychology, compared with educational sport psychologists. Both types of consultants may have expertise in psychophysiology.2

Adolescent Issues Likely to Benefit from Sport Psychology Consultation

Helping Adolescent Athletes Differentiate from Parents and Coaches

Adolescent athletes face unique developmental challenges. Growth spurts, weight gains, or a lack of both; mood swings secondary to hormonal changes; and distractibility influence kinesthetic competency, academic focus, and emotional balance, often resulting in turbulence. These athletes may struggle for autonomy, respect, and support and reject dictatorial relationships.

Practical Suggestion

You may wish to draw a Venn diagram to show the pre-puberty relationship depicted by three overlapping circles representing the athlete, coach, and parents. Then, draw the circles touching but not overlapping, depicting close but independent relationships. The adolescent athlete may seek independence yet regress on occasion to the shelter of nurturing parents. Adolescent athletes, their parents, and coaches may need help adjusting to a more mature relationship.

Time Management and Socialization Issues

Academic and social demands increase in concert with an increased athletic training load, a stressful situation for those seeking excellence in all domains. Relationships with friends can be impeded by rigorous training regimens and demanding classes in school. In sports with an aesthetic component, nutritional restrictions can make socializing with non-athletic friends difficult. Adolescent athletes may also feel guilty if they have deviated from athletic contracts, abusing drugs and/or alcohol. As complexity of skill development increases, these athletes also may fear failure or fear success. For example, sport success may be accompanied by a need to move away from home, speak in public, compete at a more demanding level, etc. Regardless of whether the pediatrician has consulted a sport and exercise psychology consultant or evaluated the athlete using his/her own skills, the following guidelines facilitate a successful interview.

Assessing an Adolescent Athlete: a Sport Psychology Perspective

To achieve a time effective, initial interview:

An Ideal Setting

Begin by interviewing the athlete alone, after advising the parents that you will invite them to join you shortly. Seat the athlete, consultant, and later the parents, at a round table, if possible, to permit eye contact and eliminate a “power chair.” Assure confidentiality, unless, as occurs in rare instances, he/she is likely to injure themselves (or others). After the interview, ask if the athlete wants your discussion to be shared with the parents (such action is mandatory only if he/she or others are in danger).

Instruments to Guide the Interview

Educational sport psychology consultants and pediatricians may find the following assessment tools helpful: the Emotional Responses of Athletes to Injury Questionnaire (ERAIQ) (, see page 314),3 the Profile of Mood States (POMS),4 and the Performance Enhancing Substance Use Questionnaire.5

The ERAIQ

Designed to guide interviews pertaining to response to injury, the ERAIQ also assesses aspirations, goals, motivation(s), perceived athleticism, emotional state, social support, and stress. If the adolescent athlete’s affect is concerning and/or the ERAIQ rating of depression is high, the POMS objectively quantifies mood disturbance.4

The POMS

With six subscales [tension (T), depression (D), anger (A), vigor (V), fatigue (F), and confusion (C)], the POMS is valid and reliable for adolescents 13 years and older. English-speaking adolescents will require 5 minutes to complete it, and the POMS can be scored and graphed in less than 5 minutes (Figure 1, see page 315). Suicidal ideation is assessed if adolescents score more than 40 for depression. In such instances, findings are discussed with the patients and their parents, and, if appropriate, a referral to psychiatry or psychology is arranged.6

Profile of Mood States (POMS) Graphed to Depict the Profile of an Injured Athletes Contrasted to the Iceberg Profile in Sport.

Figure 1: Profile of Mood States (POMS) Graphed to Depict the Profile of an Injured Athletes Contrasted to the Iceberg Profile in Sport.

Practical Suggestion

Explain that it is common for adolescent athletes after injury, failure, team conflicts, or other issues to have high total mood disturbance (TMD). TMD = the sum of the T, D, A, F, C (-) V.7 TMD often reverses quickly if, for example, a player receives a call stating that he or she has a starting position for the next game.

The Performance Enhancing Substances Questionnaire

This survey should be administered because it yields important information for pediatricians. Because adolescent athletes may feel pressure to win, be faster or quicker, look thinner, be bigger, better, or compete with pain, they risk abusing performance-enhancing drugs.8,9 Information obtained from this interview often leads to some teachable moments.

Practical Suggestion

Questionnaires can be completed by patients, in the waiting room. Trained nurses or physician’s assistants can learn to score and graph results, which may identify issues described in the following case studies.

Case Studies that Depict Psychology of Injury, Performance Anxiety, and Burnout

James: Psychology of Injury, and Performance Anxiety

Assessment

James, a 17-year-old basketball player, tore his ACL while landing after a rebound. His season was terminated when he learned that his knee needed to be reconstructed if he wanted to continue competitive basketball. During our initial visit, I conducted a routine interview, embedded in his preoperative patient education session. James, a competent point guard, was involved in basketball and soccer until this summer, when he decided to try to earn a basketball scholarship. On the ERAIQ,3 James ranked his motivation for basketball [on a scale of 1 (low) to 10 (high)] as fun (10), seeking a scholarship (9), competition (8), quality-of-life (7), fitness (6), stress (5) and weight management (4), personal improvement (3), and pursuit of excellence (2). He identified himself as 9 of 10 on perceived athleticism, and, despite his torn ACL and meniscal tear, James wished to return to unlimited activity: competitive basketball. Emotionally, he was disappointed, angry, and frustrated but highly motivated (9/10) for post-surgery rehabilitation. Because of a flat affect and low apparent energy, the POMS was administered to quantify emotional responses. Tension was 17, depression 34, anger 38, vigor 7, fatigue 18, and confusion 17. This post-injury mood profile (consistent with a serious sport injury in a competitive high school senior missing his basketball season) was graphed and contrasted to the iceberg profile in sport better the athlete, the more pronounced the profile) (see Figure 1, page 315).3

Practical Suggestions
  • James and his parents were advised that we expected him to feel better after surgery, when he has started his rehabilitation. James was asked to contact me if the depression increased.
  • His surgeon (his sports medicine physician) was notified of the mood disturbance.
Preoperative Patient Education Psychological Skills Training (PST) Interventions10,11

During the pre-surgery patient education portion of our visit, I explained that some of the same sport psychology strategies used to facilitate sport performance are those that also enhance the surgical experience and the rehabilitation.

The Goal Setting Model (see Figure 2, page 315) helped James understand the relationship between his short-term, intermediate, and long-term goals. We also discussed attribution theory (see Figure 3, page 316) and his need to remain focused on factors under his control. James was taught to use relaxation to decrease preoperative anxiety, to increase the effectiveness of pain medication, and to facilitate his range of motion exercises. In addition to a handout of the models, a copy of the relaxation method, a color chart, and biodots, a form of thermogenic biofeedback, to provide feedback (Biodot International, Inc. P.O Box 2246, Indianapolis, IN 46206) were put in an envelope with our business card. James effectively met his 2-week, 6-week, 3-month, and 6-month goals. Six months post-surgery, James was cleared for return to sport, but all was not well: He was terrified to return to sport.

The Bidirectional Goal Setting Model Helps Patients Understand the Relationship Between Short-Term, Intermediate, and Long-Term Goals.

Figure 2: The Bidirectional Goal Setting Model Helps Patients Understand the Relationship Between Short-Term, Intermediate, and Long-Term Goals.

The Attribution Theory Emphasizes the Need to Focus on Rehabilitative Tasks, Doing Them to the Best of One’s Ability, Performed at 100% Effort.

Figure 3: The Attribution Theory Emphasizes the Need to Focus on Rehabilitative Tasks, Doing Them to the Best of One’s Ability, Performed at 100% Effort.

Performance Anxiety Secondary to Injury

A week after his surgeon cleared him to return to sport, James contacted me because his performance was impaired by his fear of re-injury. The ERAIQ and POMS were re-administered, and his tension score was high. I asked whether I could be most helpful a) by assisting him in getting out of his sport or b) by helping him to return to sport at his desired level of participation. James wanted to overcome his fears of re-injury and failure and to gradually return to basketball at his pre-injury level of competition.

PST Interventions (applied Sport Psychology)10,11

Several PST strategies James was already familiar with were adapted to facilitate success in sport. For example, instead of daily goals of icing, elevation, flexion, etc. (Figure 2), daily goals were now changed to emphasizing the percentage of successful free throws, lay ups, and improving his dribbling, breakout passes, etc. James understood that accomplishing daily goals at practice leads to success in meeting game and season goals. Attribution theory, which teaches athletes to focus on factors under their control, was adapted, so that he focused simply on playing up to the best of his ability and giving 100% effort. This focus facilitated freeing himself from the expectations of others. Relaxation, followed by visualization, became a form of mental rehearsal (mental practice), which helped desensitize James to his fear of re-injury and fear of failure.

Practical Suggestion

James was taught that the two things that cannot happen at the same time are “being relaxed” and “being tense;” these are opposites. Thus, if he uses the relaxation method, has a green biodot (the optimal status depicting relaxation), and starts to see himself “in his mind’s eye” on the court, dribbling, passing and shooting, he will lose his anxiety. He will “see himself” performing well, without fear of re-injury and failure. A performance-enhancement CD, based on a personalized script we prepared, combined relaxation and the visualization of one of his best performances. Listening to his personalized CD (loaded onto his MP3 player) before competition helps channel thoughts to achievable goals and guides thinking to positive, performance-enhancing thoughts.

Cara: Overtraining-Burnout and Associated Performance Anxiety

Assessment

Cara, a 14-year-old figure skater, was referred from the East Coast for a sport and exercise psychology consultation by her pediatrician. The ERAIQ and POMS guided the interview. Cara was landing triple jumps in her program; however, in the past 2 years, Cara had lived in various cities to train with elite coaches. Recently, her self-esteem, akin to athletic identity, was crushed if she did not perform perfectly. After years of overtraining (6 to 7 hours daily), Cara became obsessive about perfection of her program. As a result of overtraining, her POMS profile showed burnout (the inverse of the iceberg profile). Cara was simultaneously de-conditioned,9 a condition that occurred because, despite overtraining, her jumps and elements were never “good enough.” Cara kept stopping her program to re-do elements, over and over. Because of her obsessive-compulsive behavior, she lost aerobic and anaerobic conditioning, and her performance faded midway through the 3-minute program. She developed pain in her quadriceps, shortness of breath, and lacked the stamina to complete her program. Her de-conditioning and perfectionism contributed understandably to performance anxiety. Cara also wanted autonomy and more respect from her coaches and parents.

Multidisciplinary Interventions

After our assessment using the ERAIQ and POMS, I called Cara’s pediatrician. We decided, after discussion with Cara and her parents, to approach her situation in a manner similar to how she would be treated at the Olympic Training Center. To get to the next level of on-ice performance, she would benefit from a multidisciplinary sports medicine team approach. Thus, she saw an adolescent psychiatrist to ensure her obsessive-compulsive disorder (OCD) was situational and amenable to cognitive, PST interventions. She saw a physical medical and rehabilitation (PM&R) sports medicine physician, with expertise in aerobic and anaerobic conditioning, to ensure that her leg pain was caused by de-conditioning. Finally, she consulted with a physical therapist-athletic trainer certified (PT-ATC) to work on core and upper body strength. Cara felt complimented that we had taken this approach and understood that it was necessary if a skater were to advance to sectionals, nationals, etc. We updated her performance-enhancing CD script and asked her coach to add cue words related to the specific elements in her program. I saw Cara a week before competition at which time her POMS resembled the iceberg profile (see Figure 1, page 315). The overtraining had reversed, and a sparkle was back in her eye.

Conclusion

In this article, we have provided information and examples to help pediatricians either to refer adolescent athletes to a sport psychology consultant or to use the assessment and intervention tools discussed in their pediatric practice.

Appendix 1: Emotional Responses of Athletes to Injury Questionnaire

References

  1. Gill D. Psychological dynamics of sport and exercise. Champaign, Illinois: Human Kinetics; 2000.
  2. Weinberg RS, Gould D. Motivation. Foundations of Sport and Exercise Psychology. 4th edition. Champaign, Illinois: Human Kinetics; 2007. p. 51–76.
  3. Smith AM. Psychological impact of injuries in athletes. Sports Med. 1996;22(6):391–405. doi:10.2165/00007256-199622060-00006 [CrossRef]
  4. McNair DM, Lorr M, Droppleman LF. Profile of Mood States Manual. Educational and Industrial Testing Services, San Diego, California. 1971.
  5. Holland-Hall C. Performance-Enhancing Substances: Is Your Adolescent Patient Using? In: Rogers PD, Harding BH. Performance Enhancing Drugs: Pediatr. Clinics of North America, 2007, 54:4, p 651. doi:10.1016/j.pcl.2007.04.006 [CrossRef]
  6. Smith AM, Milliner EK. Injured Athletes and the Risk of Suicide. J Athl Train. 1994;29(4):337–341.
  7. Morgan WP, Brown DR, Raglin JS, O’Connor PJ, Ellickson KA. Psychological monitoring of overtraining and staleness. Br J Sports Med. 1987;21(3):107–114. doi:10.1136/bjsm.21.3.107 [CrossRef]
  8. Brenner JS; American Academy of Pediatrics Council on Sports Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics. 2007;119(6):1242–1245. doi:10.1542/peds.2007-0887 [CrossRef]
  9. Nippert AH, Smith AM. Psychologic stress related to injury and impact on sport performance. Phys Med Rehabil Clin N Am. 2008;19(2):399–418, x.
  10. SmithSmith Aynsley M. RN, PhD, . Power Play: Mental Toughness for Hockey and Beyond. 1999. 3rd Ed. Athletic Guide Publishing, P.O. Box 1050. Flagler Beach, FL 32136.
  11. Williams J. M., Editor. Applied Sport Psychology: Personal Growth to Peak Performance. 2001, 4th Ed. Mayfield Publishing Company, Mountain View, CA.
Authors

Aynsley M. Smith, RN, PhD, is Sports Psychology and Research Director, Sports Medicine Center, and Associate Professor of Orthopedics and PM&R, Mayo Clinic, Rochester, MN. Andrew A. Link, BA, is with the Sports Medicine Center, and will begin a Master’s Physician Assistant Program in the fall.

Dr. Smith and Mr. Link have disclosed no relevant financial relationships.

Address correspondence to: Aynsley M. Smith, RN, PhD, 200 First St. SW, Rochester, MN 55905; fax 507-2661803; e-mail .smith.aynsley@mayo.edu

10.3928/00904481-20100422-12

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