While concussions and physical injuries in high school sports are commanding more attention, young athletes still aren't getting enough help with mental health issues such as depression, bullying, substance abuse, and eating disorders, experts say. 

New guidelines released this morning at the sixth Youth Sports Safety Summit in Dallas, hosted by the National Athletic Trainers’ Association and the Youth Sports Safety Alliance, urge coaches and parents to be more vigilant in watching for signs of mental distress.

"Concussions are a big issue and deserve to be taken seriously, but in my 35 years practicing as an athletic trainer you had four to five times more athletes requiring mental health care than trying to recover from concussions," said Timothy Neal, chair of the task force that wrote the recommendations for handling psychological problems among high school athletes.

A challenge with detecting and treating mental health issues in high school athletes is broaching concerns without making young people feel stigmatized, said Neal, former head athletic trainer at Syracuse University.

"There is no substitute for just getting to know the players, and paying attention when you see their behavior change so that you can just casually ask them how things are going and keep a dialogue going that makes them feel safe talking about whatever might be going on," Neal told Reuters Health in a phone interview.

The recommendations are intended to make sure coaches, teachers, athletic trainers, school nurses, and parents all know the warning signs for psychological problems and have plans in place for referring students to mental health professionals when necessary.

Along with ordinary pressures of high school, athletes face many situations that can contribute to mental health problems, such as being cut from a team, getting injured, making mistakes on the field, receiving media attention, and competing for athletic scholarships.

Often, physical injuries spur psychological ones, said Dr. Margot Putukian, a co-author of the recommendations and director of athletic medicine at Princeton University.

Especially if the injury requires surgery and weeks or months on the sidelines, “the injury itself can be a trigger that unmasks underlying psychological issues," Putukian said in a phone interview.

For teens who may be prone to periods of moodiness, parents and coaches should intervene if the behavior changes continue over time, she said.

"If someone is withdrawn or isolating or not spending time with their friends and having difficulty sleeping and it persists, then you have to be concerned," Putukian said.

The recommendations, published in the Journal of Athletic Training, detail common symptoms of mental health problems in athletes.

For example, athletes with eating disorders might exercise compulsively, suffer from extreme dehydration, or have gastrointestinal problems.

Athletes being bullied might have unexplained injuries, lost personal items, or complain of frequent headaches or stomach pain. Those doing the bullying might become increasingly aggressive, have unexplained money or belongings, or get in frequent verbal or physical fights.

Students who are depressed might lack energy or lose interest in sports, or have a change in appetite that leads them to gain or lose a visible amount of weight. Often, students who abuse drugs and alcohol also have an underlying mental health issue such as depression.

Parents and coaches must collaborate on mental health issues as they would for physical injuries, said Dr. Victor Schwartz, medical director of the Jed Foundation, which focuses on athletes and mental health, and clinical associate professor of psychiatry at NYU Langone Medical Center.

"Parents and coaches and every other adult in the school athletic community needs to take on responsibility not just to make sure that kids' knees are healthy but also that their minds are healthy too," Schwartz, who wasn't involved in the guidelines, said in a phone interview. "The guidelines are putting mental health front and center and providing some tools for recognizing issues and getting kids help."