In contemporary American society, participation in sports is considered a rite of passage for children and adolescents. Over the past five decades there has been a fundamental shift in the context in which children become involved in sports. Prior to the 1950s sports were largely a matter for local communities to organize for their youth; since the early 1950s, however, sports have shifted from being youth-organized activities to adult-organized activities for the youth and from being fun oriented, spontaneous activity to highly organized competitions.1–3 Today’s youth have little say in the conduct of the organized sports, which largely reflect adult perspectives. At the same time, one must acknowledge the tireless efforts of thousands of well-meaning adult volunteers making such sport experiences possible for youth.

At the outset, we should draw a distinction between professional and youth sports. In the professional athletics, sport is athlete’s full-time occupation and he or she makes a living from sport. On the other hand for children and adolescents, sport is one of many activities they do as part of growing up. Within the context of American culture, the term youth sports refers to “any of the organized sports programs that provide a systematic sequence of practices and contests for children and youth.”1 Approximately 20 to 35 million children and adolescents participate annually in organized sport programs (Table 3-1).1–4 The most popular sports include football, basketball, track and field, baseball, softball, wrestling, tennis, swimming, volleyball, cross-country running, and golf. Approximately 80% of total participants are involved in nonschool programs, and 20% in school-based programs.1 There is a significant trend toward increasing participation in nonschool programs and decreasing participation in school programs. There is none to minimal research or published information on the youth who are not part of the organized sports and those who quit. Many children take part in other valuable alternative activities such as recreational sports, music, and various other arts. Many more enjoy walking, hiking, camping, and other equally healthy activities.

A basic understanding of the psychosocial dynamics of youth sports by the pediatrician will help facilitate early recognition and effective management of potential problems. We review the salient aspects of organized youth sports in the United States, such as developmental issues, factors influencing participation or attrition, the psychology of injury, violence in sports, use of performance-enhancing substances, eating disorders, competitive stress, health risk behaviors, and effects of intensive participation. We seek to delineate the critical role of the pediatrician in this context and suggest a clinical approach. Pediatricians provide medical care to athletes on a regular basis in their practice. Because of their knowledge of growth and development of the children and adolescents, pediatricians are in a unique position to apply this knowledge and in guiding the athlete and his or her family through the ups and downs of many wonderful years of sport participation.

In spite of the perceptions held on both sides of the arguments regarding the benefits and risks associated with organized youth sports programs in the United States, evidence suggest that sport participation is inherently neither a “good” nor a “bad” experience for children.1,5–9 The most crucial factor determining whether children and adolescents will have a positive or negative experience from sports is neither the sport participation itself nor in what form; rather it is how adults impart or chose to impart this experience to the participants. The overall outcome from sport participation is the result of interplay among multiple mediating factors: the athlete, family, peers, coach, and societal attitudes as well as expectations. In fact, the vast majority of youth like sports and have a positive experience from “normal” level of participation; some children who engage in “intensive” participation may be more likely to experience problems associated with sports.

Many lifelong benefits from regular physical activity, either in the form of exercise or sport, have been well documented. Although, physical exercise and sports are inherently related and the terms are often used interchangeably, sport has a distinct social dimension.10 Many potential contributions of sport to psychological and social development of a child are enumerated in Table 3-2.1,8,11,12

Sports provide a setting for the child to test personal abilities. Self-perception is influenced by feedback from peers, coach, parents, and spectators. Behavior of adults and peers also influence self-perception. Positive feedback, encouragement, and focus on fun and participation rather than the outcome—a win or a loss—will contribute to increased self-esteem. Sports experience provides the opportunity for learning how to handle success or failure, and to realize that the most important thing is the effort rather then the result. Many physical as well psychosocial benefits from sport participation by children and youth with chronic disease and physically and mentally challenging conditions have been well documented.13

Children learn to compare their own abilities and skills with those of peers and assess their own level of competence. They learn the value of practice and preparation resulting in better performance. Many facets of social competence can be enhanced through sport, such as teamwork, cooperation, interpersonal skills, leadership skills, and self-discipline.1,14 Sport provides a setting in which appropriate physical aggressiveness can be learned and taught under supervised and controlled circumstances.1,8 Within the context of athletics, many friendships are made between athletes and between families, across racial and ethnic groups, and across socioeconomic groups.14 For older children and adolescents, sport participation provides opportunity for learning how to appropriately interact with adult authority figures other than their parents. Many children learn the value of fairness and the concept of right and wrong from their sport experience.

Sometimes sport can have negative influence also.7,8 If the child is pressured to compete, this can contribute to stress and decreased motivation to continue in sports. A perception of failure and criticisms from adults and peers can lead to decreased self-esteem. Sports can also expose children to negative adult behaviors.

Some researchers have noted that sport participants are less likely to engage in delinquent behaviors and suggested sport as alternative to gangs for youth.1 However, the contribution of sports to decreased health risk behaviors, decreased teenage pregnancy rate, decreased truancy, improved grades, decreased smoking, and decreased depression remains controversial and subject of on going research and debate.

Sport experience occurs within the larger sociocultural context and is, therefore, influenced by many factors, most significantly peers, parents, and coaches.10,11,15–19 The place of sports in contemporary society, societal attitudes on success and failure, media portrayal of sports, and societal expectations of young athletes also play influencing role.

Peers

As children grow older, they spend increasingly more time with peers. Athletic ability is considered to be an important characteristic of social status by boys while physical appearance is considered more important by girls, especially by older children and adolescents.1,7 Peer approval of athletic performance and abilities is highly valued by athletes and their families. They also begin to compare their own abilities with those of peers. Thus, peers become the most significant source of information for appraisal of personal abilities and self-worth as well as a most important socializing influence, especially for adolescents.8–10,15 Athletic ability, an important marker for social status, is most highly valued by high school students; they would rather succeed in athletics than in academics.1 Participation in team sports is believed to greatly increase the teenager’s popularity and peer acceptance. Sport participation becomes the sole motivation for some students to stay in school.1

Athletes enjoy more peer acceptance when the team is successful; on the other hand, a loss may result in rejection and intense criticism.10,15 The athlete has to be a team player and needs to be cooperative with teammates; at the same time, he or she must compete with friends. Pursuit of athletic excellence and success may potentially lead to alienation from peers, because of jealousy. Whether to continue high level athletics or not depends upon the athlete’s need for peer acceptance or need for personal achievement.8,12 Memories of success or failure in athletics and with peers remain with individuals throughout their lives.

Family

The family is the most important support system for an athlete. Parents have the greatest influence on children younger than 10 to 12 years.10,15 Parental attitudes and feedback affect a child’s self-perception of his or her own capabilities, and emotional outcomes from sports involvement. Whether sport participation is a positive or a negative experience is greatly dependent upon parental influence. Parents can provide positive evaluations, encouragement for their efforts, support for sport participation, realistic expectations of winning or losing, and involve the children in decisions about participation; these factors all contribute to an overall positive sport experience.7,8 Some children are more likely to enjoy and do well in sport. For the vast majority of athletes parental influence leads to a positive sport experience. However, for other athletes, parents can be a source of negative influence.

Some parents may have unresolved needs of their own (such as unfulfilled athletic wishes from childhood), and identify their self-esteem with athletic success of their children.9,16,20–22 This creates undue pressure on children to perform and excel in sports. Some parents consider sport participation by their child as an investment for future rewards such as athletic scholarship or financial success.7,14 In other instances a child’s success in athletics may become a symbol of social status for parents, and parents may enter into unhealthy competition to push their children to perform.7 A child’s success in sport becomes the sole focus at the expense of development in other psychological and social aspects. In few instances parental over involvement, e.g., yelling at children or other parents or fighting with coaches, can lead to aggressive behaviors at the game or practice, with negative influence on social and psychological development of the child athlete. Parent may become angry at the child who loses, makes mistakes, or wants to drop out of one or more sports.14 Children may be pushed to continue to participate despite injury; parents may shop physicians for favorable opinion and may even request surgical or hormonal treatments to enhance athletic abilities of their children.7,14,16,22 For the athletes who want to pursue competitive athletics, parents have to invest considerable energy, time, and financial resources, often stressing the family system.7,8 The balance between appropriate positive encouragement and over involvement can be difficult to achieve by all family members.

Coach

The influence of a coach on the child and adolescent athlete’s life in and out of sports has been well recognized.1,7,11,15,20,23,24 The coach’s role, interactions, and influence changes over time for the young child playing sports for fun to that of the child or adolescent engaged in intense participation for competitive athletics. The coach becomes increasingly more important for the adolescent.

The coach is involved in player selection, recruitment, determining the role of the athlete in the team, training, game plan preparation, and foster team cohesion.12 The child’s behaviors, self-perceptions, and self-esteem are greatly influenced by a coach’s interpersonal behaviors, values, goals, and priorities that are set.12,16 Casual remarks by a coach can have significant effects on an athlete, as for example in dieting behaviors or use of performance-enhancing substances. For most youth sports, the coach’s priority is mainly to ensure enjoyment of the participants; for more competitive settings and those potentially leading to a life in professional sports, the goal becomes winning at all costs. A vast majority of coaches are volunteer coaches with no formal training in coaching or child development, and thus, may not have a developmentally appropriate coaching style.8 In fact one study notes that many coaches at the junior high level tend to have an aggressive behavior, and tend to have inappropriately high expectations for performance and behavior for their athletes.14

Not unlike parents, some coaches may have their own unmet needs and may be living them through their athletes. On the other hand, the adolescent may also have unmet dependency needs and become dependent on the coach as an adult figure or fatherly figure (surrogate parent) in a so-called dependency relationship. Also incidences of sexual exploitation of athletes by coaches have been reported.5,7,25,26 Thus, parents walk a fine line between giving total control of the child to the coach and being over involved themselves.

Coaches can have a great positive influence on the moral and social development of a child and an adolescent. This influence involves setting good examples by their own behaviors and attitudes; coaches can act as advisors and help adolescents in trouble as well as teach them prosocial values, teamwork, and cooperation. A philosophy of winning which has been developed for coaches of youth sports is outlined in Table 3-3.8

Society and Media

Sports have become a major economic factor in society. It is estimated that the sport industry ranks tenth with revenues of $120 billion in the United States.7 Media portrayal of professional athletics can be highly influential in shaping young athlete’s perceptions of athletics, with potential fame and success.27 Many professional athletes are heroes and role models for children and adolescents. The importance of winning reinforces the message that winning at all costs is success in life! However, only a very handful of youth may ever be fortunate enough to reach the glory and fame of elite and professional athletics. For the many that are left behind, the unrealistic expectations can be detrimental. More importantly youth must understand that success in professional athletics does not necessarily translate into success in overall life.

Many elite and professional athletes and their media exposure can also be a positive influence. Athletes can serve as positive role models by contributing to youth programs back into their schools and communities. Some athletes show self-determination and value of hard work by succeeding in spite of physical handicap or socioeconomic barriers. Also coverage of local youth sports can potentially be quite positive.

An athlete’s attitudes, personality, and personal motivation play central roles in sports participation. Many individual factors (cognitive and physical maturity, importance of success in sports) and environmental factors (rewards from sports, type of sport, sociocultural factors, coaching style) influence individual motivation.28–30 Some athletes are primarily motivated to improve personal sport skills and to do their personal best (intrinsically or mastery-oriented); others are motivated to excel in comparison to peers (extrinsically or outcome-oriented).31 Mastery-oriented athletes enjoy playing the sport, and for them, success is personal improvement and the effort itself. For outcome-oriented athletes, success mean winning the game, and thus, a loss can be difficult to tolerate.

Many youth have unrealistic expectations from sports. Studies suggest that in middle and high school years 40% to 50 % of students, especially boys, intend (dream) to become professional athletes.32 Their reasons to pursue professional athletics in the future were the “rewards” of athletic participation such as money, social status, praise from others, independence, and the admiration of women. It was not for the “fun” of sports.

However, for the vast majority of children and youth, the most common reason to participate in sport is to have fun and be with friends. Motivation and reasons to be involved in sport also vary depending upon the age and developmental stage of the child. Young children tend to focus on having fun and being with friends, while adolescents may want to achieve status among peers, or “impress” others. Many other reasons are enumerated in Table 3-4.8,12,30,33

Attrition refers to those who drop out of a sport before the season officially ends.1,34 Studies suggest that attrition from youth sports generally begin by age 10 years and peak at 14 to 15 years.1 Highest rates of early dropout are noted in gymnastics and the least in football. Fifty percent of sports participants may drop out by the time they reach early adolescence.1 One study of high school students noted that 26% dropped out from one sport; this increases to 29.8% when attrition from more than one sport was considered.34 Injury was cited as the most frequent reason for quitting sports. Intensive participation in organized sports beginning at an early age has been noted to be an important contributing factor to early attrition; one study noted 75% dropout rate by age 15 years among those who began participating in organized sports by age 7.14

Dropout may be either athlete-initiated or because of reasons not under an athlete’s control. Some authors consider dropping out to be a normal process in which the athlete is trying out different activities.35 There is very little information on the relationship between developmental stage and reasons to quit sports. It is noted that reasons to quit are different at different ages and developmental level. In one study, elementary school students cited overemphasis on winning as a main reason; while high school students cited conflicts of interest as a main reason.35

Contrary to popular belief, burnout is just one of many reasons to drop out from sports. Burnout is a response to chronic stress from intense sport participation and the athlete no longer enjoys the sport.17 The athlete perceives that he or she is not able to meet the demands of the sport and perform adequately. Table 3-4 outlines a number of other reasons for quitting sports.