Martha Graham reminds us: “It takes about ten years to make a mature dancer” [1]. It is of great significance that these training years occur in adolescence, which is a span of time that involves rapid changes across almost every major developmental domain [2]. Developmental events, including increased independence, identity exploration, pubertal changes, cognitive limitations, and risk-taking, exert influence over the elite adolescent dancer’s injury experience [2]. Indeed, young dancers who become injured must endure the consequences of this event in the midst of a period that necessitates experimentation, risk-taking, and honest self-evaluation of one’s potential relative to one’s dreams.

The dancer’s elite training experience, which includes high-level competition and early specialization, is of great relevance to his or her response to injury, particularly if a professional career is the primary training goal. This rare achievement is granted to a select few endowed with a distinct talent profile and favorable circumstances. Early dance specialization, which follows a time-urgent path with limited room for error, demands intensive investment and sacrifice. Often, dancers prematurely separate from their caregivers for a boarding environment. The impact of early separation includes both marked advantages (e.g., independence) and weaknesses (e.g., disconnection from family of origin) [3]. Further, with such specialization the balance between life skills and academic schooling may be de-emphasized [4]. In the event of an injury, this combination of cultural and developmental factors can result in amplified psychological duress.

On the one hand, it is no wonder that injuries have been linked to ballet training attrition [5]. On the other hand, as one seasoned dancer interviewed for this chapter noted, “Injuries are the ‘wait’ weight room emotionally.” With support, a break in intensive training due to injury can become less of a setback. Rest can enable the dancer to focus on other priorities, including academic work, family connection, novel life experiences, and interaction with non-dancer peers. Moreover, injuries may present as a potential platform for stress–related growth [6]. It is possible that the young dancer will develop adaptive coping skills, increased resilience, improved self-care, and injury prevention strategies that he or she can carry into a fulfilling professional career.

There is a paucity of general research on the mental health needs of adolescent dancers, as well as the specific relationship between injury and psychopathology. To date, literature on this population has focused largely on eating disorders (ED) and the female athlete triad [7]. Beyond the prevalence of ED, domains of psychopathology have been insufficiently examined in pre-professional ballet dancers. In lieu of rigorous epidemiological evidence, clinicians working with this population must rely on rates of psychopathology among adolescents in general and the few small studies that have been conducted on dancers.

Among a large sample of male and female adolescents aged 13–18 (National Comorbidity Survey Replication–Adolescent Supplement), there is a lifetime prevalence rate of 49.5% for teens meeting DSM-IV criteria for at least one disorder, with anxiety and mood disorders (including unipolar depression, dysthymia, and bipolar disorder) most commonly represented [8]. Moreover, approximately 40% of teens meeting the criteria for one mental disorder also met criteria for at least one other disorder from another diagnostic class [8]. Given the high prevalence of ED in preprofessional dancers coupled with the prevalence of mood and anxiety disorders in the adolescent general population, we might suspect frequent comorbidity of a mood or anxiety disorder in conjunction with ED symptomatology.

Small experimental and case studies utilizing dancers illustrate some biopsychosocial nuances of the adolescent dancer’s injury experience. Such nuances include characteristics of the injury. Specifically, it appears that dancers with chronic or overuse injuries tend to ignore their injuries despite potential consequences ranging from psychological distress to severe physical damage [9].

Pre-existing psychological vulnerabilities may exert influence over the young dancer’s reaction to injury, for example, the presence of a pre-existing mental illness (e.g., depression) [10] may impede recovery from injury. Given the prevalence of mental illness in adolescence [8], it follows that injured adolescent dancers may be at least equally vulnerable to the development of mental health issues. It has been suggested, however, that a flexible versus rigid approach to dance activities when injured and engagement in self-motivated injury prevention behaviors are associated with lower rates, duration, and overall suffering from injuries during training [11].

Beyond a dancer’s pre-existing vulnerabilities, his or her post-injury behavioral and psychological reactions to injury can also impact the injury experience. Indeed, injuries may threaten one’s sense of self [9] and induce ruminative concerns regarding one’s self-worth and status in a highly competitive training environment [12]. Such emotional and cognitive reactions can lead certain dancers to deny or hide an injury or return to training prematurely due to his or her drive for success and fear of falling behind classmates and missing opportunities. Implicit efforts to avoid identity disruption and cultural acceptance of pain may additionally exert influence over decisions to train while injured [9]. Notably, most professional dancers do not seek medical attention for their injuries [12], and 28% of professional dancers in one sample reported making a unilateral decision to return to work prematurely [13]. Given inherent adolescent immaturity in foreseeing the consequences of one’s behavior, it is possible that pre-professional dancers would also have high rates of premature return to training. Further, among typical adolescents there exists an adolescent health paradox [14], which describes marked increases in morbidity and mortality despite peak physical health due to factors such as immature impulse control and decision-making capacities. This paradox can have notable implications for the adolescent dancer’s rehabilitation behavior. Factors such as lack of insight into the consequences of dancing injured can further the denial of injury, treatment non-compliance, and a premature return to training.

In addition to the dancer’s pre-existing vulnerabilities and post-injury reactions, negative environmental circumstances can also impact the injury experience. Such circumstances have been observed to significantly predict subsequent injuries among ballet dancers [15]. In the midst of negative life events, lack of proper social support appears to further increase vulnerability to injury in young dancers [15].

These authors have observed a variety of clinical and subclinical presentations of mental suffering accompanying injury in the young dancer. Below, we illustrate diagnostic features of psychopathology and problem behaviors that we have anecdotally observed occurring with dance injury. These include Adjustment Disorder, Major Depressive Disorder, Anxiety Disorders, Eating Disorders, and Substance Use Disorders.

A diagnosis of Adjustment Disorder is the most conservative diagnosis for many young dancers who initially present with mood and anxiety symptoms following injury. Injury may prompt concerns regarding one’s career potential and produce a void in the dancer’s activity schedule and social support. Recovery activities take immediate precedent over his or her cohort’s regular training schedule. This loss of community at a time when peer relations are developmentally necessary can amplify threats to the adolescent dancer’s identity and prompt feelings of isolation. Further, when seeking support from classmates, the injured dancer may experience a paradoxical combination of closeness and competition, which can serve to exacerbate emotional reactions including depression and anxiety. While these depressed and anxious symptoms fall under the diagnostic domain of Adjustment Disorder, a full-blown Major Depressive Episode or Anxiety Disorder may occasionally emerge, as illustrated in the following case:

Amy¹ is a 17-year-old female pre-professional dancer living in a residential ballet program far from home. Her dance training occurs upward of six hours per day. For the past 6 months she has been struggling with plantar fasciitis. Amy initially managed her pain by skipping classes as needed. Feeling overwhelmed because her pain ‘just won’t go away’, she now presents to her school’s on-site psychotherapist. A cascade of tears overcomes her as she describes her intense fear of losing precious time while unable to dance as fully as she wants to and sadness at not being able to be with her family during this difficult time. She additionally reports an inability to concentrate, has been withdrawing from her peers, and feels alone in her struggle.

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