Mental Health

Mental Health

Health means both physical and mental health: they are two sides of the same coin, with one often affecting the other. Physical problems, including sport injury, often have psychological or emotional consequences. Psychological problems, which can include eating disorders and substance-use problems, typically have physical consequences. As with physical injuries, mental health problems may affect athletic performance and limit, or even preclude, training and competition until successfully managed and treated.

Mental health issues are a critical issue in collegiate sport.  Collegiate student-athletes face many of the same mental health risk factors as their non-athlete peers.  However, their role as student-athletes may expose them to an additional set of risk factors.  These risk factors can take the form of direct stressors (e.g., time demands, performance pressures, coaching style), interactions with others in their environment that encourage risk behaviors and discourage help seeking, harassment and discrimination related to personal characteristics such as race/ethnicity or sexual orientation.  Stakeholders in the sport environment, including coaches, medical staff, administrators and teammates, play an important role in mitigating these risk factors through prevention and screening programs and interactions that encourage and support help seeking. 

The NCAA Sport Science Institute is committed to providing resources to help stakeholders at member institutions address the mental health concerns of student-athletes, with a goal of creating a culture where care seeking for mental health issues is as normative as care seeking for physical injuries.  The centerpiece of these efforts is an e-book entitled “Mind, Body and Sport”.  Additional resources are available in the resource section of this webpage and will be updated on a rolling basis in response to feedback from stakeholders and member institutions.  We invite your feedback and suggestions about these efforts.  To receive alerts when new resources are posted and to be kept apprised of the latest research and news related to student-athlete mental health, please follow @NCAA_SSI on Twitter or sign-up for the NCAA Sport Science Institute newsletter.

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ADHD and the Student-Athlete

By Christopher J. Richmond, Ph.D., LP, LMFT

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurobiological disorders of childhood and often continues through adolescence and adulthood. In the past, some individuals and groups believed that young adults would simply “outgrow” ADHD. However, we’ve learned that some young adults develop strategies to mitigate ADHD symptoms, but many find that these symptoms persist into adulthood. Population surveys reported by the American Psychiatric Association indicate ADHD occurs in approximately 5 percent of children and 2.5 percent of adults.

Many people assume that student-athletes are emotionally healthy in the same ways that they are assumed to be physically healthy. However, just as student-athletes may suffer with physical illnesses and injuries, they are also vulnerable to mental health disorders, including ADHD.

The three core symptoms of ADHD are:

  1. Inattention.
  2. Hyperactivity
  3. Impulsivity

Each core symptom includes several additional symptoms. ADHD symptoms are often noticed by student-athletes in situations such as listening to a lecture in class, completing homework assignments, talking with friends or listening to a coach’s instructions.


The core ADHD symptoms of inattention, hyperactivity and impulsivity, as outlined in the newDiagnostic and Statistical Manual of Mental Disorders, (5th ed.; DSM-5; American Psychiatric Association, 2013) are listed in the table below. In order to be diagnosed with ADHD for either the Inattention or the Hyperactivity/Impulsivity symptom set an individual (17 years of age or older) must have at least five of the nine symptoms listed below for at least six months. And they must have been severe enough to interfere with the patient’s quality of life (See Table 1). For the student-athlete this means that ADHD symptoms are usually present on a daily or weekly basis both within the academic setting and in the athletic, social, job or home setting. To confirm a diagnosis of ADHD, there must also be evidence that there were ADHD symptoms prior to age 12. Table 2 lists the three ADHD presentations.


Case Study

At Ferris State University, student-athletes are primarily referred for an ADHD assessment by a certified athletic trainer. Athletic trainers may refer a student whom they suspect has ADHD because of difficulties in the classroom, on the field or both. Athletic trainers also refer students that have been previously diagnosed and are currently taking a stimulant medication, but lack proper documentation of an ADHD diagnosis. This scenario is common at Ferris State. Often, a student-athletes is diagnosed by a family doctor or primary care physician without a comprehensive assessment, and that physician will make a diagnosis of ADHD based upon the results of just one rating scale assessment or a short diagnostic-focused conversation with the patient.


Evaluation Process

After the referral has been made for the ADHD assessment, the student-athlete is evaluated at the Ferris State Health Center to assess current symptoms. The Health Center physicians utilize an ADHD screening assessment to determine the presence and severity of symptoms. The physicians then use the data from this assessment to determine whether or not a student should be evaluated further. In this case, the health center physician will refer the student-athlete to the counseling center for a comprehensive assessment. Following the completion of this assessment, which typically spans the course of four to five sessions, the report is released (with the client’s permission) to the health center and the athletics department.

The ADHD assessment protocol employed at the Ferris State Counseling Center follows a multi-method approach, which includes assessment procedures such as interviews, rating scales, psychological tests and a review of past academic records. A multi-method approach to the assessment of ADHD is important because there is no single procedure that addresses all of the criteria for ADHD. ADHD interviews typically fall within one of three areas: (1)structured; (2)semi-structured; or (3) unstructured. The Ferris State Counseling Center protocol utilizes a semi-structured assessment during the first session, which is adapted from the standard intake interview. The protocol employs a structured interview at the second session that more closely examines each symptom of ADHD. This structured interview is geared specifically to the adult population and assesses symptoms that were present during childhood and adulthood.

The ADHD rating scales generally fall within either a broad-band or narrow-band category. The broad-band rating scales assess a wide range of behaviors that typically include psychological symptoms beyond those specific to ADHD such as depression and anxiety, which are often associated with ADHD symptoms. The narrow-band rating scales more exclusively assess ADHD symptoms. Some ADHD rating scales include both a self-report and observer-report version. It is advantageous to collect important ancillary data from close family members or friends.

The psychological tests are typically measures of sustained attention. The continuous performance test is one of the most common diagnostic tests used in the assessment of ADHD. Most are computer-based assessments of attention. For example, the student-athlete may be asked to press the space bar every time the letter A appears on the monitor. These continuous performance tests detect brief lapses of attention through omission errors (lack of attention) and commission errors (impulsive response).

The last assessment area pertains to the review of academic records. This review typically consists of an evaluation of elementary and middle school report cards. The new diagnostic criteria indicate that there must be evidence of ADHD symptoms prior to age 12. Most report cards assess classroom behavior and study habits, which typically include areas closely related to ADHD symptoms. For example, “listens attentively” and “follows directions” are common assessment areas specific to study habits. Teacher comments in the narrative form may also indicate problems related to ADHD.

Due to the complexity of a comprehensive ADHD assessment, they should be completed by a professional—namely, a psychologist, psychiatrist or medical doctor with experience in this area. It is the experience of this author (as the psychologist providing the assessment), that having a close working relationship with the athletic trainers and physicians on campus facilitates an effective and efficient protocol in managing student-athletes with suspected ADHD.



ADHD treatment is often multi-disciplinary in nature, and may include any combination of cognitive-behavioral strategies, goal-oriented strategies, nutritional guidance, psychotherapy and medication management. Stimulant medications are the mainstay of pharmacologic treatment of ADHD (commonly prescribed ADHD stimulant medications are listed in Table 3).


Stimulant medications are NCAA banned substances, and their use requires the institution to maintain documentation on file and submit a medical exception request, using the NCAA medical exception ADHD reporting form, in the event of a positive drug test. The documentation must include a written report of the evaluation conducted to support the diagnosis of ADHD, and medical treatment notes from the prescribing physician. Sometimes, anti-depressant and other medications are used in ADHD treatment, and these drugs are not prohibited. If the health center physician recommends a stimulant medication based upon the outcome of the report, he or she must complete the NCAA medical exception ADHD reporting form, which can be found here.



American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders(5th ed.). Arlington, VA: American Psychiatric Publishing.

Last Updated: Nov 12, 2013

More than just a drink: effects of alcohol on training and competition

By SCAN Registered Dietitians

Despite being more of a target for education programs, as compared to their non-athlete counterparts, collegiate student-athletes have been found to drink more and do so more often than the general collegiate student population.1 Neither the education efforts directed toward nor the competitive motivation of student-athletes seem to deter use. So what exactly is the harm of alcohol use for a student-athlete?

The facts:

Alcohol, otherwise known as ethanol, is defined as “a colorless, volatile, flammable liquid,” according to the Merriam-Webster dictionary.2 The standard serving sizes for alcoholic drinks are: 12 ounces of beer or wine cooler, 8 ounces of malt liquor, 5 ounces of wine, and 1.5 ounces of 80 proof liquor.3 When consumed in excess, often referred to as binge drinking, the social and physical repercussions can be especially detrimental to student-athletes. Binge drinking is considered five or more drinks for men and four or more drinks for women within a two-hour period.4

The internal process:

Digestion of alcohol begins in the mouth, moving through to the esophagus, stomach and small intestine. While alcohol is absorbed into the blood stream quickly, simultaneous food consumption can help slow the process. Once alcohol has been digested and absorbed, the body’s goal is to process it via one of two pathways: metabolize it for energy or convert it to fat for storage. Due to its effects on the central nervous system (CNS), alcohol is also considered a drug, and its overuse can lead to impaired judgment and slurred speech, among other CNS side effects.3,5

The performance risks:

For the collegiate student-athlete, alcohol consumption can result in a huge detriment to athletic performance. Excessive alcohol use can lead to loss of balance and coordination, reduced reaction time, and increased appetite.2 The decline in cognitive function can lead to an increase in sports-related injuries. Furthermore, studies have shown that regular consumption of alcohol can depress the immune system and slow the body’s ability to heal.6 Vitamin and mineral deficiencies are common in those who excessively drink alcohol, further compromising the immune system. Alcohol can interfere with adequate nutrient intake and absorption of vitamins and minerals, be destructive toward vitamins in the body, and cause higher nutrient losses through urine. Common nutrient deficiencies are calcium, magnesium, iron, zinc, and B vitamins, all of utmost importance to athletes.7

Alcohol has a diuretic property that can lead to rapid dehydration and decreased athletic performance. Dehydration can cause increased core temperature, rapid heart rate, nausea/vomiting, and a general feeling of fatigue; all of which can be detrimental to performance. These side effects can begin to set in with a water weight loss of as little as two to three percent of total body weight.5 Dehydration and alcohol toxicity can also lead to a hangover, which has been reported to decrease aerobic capacity, by 11.4%.6

The common practice of drinking after a big win or competition can also negatively affect recovery. Muscle glycogen synthesis and storage may be decreased, and gluconeogenesis may be stunted, potentially leading to hypoglycemia and impairing future performance.6 Post-activity nutrition should focus on replenishing depleted glycogen stores with nutrient-dense carbohydrate sources. Athletes who consume alcohol after competition or practice are less likely to consume adequate carbohydrate, thus compromising performance in the next exercise bout.5 Alcohol consumption also affects sleep quality, a major component of recovery. Alcohol has been shown to help one fall asleep faster (e.g., reduced onset sleep latency); however, an increased disruption in sleep throughout the night has been observed. A delay in REM (rapid eye movement) sleep onset and decreased total amount of REM sleep are especially evident with moderate and high levels of alcohol consumption.8

Also related to athletic performance is the effect of alcohol on body composition. Alcohol is often mixed with high-calorie accompaniments such as soft drinks, juices, and sugary toppings. These extra “empty” calories, along with the potential for alcohol to be converted to and stored as fat, can lead to less than optimal body composition for an athlete. For male athletes specifically, alcohol may lead to a reduction in testosterone production. This reduction in testosterone can, in turn, decrease the ability to gain muscle mass – again negatively affecting body composition and ultimately performance.6

As a general rule, abstaining from alcohol 48 hours prior to competition can be beneficial for athletic performance, and making it a priority to properly rehydrate and consume food after activity will help facilitate recovery (See the Alcohol and Athletic Performance fact sheet for more information).

Written by SCAN Registered Dietitians (RDs). For advice on customizing a nutrition plan, consult a RD who specializes in sports, particularly a Board Certified Specialist in Sports Dietetics (CSSD).  Find a SCAN RD at


  1. Nelson, Toben F., and Henry Wechsler. "Alcohol and College Athletes." Medicine & Science in Sports & Exercise 33.1 (2001): 43-47.
  2. Merriam-Webster . "ethanol." Web. April 2, 2013.
  3. Academy of Nutrition and Dietetics. Nutrition Q&A: What Is Considered One Serving of Alcohol? Web. March 20, 2013.
  4. Centers for Disease Control and Prevention. Fact Sheets: Binge Drinking. November 7, 2012. Web. March 20, 2013.
  5. Fink, Heather H., Alan E. Mikesky, and Lisa A. Burgoon. Practical Applications in Sports Nutrition. Burlington, MA: Jones & Bartlett Learning, 2012. Print.
  6. Volpe, Stella. “A Nutritionist’s View. Alcohol and Athletic Performance.” ACSM’s Health & Fitness Journal 14.3 (2010): 28-30.
  7. Insel, Paul, Elaine R. Turner, and Don Ross. Nutrition. Sudbury, MA: Jones & Bartlett Publishers, 2002. Print.
  8. Ebrahim, Irshaad, et al. “Alcohol and Sleep I: Effects on Normal Sleep.” Alcoholism Clinical and Experimental Research 37.4 (2013): 539-549.


Last Updated: Oct 11, 2013

NATA, NCAA and others announce mental health recommendations

By Brian Burnsed Will Heininger suffered in silence. The 2011 Michigan graduate was a defensive tackle on the school’s football team and a four-time Academic All-Big Ten winner. Despite playing Division I football at a storied program and...


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