NATA Releases Consensus Statement for Developing a Plan to Recognize and Refer Student Athletes with Psychological Concerns at the Collegiate Level

Wednesday, September 25, 2013
   Indianapolis, September 25, 2013 –At a national press conference this morning, leading health care professionals released an inter-association task force consensus statement titled, “Recommendations for Developing a Plan to Recognize and Refer Student Athletes with Psychological Concerns at the Collegiate Level.” The event was convened by the National Athletic Trainers’ Association and held at NCAA headquarters in Indianapolis. This is believed to be the first time a cross section of interdisciplinary professions has collaborated on this type of document. The executive summary of the guidelines is published in the September/October issue of the Journal of Athletic Training, NATA’s scientific publication.
Approximately one in every four to five youths in America meets the criteria for a mental health disorder and experiences severe impairment across a lifetime. In 2012, the U.S. Substance Abuse and Mental Health Services Administration reported that 45.9 million American adults aged 18 years or older experienced a mental illness in 2010. The rate of mental illness was more than twice as high for those in the 18-25 year range than in those aged 50 years and older.
“Given the NCAA student athlete participation rates of more than 450,000 in 2011-2012, the probability of encountering one or more student athletes with psychological concerns within an athletic department is a certainty,” said Task Force Chair Timothy Neal, MS, ATC, assistant director for sports medicine and adjunct professor at Syracuse University. “These guidelines were created to provide school administrators, physicians, athletic trainers, mental health experts, coaches, athletes and others with a clear roadmap to address the psychological challenges college athletes may face today.”
The task force was spearheaded by NATA and supported by the American Academy of Pediatrics; American Medical Society for Sports Medicine; American Psychological Association; Association for University and College Counseling Center Directors; Association of Applied Sports Psychology; International Critical Incident Stress Foundation; International Society of Sports Psychiatry; National Collegiate Athletic Association and the University Risk Management and Insurance Association.
“It is well known that regular physical exercise can have positive benefits on an individual’s mental health and lead to a healthier, happier life,” added Neal. “The mental health of a college athlete or those who are physically active can be challenged by any number of factors including stressful life situations or injury. These issues are of paramount concern to health care professionals, organizations, administrators, coaches, athletes, parents and others.”
The athletic trainer and team physician are in positions to observe and interact with student athletes on a daily basis. Some athletes suffering from a psychological concern may not inform their athletic trainer, team physician or coach to their problem, but may “act out” nonverbally as a way of alerting others that something is bothering them.Psychological concerns may include depression; anxiety; eating disorders; abuse of drugs, alcohol or other substances; hyperactivity, violence or even suicidal thoughts.
Consensus Statement Executive Summary Recommendations
To develop a plan that recognizes and refers student athletes with psychological concerns at the collegiate level, the task force developed the following guidelines:
  1. Refer the student athlete for psychological evaluation and care: Having a team in place to address these concerns is important. This team should include the team physician(s), athletic trainers, campus counseling service and community-based mental health professionals.
  2. Address mental health concerns during pre-participation exams: These exams are the optimal time to ask about a history of mental health problems. Any affirmative answers about mental health should be brought to the attention of the team physician so he or she may discuss with the athlete and determine appropriate follow up.
  3. Approach the student athlete with potential psychological concerns: This can be uncomfortable and should be handled once the health care expert has the right facts and is in a position to listen and encourage the athlete to talk about his or her challenges and seek a mental health evaluation.
  4. Schedule a routine referral for a mental health evaluation: Once the student athlete has agreed to undergo psychological evaluation, he or she should be referred as soon as possible to the mental health care professional. If possible, the athletic trainer should help that individual make the appointment. Having pre-existing relationships with the mental health experts will help facilitate the referral.
  5. Discuss confidentiality issues:For a routine referral, the athlete should be informed that although it is confidential it may be helpful to notify the coach and parents of appointments. The athlete is not compelled to do so. With regard to use of medical insurance, the athlete should also be informed that parents will receive notifications of treatment and an explanation of benefits from the insurance company.
  6. Know when emergent mental health referrals are necessary: If a student athlete demonstrates violence or imminent threat to himself or herself, others or to property; or reports feeling out of control, unable to make sound decisions or incoherent or confused, an emergent mental health referral is recommended. When this protocol is used, consider the following steps:

    Obtain and have available the institution’s protocol for emergent mental health evaluations;
    - If the student appears violent, call campus or local law enforcement;
    - If the student is not violent, do not leave him or her alone and call for assistance following the institution’s protocol; and
    - Seek advice or assistance from the athletic administration, office of student affairs or general counsel on contacting the family and informing them of the incident.

  7. Be aware of suicide and student athletes: More than 30 percent of all undergraduates in a national college health assessment reported feeling so depressed that it was difficult to function and few youth or young adults receive adequate mental health care. Therefore the possibility of suicide is ever-present.
  8. Address campus counseling services and catastrophic incident considerations: Student athletes are concerned with team status and playing time and may be negatively affected if their coaches become aware of their mental health problems. The athlete is more likely to favor therapists that understand this challenge and as a result, it is important for the counseling center to have a relationship with the athletic department to ensure good communication and care. Having a primary point person in that department can be beneficial and may fall to the athletic trainer.

    Catastrophic situations may require support, time and resilience. Early intervention can be helpful in resolving traumatic stress. The collaborative approach to care may be most beneficial with the athletic trainer providing initial support until the mental health expert is identified.

  9. Consider risk management and legal counsel:University administrators face the challenges of managing risks associated with mental health and student athletes and should be aware of the following:

    - Develop a plan to include a policy statement and related procedures for identifying and referring student athletes with potential health concerns to appropriate administrators and counselors;
    - Carefully evaluate the institution’s insurance policies that may be triggered in the event of a mental health incident;
    - Protect confidentiality; and
    - Consider an interdisciplinary approach where individuals from different departments collectively confront the complex problems of mental health in student athletes.

“The key factors in helping a student athlete with psychological concerns are education, early recognition, effective mental health referral and addressing potential risks with the athletic department and institution,” concluded Neal. “Our goal is to immediately address and care for the student athlete with the best protocols in place. This statement offers clear steps that if implemented will help that athlete excel on the field and in life. And that’s the best education we can ever hope to offer.”
The press conference featured some of the country’s leading collegiate sports safety medical and mental health experts. In addition to NCAA chief medical officer Brian Hainline, MD, and NATA president Jim Thornton, MA, ATC, CES, who opened the program and provided introductory remarks; and Neal who provided an overview of the consensus statement executive summary, speakers included task force members:
Margot Putukian, MD, director, athletic medicine and head team physician, Princeton University, University Health Services, and past president of the American Medical Society for Sports Medicine, who discussed the team physician’s perspective on mental health and collaborative care; and John P. Sullivan, PsyD,clinical sport psychologist and applied sport scientist at Providence College and the University of Rhode Island, and American Psychological Association representative who talked about the psychologist’s role: addressing mental health and student athlete welfare and performance. Also presenting was Will Heininger, a University of Michigan defensive tackle (class of 2011) and four-time Academic All-Big Ten Winner and Distinguished Scholar, who suffered from severe depression that not even his coaches, closest teammates or friends knew he had. He eventually opened up, sought counsel from his team athletic trainer, coach and physician and was referred to a social worker all of whom helped to change his life.                      
About NATA: National Athletic Trainers’ Association (NATA) – Health Care for Life & Sport
Athletic trainers are health care professionals who specialize in the prevention, diagnosis, treatment and rehabilitation of injuries and sport-related illnesses. They prevent and treat chronic musculoskeletal injuries from sports, physical and occupational activity, and provide immediate care for acute injuries. Athletic trainers offer a continuum of care that is unparalleled in health care. The National Athletic Trainers' Association represents and supports 35,000 members of the athletic training profession.