1. What are red flags for parents that their student athlete is using performance enhancing drugs?

In my personal experience as a pediatrician for over 25 years, I have only taken care of a handful of student athletes that were using performance enhancing drugs (PEDs). It is estimated that 1 to 7 percent of all U.S. high school athletes have tried PEDs, and fewer than 3 percent regularly use/abuse banned substances.  Not surprisingly, in almost all of these cases one or both parents were aware and/or complicit in their offspring’s “doping” because they themselves were using “supplements” to enhance their own health/vitality and/or performance. 

In another few cases, a private coach or peripheral member of the coaching staff of an organized sport (school team or travel team/private league) was the individual who introduced the student athlete to the performance-enhancing agent.  In these cases, the most susceptible student athletes were those who suddenly start consuming creatine-containing protein supplement shakes and products in order to build muscle. While creatine and protein shakes are not banned (and when used properly, with a physician’s supervision, are not dangerous), the idea that the athlete needs to consume something other than healthy, nutritious, home-cooked meals in order to be successful in their sport sets up for susceptible students the mindset that they “need” something extra to feel good and excel. A student’s acceptance of taking or drinking a supplement provided by a coach, friend or trainer should be a “red flag” to the parent of potential grooming behavior on the part of the coach/trainer who wants their protégé to perform exceptionally. Parents often start paying the coach or a random “trainer” for the “special shake” or supplement that their teen brings home, setting up a mechanism for payment by the parent of these often increasingly expensive PEDs.

Parents with high expectations of their children’s performance in their chosen sport seem to have teens who are most at risk for using steroids, human growth hormone, testosterone and erythropoietin.  These parents (and coaches) set the often unrealistic expectation for the child that they always need to be at the top of their game because they are being scouted by college coaches and/or professional teams. In my experience, those student athletes who are most likely to succeed are the LEAST likely to use/abuse PEDs as they’re often involved in programs and leagues that regularly drug test. The teen who is trying to “make the cut” in their sport so that they don’t have to sit on the bench or in the stands is the student that parents need to worry about most.

Another red flag for use/abuse of PEDs would be the kid who goes to the gym all summer and starts the fall with a significant change in physique. While this could be in part due to normal pubertal changes and/or true dedication on the part of the student athlete, if there is a disproportionate change, this should trigger questions. Other red flags would be sudden masculinization, aggressive behavior, being secretive about workouts and being vague about supplements.  Supplements bought at an outside gym, online and from random “trainers” should be highly suspect.  The sports that put students most at risk are those that require an increase in body mass such as bodybuilding, football and baseball. Athletes who participate in track (especially distance runners) are at higher risk for eating disorders. Those involved in endurance sports are at particular risk for use of erythropoietin (EPO). 

2. How can concussions impact the health of student athletes years after the injury?

Although most concussions in adults resolve within seven to 10 days, it often takes longer for children and adolescents to completely recover. With mild, single concussions student athletes should suffer NO long-term or permanent consequences, as long as concussion protocols are followed, which involves strict brain and physical rest, with slow re-introduction of usual activities.  Teens who are anxious to return to sports are the most likely to under report on-going symptoms because they think that by reporting that they are “symptom-free” they will be allowed to return to play.  The strong motivation and desire to return to play puts the young athlete at risk for long-term consequences, which include (but are not limited to) anxiety, depression, difficulty with concentration and performing tasks, balance issues, insomnia, personality changes, irritability and reduced tolerance to stress. Post-concussion syndrome is a well-described disorder that involves having at least three of these characteristics as long-term consequences, often with a co-existing alcohol abuse disorder.

It is important for all patients to understand that a normal CT scan and/or an examination by an Emergency Room provider immediately following an injury does not preclude the development of post-concussion syndrome.  It has been my experience that the post-discharge instructions from many Emergency Rooms almost never emphasize the need to cognitively rest. This means NO cell phones/TV/video games and other forms of screen time.  Children and teens with concussions may need to stay home from school for a few days, or spend time in a quiet, dark room (nurses’ office or library) if they do feel up to going to school.  They need to avoid schoolwork and all academic and after school activities until able to be evaluated by their Primary Care Physician.  Parents do not reliably keep their children and teens home following a concussion, and this unfortunately puts their child behind on the natural trajectory of recovery.

Behavioral health diagnoses (depression, anxiety, loss of self-esteem) are the most devastating long-term consequences of a concussion. For the athlete who becomes afflicted by three concussions or more it is often recommended that they permanently avoid return-to-play. The athletes that fair best when this occurs have families and a support system who are able to help them transition to other activities.  For the families that “live and breathe” sports and who do not value academic achievement, a career-stopping concussion can signal a downward spiral for the teen who was hoping to follow in his father’s, grandfathers’ and uncles’ footsteps. Instead of becoming the local high school football team’s star player, a concussed teen can become isolated, angry, depressed and sometimes even suicidal.  In my career as a pediatrician in rural Pennsylvania counties, I have unfortunately witnessed this first-hand, making me wonder if we had “gone too far” with brain-protecting concussion protocols that permanently benched a morbidly obese linebacker who never had plans to go to college or further his education. In retrospect, he would have probably fared better continuing to play football, because he would have been able to maintain a camaraderie with his teammates and get SOME exercise. Instead, he dropped out of high school after too many unexcused absences, became even more morbidly obese and went on disability when he developed diabetes. He rarely leaves his house, and my understanding from his parents is that he plays video games all day long and rarely showers or brushes his teeth. 

The ideal management and treatment of sport-related concussions includes a team-based approach that simultaneously addresses the physical AND psychological/emotional health of the student-athlete. The concussed athlete that is unable to practice or train endures significant physical, cognitive and emotional changes that sometimes forever alters their identity, sense of self-worth and in many cases, their future plans and goals.

3. How can coaches and parents manage student athlete expectations so they don't lead to obsessions?

When an athlete becomes obsessed with being the best in their sport, it puts them at risk for eating disorders, anxiety, obsessive-compulsive behaviors and sleep-related disorders.

The best way that coaches and parents can manage student-athlete expectations so that they don’t lead to obsessions is to model appropriate behavior themselves. Coaches can and should expect a lot from their athletes in terms of participation in organized practices, weight-training and cardiovascular endurance activities, BUT the most successful coaches are those who make it fun for their team-members. They unexpectedly plan a movie night complete with popcorn when the team was expecting to watch film from the previous night’s game. They set up scrimmages between parents and team members. They provide opportunities for their varsity athletes to volunteer as coaches for younger students in middle school or who are Junior Varsity players. These mentoring relationships are invaluable tools that help build students’ confidence and get them to focus outside of themselves, making it much less likely that they become self-obsessed and absorbed. 

Parents need to mentally check themselves and their own expectations for their offspring. In my career as a pediatrician I have witnessed many a parent who appears to be living vicariously through their student athlete. It is not healthy nor wise for children to train year-round in a single sport. Children of all ages need to be given the opportunity to BE childlike and have unstructured time to explore, to take breaks and to play. Families who take vacations away together, and who allow their student athlete time away from “mandatory” practices, produce better, more-well rounded athletes.

Childhood and adolescence are very important bonding times with peers, and participation in sports is very conducive to forming meaningful long-lasting relationships. •