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Abstract
Objective The aim of the present study was to examine how six young female handball players (aged 13–14 years) perceived the transition from primary school to a sport-specialised secondary school.
Methods Physical and physiological data as well as data from questionnaires were collected at baseline and after the first year at the sport school, and qualitative interviews were performed retrospectively after the first year at school.
Results Evidence of competition-related stressors, organisational stressors (sport and school balance) and personal stressors (social life and sport balance, lack of sleep and severe injuries) was found. Three girls developed long-lasting musculoskeletal injuries (>3 months out of ordinary training) and one experienced repeated short periods (≤2 weeks out of ordinary training) of injuries during the first year. Onset of menarche and a length growth between 6 and 8 cm during the first year were characteristic traits of the four injured girls.
Conclusions From our small study, it appears that young athletes attending a specialised secondary sport school experienced many stressors due to a significant increase in training volume, reduction in sleeping time and development of severe and long-lasting injuries. Hence, trainers at sport schools, club trainers and parents need to communicate and support them in order to prevent this.
- Adolescent
- Injuries
- Exercise physiology
- Physiology
- Psychology
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Background
When pursuing an athletic career, a person commits to an activity and strives for excellence with the aim of peaking in athletic performance.1 There are different levels of careers. Early sport specialisation may lead to an international and professional career, but many young and aspiring athletes end up with a local or national career. A career proceeds through four stages and transition2—the initiation stage, the development stage, the mastery stage and the discontinuation stage.3 The focus of this article are athletes aged 13–14 years who attend a secondary sport school and who combine school and athletic training.4 These are athletes in the development stage and they make a huge transition school-wise and sport-wise, and the question is, to what degree does this transition influence young athletes' experience of the sport—how do they perceive and respond to early specialisation and the following increase of workload?
Theoretical background: the training of young female athletes
Young athletes may not be in a position to make an informed decision about the consequences of being talented and pursuing an elite career. Are they aware of the long-term risk and consequences of almost doubling their training volume at the age of 13? In an editorial in this journal Bahr5 discusses the negative effects of increased unilaterally training in youth in relation to acute and long-term injuries in sports like volleyball. The International Olympic Committee and the American Orthopaedic Society for Sports Medicine (AOSSM) published recently consensus statements on youth athletic development regarding their concerns about early sport specialisation as well as giving recommendations of ‘best practices’ for young athletes' psychological and physiological development.6 ,7 Physiological and psychological research support this.7 Hall and colleagues8 found that early sport specialisation in female adolescents was associated with increased risk of anterior knee pain disorders, including different knee diagnoses, while psychological research focus on dropout.9 ,10
Girls reach puberty about 2 years earlier than boys, and the mean age of menarche in Norway is 13.3 years.11 In addition to length growth, the unfavourable distribution of fat and muscle mass results in reduced relative muscle strength and endurance in girls. This may reduce their adaption to intensive and specialised training during puberty and cause more injuries than in boys.12 In an evidence-based review, Jayanthi et al13 concluded that too much intensive training and early specialisation should be delayed until late adolescence to avoid injuries and psychological stress. Biber and Gregory14 report on overuse injuries in youth sports caused by stresses, such as inappropriate increases in training and unfavourable training surfaces or improper equipment.
Chronic lack of sleep is associated with increased risk of sports injuries15 and previous studies have reported on the negative effect of sleep restriction on physical performance16 as well as mental skills such as cognitive function, mood, daytime sleepiness, reaction time, and learning and memory tasks.10–11 The optimal duration of sleep per night for adolescence is individual, but 8.5–9.5 hours per night are recommended by the Adolescent Sleep Working Group.17 Doran et al18 showed a dose–response pattern between sleep and coping with psychological and physiological tasks after 3 weeks with respectively 4, 6 and 8 hours sleep per night. The more they slept the better they were to solve problems.18
How to cope with sport, school and a social life
When entering a specialised sport school with dual demands of academics and elite sport,19 coping becomes vital. Coping is the way athletes deal with injuries, high expectations, and coping mechanisms are learnt behavioural responses that successfully lower arousal by neutralising or minimising the importance of a threatening condition.19 Fletcher and colleagues suggest that stress should represent the overall process incorporating stressors, appraisals, strains and coping responses. In the transactional framework, strain is defined as an individual's negative response to stressors. Further, stressor is the environmental demand or stimulus encountered by an individual.20 When defining these three major types of stressors, the individual's ongoing transaction with environmental demands is associated with ‘competitive performance’, ‘the organisation which he/she operates within’ and ‘personal life events’, respectively.21 Fletcher and colleagues underline that personal and ‘non-sporting’ life events like family ‘should not be considered aspects of the organisational stress process’.20 ,22–25
Previous studies have revealed a link between general coping resources and athletic injury,26 and also highlighted that the needed coping resources may come from personal resources or the environment.27 As the former, for example healthy diet, social competence, may be limited due to their young age, the environment becomes more important. Csikszentmihalyi et al28 argue that schools are valuable resources due to young athletes' access to coaches and teachers who create a positive environment for development, and that specialised sport schools have made life easier for many athletes.4 ,29 Furthermore, parents, club coaches and peers are all perceived as valuable support persons for young athletes coping with stress.2 ,30 ,31 Parents are of major importance, and family life is often strongly focused on the young athletes' needs.32 Even at this age, to pursue a dual career is a choice that involves extensive commitment and support from the family.33 It is tough to maintain the fragile balance between the two extremes of athletics and academics, and the participants of the present investigation have just started on this journey.
Social support is important for young athletes as it facilitates problem-focused (manage and alter the problem) and emotion-focused (maintain hope and optimism) coping.34 Lazarus and Folkman20 suggest that social support is the opposite of social demands, and the demands and the social resources vary in severity and intractability. Used in the sport setting, Bianco and Eklund34 define it as social interactions with positive outcomes. A distinction between three types of functions of social support also makes sense: emotional (ie, making one feel loved and cared about), informative (ie, advise, feedback) or tangible (direct aid such as money) support.35 Social support is often considered among the emotion-focused coping strategies after the Lazarus and Folkman dichotomy, and the lack of social support from a coach may be perceived as stressful.22
Furthermore, these young athletes in the development stage3 ,36–38 transition into an intensive level of training and experience normative (psychosocial, psychological and predictable academic–vocational development) and non-normative (less predictable such as injury) changes.3 Effective coping is needed in order to be successful for these young athletes in their transition. The number of secondary sport schools in Norway is increasing and presumably resulting in earlier sport specialising and increased training volume among the young athletes. Hence, more research is needed to examine how young female and male athletes respond to the total load in order to promote a healthy development, avoiding overuse injuries, burnout and overtraining, and retain the talents. The purpose of the present study was therefore to explore how six young female handball players psychologically and physically perceive the transition from primary school into a specialised secondary sport school.
Methods
Design and participants
After the study was reviewed by the Regional Committee for Medical Research Ethics, South-Eastern Norway Regional Health Authority, and approved by the Norwegian Social Science Data Services, a convenient and purposeful sampling procedure39 was conducted to recruit six young female handball players before entering a sport-specialised secondary school programme in Norway. Club coaches helped us gain access to the girls, and after permission was received from gatekeepers, the researchers contacted players and their parents to provide information about the research project and to elicit their participation. Players and at least one parent signed a written informed consent form before inclusion. The athletes were ∼13 years when they volunteered to take part in this investigation. We collected physical and physiological data at baseline (13 years) and after 1 year at the sport school. The interviews were performed retrospectively after 1 year at the sport school. In addition, they reported injury experiences once a week on short message service (SMS) (not injured, still injured and/or new injuries).
Test methods
We measured all girls' body composition and maximal VO2 (VO2max) twice, at baseline (13 years) and before the interviews (14 years). All girls completed a validated questionnaire measuring puberty status according to Tanner's classification of puberty stage,40 and in addition, they answered questions about training volume, sleeping time, injuries and number of participating sports.
Height was measured standing barefooted to the closest cm and weight was measured with light clothes on to the nearest 0.5 kg. Body composition was performed with the BIA device InBody 720 (Body Composition Analyzer, Biospace Co., Soul, Korea) with standardised procedures including a minimum of 2-hour fasting and no drinking before measurement.
VO2max was measured on a treadmill with a stepwise protocol, the Oslo protocol41 until exhaustion. The participants were breathing through a mouthpiece with a one-way valve wearing a nose clip. The Oxygen Pro analyser (Würzburg, Germany), analysed the expired gas (VO2 and VCO2) and gas volume.
Interviews
The face-to-face interviews were conducted at the end of their first year at the school, and the interviews were carried out at the training location. All girls belonged to the same team. The interview consisted of four main sections: (1) demographic background; (2) experiences of playing team sport at their level and the combination with school (‘describe a normal day’?); (3) why they chose to enter a sport school (‘has the school system helped you to become a better athlete?’); (4) types of stressors perceived by the players (‘what do you perceive to be the main demands from school, club, parents…’); and (5), coping with the aforementioned stressors (‘how do you cope with this/these demands’ and ‘who do you perceive as supportive’?). Follow-up questions were used in order to elicit in-depth responses from the participants. The interview lasted for 40–55 min.
Data coding, theming and analysis procedures
The interviews were transcribed verbatim and were content analysed using the procedures recommended by Miles and Huberman.42 We read and reread the transcripts in order to become familiar with the data. Themes, quotes and paraphrased quotes representing a meaningful point/thought were individually identified. Next, researchers from different sport fields, such as psychology, sport management and physiology, had a meeting to discuss and consensually validate themes and quotes into patterns of responses in the data (such as the importance of recovery, injuries) and a summary label for the category (physical and physiological issues) was determined. All transcribed interviews are enclosed as supplements.
Supplemental material
Trustworthiness
In accord with Lincoln and Guba's criteria for trustworthiness,43 we spent prolonged time in the field to build trust with the participants. Further, we used analysis triangulation to help establish accuracy in the interpretations.44 Emerging findings were compared again with the data to verify understanding, and these were discussed in a university research workshop (ie, a group of scholars independent of the research). This procedure was conducted in order to curb bias.45 Finally, a thick description of the context and other aspects of the research setting was made in order to provide evidence for transferability.
Results
The findings revealed that young female athletes have a busy schedule and that they experience several daily stressors, which we will elaborate on in the first part of the results. We will then present the physical and physiological results in combination with the athletes' perception of their own situation.
The daily schedule and group perceptions of stressors
In the interviews, the numerous hours of training (especially in the evening), lack of sleep and associated fatigue, and injuries were issues they brought up right away (see table 1).
Activities, recovery and competitive schedules for the student athletes aged 14 years
The girls get up at 7am, eat and leave for an 8-hour school day. The school is organised, so when they leave at 4:15pm, all assignments and homework are completed. Some of them have time to go home for dinner, while others have not. This depends on where they live and parents' schedule (and availability to drive them) and the time of the training, which varies over the week. If there are no tournaments, then the weekend is devoted to rest, recovery and preparing for a new week. Naturally, some periods are harder than others, as one of them expressed in the interview: ‘There was a period where I would not eat, I was hungry but did not have the energy to eat, and I really had to force myself to start eating again’. This quote underscores the level of fatigue experienced and why they constantly emphasise the need for recovery (see tables 2 and 3).
Athletes’ perception of stressors revealed in the interview
When talking about sacrifices, they admitted that they missed their old friends—‘but if I want to be a good elite athlete, there is nothing I can do about it’; or as another one admitted—‘we choose not to be with our former friends to pursue this dream. In order to make it to the top, we need to start now’. To make things even harder in this transition phase, two of the girls pursued two sports, something the respective coaches were not encouraging: ‘If I missed a few practices, my ‘punishment’ was reduced playing time. That kind of ruined the love of the game for me’. The girls were not afraid to say that they hoped to make it to the national team one day, which is their ultimate dream. What they are doing now is a stepping stone on this journey, they have to make the sacrifices. Following that decision, they also experience several stressors that we have divided into physiological issues, logistical issues and team issues (see table 2).
The mean increase in training volume was 5.8 hours/week, mean reduction of sleeping time was about 1 hour per night and the mean length growth was 6 cm, ranging from 1 to 8 cm during the first year at the sport school. Two of the players had an Osgood-Schlatters diagnosis at baseline. Three of the players developed long-lasting injuries (>3 months without ordinary training), including stress fractures, anterior cruciate ligament (ACL) and ligaments injuries, during the first year at the sport school and one girl reported repeated shorter periods (≤2 weeks without ordinary training) with knee and ankle problems. Individually, differences were observed in body composition (fat mass) and VO2max at baseline and after 1 year. All girls that experienced injuries, reached menarche during the first year at the sport school and grew 6–8 cm.
Discussion
The aim of this investigation was to elaborate on the psychologically and physically experienced transition from primary school into a secondary sport school for six young female handball players. From the above, it is obvious that the lives of these young athletes appear to revolve around training/playing, eating and resting/sleeping. Their social network tends to consist of the team, as they are together at school and training. The athletes have to make sacrifices in order to become elite athletes, and their parents have to make some too, as sport for young athletes is time consuming and expensive.4 Fatigue was related to the overwhelming number of stressors they were exposed to—we found evidence of all the three major categories of stressors:23 competitive stressors related to the tough game schedules and constant comparison; organisational stressors from commitments to several sports and from the school sport balance; and personal stressors when they sacrifice social life for sport and when they struggle with injuries. In addition to turning to parents as support persons in times of stress, the sport school offers advice on lifestyle management48 and teaches them about nutrition, recovery and life balance. Teachers were also perceived as supportive. Interestingly, however, the parents seem not to push them as hard as the coaches and advised them to rest more if they were tired/injured. This reveals that the network around the athletes may make it more complicated for athletes to make decisions,14 as their support persons are not always on the same page. Research has previously revealed that older adolescents have a greater range of coping strategies than younger ones,49 which include more use of problem-focused coping strategies in addition to social support (from parents and coaches). Skinner and Zimmer-Gembeck argue that when young people mature, they increasingly draw on behavioural and cognitive strategies, and by the age of 19–21 years they are able to regulate and monitor their own emotional states.50 Teaching young female athlete's ways to cope with stressors other than sleep (and watching movies on Netflix) is vital.
All girls reported time management and enough sleep as significant and most challenging in relation to recovery in the interviews (enclosed as supplements). Research conducted on sleep for this age group unanimously shows that physical performance and mental skills improve when athletes sleep well,16 and that <8 hours sleep per night is associated with increased risk for injuries.15 While optimal duration of sleep per night for adolescence is individual, lack of sleep was a main theme in all the interviews. Adding the changes in physical and physiological variables as well as the changes in training volume in the first year of the sport school (table 3) shows that the increase in training volume together with length growth of 6–8 cm was distinctive of all four girls who had experienced injuries the last year. Three of the players had experienced long-lasting injuries (>3 months) including stress fractures and knee and ankle problems, and one reported repeated shorter periods of injuries (≤2 weeks). This is in line with earlier studies reporting associations between early specialisation and increased training volume and overuse injuries.13 ,14 For example, it is likely that the growth spurt in addition to 6 hours increase in training volume and lack of sleep may be the main reason for the development of a stress fracture in participant two. She reported in the interview that she was not physically prepared to cope with the increased training volume, and after the first stress fracture she resumed training too soon and developed a new and long-lasting stress fracture (see online supplement file). Furthermore, two of the three girls with long-lasting injuries competed in two sports. In addition, they did not take part in strength and injury prevention training as they prioritised football or rest.
Anthropometric characteristics, including age, height, body weight, percentage fat (%) and maximal VO2 (VO2max), number of sports (n), training volume (hours/week), sleeping time in the school days and weekends (hours per night) and number of injuries (n) at baseline (13.4 years) and after 1 year (14.4 years)
Body composition (fat mass) and VO2max results showed individual differences, but they were not different between the injured and non-injured handball players (table 3). There were also some common denominators of the physical and physiological characteristics of the two non-injured players that differed from the other four; they had a small increase in growth and their time of menarche differed (one at the age of 11.5 years, before starting at the sport school and the other had not reached menarche at the time of the interview). In addition, they took injury prevention training, which was emphasised by the school and club trainers, more seriously. Participant one appeared already as the ‘24 hours athlete’. She was serious about nutrition and recovery, and she knew how to avoid diseases and injuries. She reported that physical activity in different outdoor environments (eg, skiing, mountain expeditions, cycling) was mandatory during her childhood and the versatile motoric base may help injury prevention in addition to supporting parents. However, she still reported lack of sleep as one of the major challenges during the first year at the sport school (see online supplement file).
Obviously, younger athletes need even more help to prepare for and cope with athletic and non-athletic transition.3 Stambulova and Wylleman consider two perspectives as important—preventive supportive and crisis/negative consequences. The latter is a result of ineffective coping, which in this investigation was exemplified through sleeping, exhaustion and depression. Some interventions can help athletes with the transition in order to avoid negative consequences such as dropout and overtraining, which we also found examples of. Furthermore, those who perceived that they got high-quality social support during the transition34 ,35 were more successful. The finding from this study further support this, as the athletes with resourceful parents in combination with physiological advantages cope better with the increase of training and dual workload, as this is a critical development phase where dedication and specialisation may be perceived differently by the athletes.32 The two non-injured girls had parents who encouraged them and injury prevention training was prioritised before handball training, if they needed to choose. They also monitored the daily workload more closely than the parents of the other girls, and had a good relationship with the club coach. Emotional support is not enough—the support must also be informative feedback on the daily training and effective strategies for training and life situation.6
Limitations
The results of the present study must be interpreted in lights of its limitations and strengths. We have followed these girls weekly over one year in order to minimise the often cited limitation of asking about coping with stress in retrospect49 ,50 which was here minimised as much as possible. Also, being present at the venues gave us opportunity to build trust in the group and observe their psychological and physiological challenges first hand. Generalisation of results based on data from six individuals is not possible. This study aimed to explore possible consequences of the workload (psychologically and physically) young elite athletes at specialised sport schools are exposed to.
Conclusions and recommendations
The young athletes transitioning into a specialised secondary sport school perceived several stressors (competition, organisational and personal) due to a significant increase in training volume, lack of sleep and development of severe and long-lasting injuries. Parental support, support from teachers/trainers at school and rest were mentioned as main coping mechanisms that contributed to effective coping.3
The six young female handball players express a mature struggle as they combine dual careers and adapt to a high workload. In addition, high expectations and the huge demands of elite sport will create a constant ‘need’ to cope with new and different sources of strain, and this was also true for the young female athletes in this investigation. The importance of sleep, growth and stage of puberty needs to be taken into consideration for young female athletes (at age 12–13). Naturally, the complex network of people working with young athletes may make maintaining a balance between training and rest complicated. What is critical is the unclear support or almost lack of support from club coaches when the girls were injured and also the number of injuries among them—while the parents and school teachers appear more concerned about their welfare. Generalisation is not possible with the small number of athletes included in the present study, and more knowledge is thus needed. Stambulova and Wylleman3 underline the importance of helping athletes to cope with normative and non-normative transitions; teaching coping strategies is helpful, but clinical interventions are also needed. These young athletes need help and support from trainers and parents. As shown in table 3, young athletes are different and this needs to be taken into account when planning training and recovery because the combination of psychological stress, lack of sleep and physiological factors including stage of puberty and growth may influence the development of injuries. In order to prevent injury, we recommend that biological more than chronological age is taken into account and that for each individual, progressive training volume and intensity and deliberate recovery is planned. In addition, extensive collaboration between school trainers/teachers, club coaches and parents is key for monitoring the total workload for athletes in a secondary sport school.
What are the finding?
Young female handball players experience fatigue, lack of sleep and long lasting injuries during the first year after entering a secondary sport school.
Parental support, support from teachers/trainers at school and rest are mentioned as main coping mechanisms that contribute to effective coping.
The players with resourceful parents, in combination with physiological advantages, cope better with the increase of training and dual workload.
Onset of menarche and a length growth between 6 and 8 cm during the first year are characteristic traits of the injured girls.
How might it impact on clinical practice in the future?
Trainers at sport schools, club trainers and parents need to communicate and support the young athletes in order to reduce the total load.
The teaching of coping strategies needs to be combined with clinical interventions for young athletes.
Biological more than chronological age must be taken into account and more individualised training volume and deliberate recovery are important in order to avoid overuse injuries.
The importance of sleep, growth and stage of puberty needs to be taken into consideration for young female athletes (at age 12–13).
References
Footnotes
Competing interests None declared.
Patient consent Obtained.
Ethics approval Regional Medical and Health Research Ethics Committee and Norwegian Social Science Data Services.
Provenance and peer review Not commissioned; externally peer reviewed.