Starting young to protect elite athletes’ mental health

Mental ill health is an important health condition affecting young people globally. Approximately half of all common mental disorders emerge before the age of 18, including mood, anxiety, eating, substance use and neurodevelopmental disorders.¹ Yet an estimated 58% of mental disorders in adolescents go undetected and untreated² with barriers to accessing appropriate mental healthcare including the cost and availability of services, or their developmental appropriateness. Youth elite athletes exhibit significant stigma to mental health and negative attitudes towards help-seeking,³ including fear of the consequences of seeking help in elite sporting context (eg, loss of selection). This underscores the need for attention to mental health in this population.

A neglected population?

Youth elite athletes can compete in highly specialised and demanding sporting contexts prior to professional or elite adult competition. Such contexts can be considered as separate and distinctive from recreational or social youth sport. The mental health of youth elite athletes represents a critically under-researched issue,^{4 5} despite a tripling of published research on mental health in elite sport over the past two decades. Only a handful of cross-sectional studies have reported the prevalence and correlates of mental health symptoms or disorders in youth elite athletes aged 12–18 years.^6–9 Reflecting this research nascency, few consistent findings can be extracted. Routine clinical evaluations of a large sample of youth elite athletes performed by trained professionals found that 16.9% were currently experiencing at least one mental disorder, with a lifetime prevalence of 25.1%.⁶ Current mental health symptoms self-reported by youth athletes have ranged from 6.7% for anxiety to 9.5% for depression,⁷ while 23% of youth athletes report at least four or more mixed symptoms across both the past year and lifetime.⁸ Gender differences have been observed in two of these three studies^{7 8} with girls/women significantly more likely than boys/men to report symptoms or to be clinically evaluated as experiencing psychopathology. Type of sport may also differentiate symptoms (in this case depression), with youth athletes in individual sports reporting greater symptom severity than those in team sports.⁹ Beyond these foundational studies, to our knowledge, there are no prospective studies of mental health in youth elite athletes, including research on the impacts of the COVID-19 pandemic.

What makes youth elite athletes vulnerable to mental ill health?

We argue that there is an urgent need for a robust research agenda on this topic. Similar to young people more broadly, youth elite athletes can encounter a range of life circumstances that heighten their risk for developing mental ill health, including developmental ‘milestones’ such as puberty, individuation from parents (especially those directly involved in their child’s sporting development), navigating more complex interpersonal relationships (eg, romantic or sexual), engaging with social media as ‘digital natives’, and ultimately negotiating aspects of their identity formation, such as gender, culture or sexuality. Additionally, youth elite athletes must contend with the emphasis on performance outcomes or winning in high performance contexts. Researchers have highlighted the benefits of exercise and supportive developmental pathway sports environments for young athletes. However, negative consequences of a performance outcome focus include pressures to perform, perfectionism, burn-out and overtraining, abuse and maltreatment, parental pressure or conflict, increased susceptibility to injury and risk-taking by training through pain, injury, and exhaustion (see reference⁵ for a comprehensive review).

A way forward through research

We argue that the confluence of general and high performance risk factors that may be encountered by youth elite athletes puts them at risk of impaired mental well-being and simultaneously may jeopardise their longer-term engagement in professional and elite sport. This is especially the case if mental health problems emerging during elite sport development pathways largely go undetected and untreated, as they do in the broader society.² High-quality, longitudinal research is needed to better understand the risks posed by these stressors, and in-depth qualitative studies are warranted to explore both contributing factors and possible solutions to impaired mental health within the broader elite sport ecology.¹⁰ Future research must also centre the voices of youth elite athletes so that their perspectives and preferences for mental health service design are met in relation to their contextual, developmental and technological needs, thereby eliminating potential barriers to help-seeking and intervention. Not engaging with the lived experiences of youth elite athletes with impaired mental health only risks creating further unmet need.

Early intervention is needed, now

As in other areas of sports medicine, early intervention is critical to promoting mental health among youth elite athletes and ensuring the timely provision of evidence-based clinical care to those at risk of, or experiencing, mental disorders. It is perhaps ironic that the peak onset of mental ill health occurs during the life stage of maximum physical health, at least in high-income contexts. The latter should never diminish the need to acknowledge and address the former, including in elite competitors. It is time to focus on the mental health of youth elite athletes. In doing so, we may identify and unlock new ways to build high-performance environments that promote mental well-being and resilience in the long run.

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