CASE 1: An athlete is on a team enduring a long season turning over more wins than anticipated.

She was struggling with an injury that was minimally intruding on her play, but now demands and expectations from the coach are higher. On numerous accounts she shares with the athletic trainer she is hurting and with no relief from all the treatments theyve exhausted, but her choice is to push out through the season. Since then, several teammates have been in and out of injury status, and have been made an example of. The athlete is afraid of seeming selfish or not dedicated if she chooses to take appropriate measures. She does not want to have any imaging or special treatment to put a mark on her back. Now she has had an acute injury to the opposite extremity, and feels completely compromised. She is being pointed out for not trying and whining, but she feels that her sacrifice has been unnoticed. She comes into the training room crying and feeling like she has nothing left to give. She does not know how to move on from here even though she wants to give what theyre asking, but she physically cannot. She feels like she is choosing between her health and her future with the team.

Red flags: Recall symptoms of depression: Sleep issues or fatigue Interest changes Guilt feelings Energy change Concentration change Appetite change Psychomotor suicidal ideation

Management/Referral: Ask questions like: How is this affecting you? (global, not only sport specificfamily friends, school relationship, sleep) Are you eating? Drinking? How is your diet? What have you done to cope so far? Do you think it would be helpful to talk to someone else (if tried talking to parent/friend unsuccessfully) versus a more pressing issue in which to say I think it would be good for you to talk to someone about this Share responsibilities with other professionals and seek council if uncertain what to do so there are more than one set of eyes watching the individual

Refer if:

Persists for several weeks or worsens Leads to self-destructive thoughts or behavior Changes in eating or sleeping Suicidal talks or gestures

CASE 2: One girl on the team has not been in the training room as much as usual to manage her chronic injury. When she finally does rush in to grab some tape on game day, the athletic trainer brings this up as she rushes outseemingly too busy to talk. The AT notices she seems anxious and out of breath, but also that she looks more tired and thinner. She is a naturally slender person, but once she leaves another teammate comments on how over-the-top she has been about her busy schedule. She says that she knows she hasnt had as much time to eat between classes and practice, but she is also staying up late to study almost every night. During pre-game you see that she doesnt want to eat the food provided and claims it is what we eat every week. I cant eat this stuff. She says she will just eat something from the locker room, but you never receive confirmation that she actually followed through.

Considerations: Signs/symptoms of Anorexia Nervosa: Preoccupation with food, calories, & weight Dramatic weight loss Mood swings, depression, anxiety, irritability Excuses to avoid meals or situations involving food Excessive rigid exercise regimen

Signs/symptoms of Bulimia Nervosa: Purging behaviors Excessive exercise regimen Laxative abuse Calluses on back of the hands Teeth discoloration Creation of schedules for time to binge

Management/Referral: Challenges include: o Athletes control of situation o Athletes fear o Low motivation o Body-image distortion o Societal pressure (uniform of team) o Sport types like volleyball can increase body image issue or disordered eating An athlete that meets diagnostic criteria for anorexia should NOT be allowed to train or compete If symptomatic but not anorexic, met other criterion before continuing training What to say to address it: o Talk privately o Communicate concerns with specific observations o Avoid placing shame, blame or guilt o Express support o Consult with supervisor or other professionals

CASE 3: An athlete is recovering from a month long hiatus of practice play due to a mild traumatic brain injury. She has been officially cleared by the physician and is back practicing full-go. She is struggling to return to where she was, and she seems to feel that the coaches doubt the authenticity of her concussion in the first place. The athlete is tightening up her ankle braces one day with her best friend on the team in the athletic training room one day ranting about the intolerance of the coaching staff. You think you hear her say it would just be easier if I wasnt even here at all.

Red flags: Verbal cues such as it would just be easier if I wasnt even here at all Other clues include: o behavioral changes: withdrawal, school performance, neglect of personal appearance, sleep o environmental clues: financial issues, pressure, parental separation, or substance abuse o Depressive clues: mood, slower psychomotor

Management/Referral: Very important to understand my comfort with suicide and death o Know the schools guidelines on suicide Do what have to do in that moment: o Make note of risk factors observed o Ask follow up questions like I thought I heard you say this just wanted to check in with you.. Talk after practice and tell coach need to see them, pull them off to side and follow up o Will not increase the risk of suicide if ask questions o Never agree to keep someones suidcidal thoughts confidential If suspect suicide, directly ask, have you thought about or attempted suicide?

GENERAL GUIDLEINS TO ASSIST STUDENTS 1. 2. 3. 4. 5. 6. 7. Ask simple direct questions Careful listening Caring confrontation Observation of students behavior Trust intuition Ensure the safety of the student Follow up