Sport-related performance anxiety in young athletes: a clinical practice review

Introduction

Pediatricians play an important role for their patients engaged in organized, competitive sports. Among school-aged children and adolescents, slightly more than half participate in at least one sports team (1). Nearly eight million high school students play on a school team, and about 530,000 college students play National Collegiate Athletics Association (NCAA) sports (2,3). There are known benefits associated with participation in organized sports, such as developing physical skills, building social relationships, enhancing mental health, and improving physical fitness and health (4).

Participation in organized sports is not without its risks, including the potential for burnout if there is early sports specialization, overscheduling of sports activities on top of school and other commitments, risk-taking behaviors, injury, the potential for bullying and/or hazing within teams, financial costs, and pressures placed on young athletes by parents and coaches (4,5). In addition to these unique risks posed by athletic involvement, some young athletes may go on to develop significant feelings of anxiety in the setting of athletic competitions.

Performance anxiety differs from normative pre-competition nerves or jitters in the level of distress and/or impairment it can cause (6). It was not until the 2013 publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, now in its text revision (7), that some presentations of performance anxiety were classified as a psychiatric disorder.

Rationale and objective

Performance anxiety may cause an athlete to perform well below their demonstrated capabilities outside the competitive context. For those experiencing it, performance anxiety can cause significant psychological distress and impairment; it is also associated with attrition from sports (6,8). Athletes are more likely to seek treatment of anxiety that impedes performance (9), and both pre- and post-competition anxiety may go unaddressed if the youth does not self-report symptoms or if parents or coaches do not directly observe any outward changes to mood or behavior (e.g., tearfulness, fidgeting, avoidance).

Performance anxiety in female athletes was explored in a mini-review by one of the authors of the current paper (9). Our objective is to provide updated guidance to pediatricians and other medical practitioners relevant to direct application in clinical practice on evaluation and management of young athletes who may present with sports-related performance anxiety.

Methods

Searches were conducted, for a period from 2010 to 2024, in PubMed, Embase, Scopus, and PsycINFO. This time period was selected in order to provide the most up-to-date review of the literature on the topic of performance anxiety in pediatric athletes. Peer-reviewed articles written in English were included. Searches were created using a combination of subject headings when available, keywords, synonyms, and word and spelling variations. In addition, chain searching, or backward searching, of papers referenced in the bibliographies was carried out to identify further studies for inclusion. To expand upon the behavioral intervention section, the search included articles published prior to 2010.

Epidemiology

Anxiety disorders are among the most common mental health diagnoses in children and adolescents. Based on data from the National Survey of Children’s Health, in the United States 8.6% of children age 6–11 years had anxiety problems in their lifetime, and among 12–17 years old this increases to 13.7% (10). While data on prevalence rates of anxiety in school-aged or young adult athletes is generally lacking, some estimates among collegiate athletes suggest they are no more likely to experience symptoms of anxiety than the general population (11,12). The individual characteristics of an athlete or their sport may pose special risk factors for the development of performance anxiety. For example, those who participate in individual sports are more likely to experience performance anxiety than those who participate in teams. Personality type has also been shown to affect the athlete’s susceptibility to performance anxiety, with neuroticism being particularly associated (13). The unique stressors athletes face along with the rising trends of sport specialization, athlete identity, perfectionism, and overtraining in youth sports make performance anxiety an ever-growing issue in this community (14).

A number of factors may variably influence the development, progression, severity and persistence of sport-related anxiety (9). These may include factors unique to the individual athlete, those related to the sport, or those related to the context and environment within which the sport is played. Factors that relate to the athlete include personal achievement goals, psychosocial and cognitive maturity, coping skills, personal expectations of performance, experience, fear of failure, gender, perceived abilities, self-confidence, value assigned to a win or a loss, and anxiety traits. Factors that relate to the context and environment include coaching behavior and style, degree of difficulty of sport routine, level of competition, location of the game, intensity of the sport, team or individual sport, team goal, and support system for the athlete.

Clinical presentation

Athletes who experience symptoms of anxiety may first seek help when they notice a deterioration in their sports performance. Symptoms may range in severity from mild to debilitating and may present before, during, or after the sports activity. The onset of symptoms or the adverse impact on performance may be sudden or gradual and may persist for several weeks or even months in some cases. There is some research to suggest that individuals with performance anxiety may have a mild form of social anxiety (15). A diagnosis of social anxiety disorder, performance only subtype can only be made if symptoms have been longstanding (i.e., at least six months). Individuals with this disorder will endure marked and disproportionate fear or anxiety over engaging in a performance-related activity when there is a chance they will be scrutinized by others, due to fears of negative social evaluation. The fear or anxiety causes distress and/or functional impairment (7). However, even sub-threshold symptoms often warrant evaluation and management.

Performance anxiety arises from a discrepancy between the demands placed on an individual and their perceived ability to perform a given task. Commonly, performance anxiety will manifest in three ways: somatic, cognitive, and behavioral. Somatic symptoms are the individual’s perception of physiologic arousal, and includes symptoms of tachycardia, tachypnea, hypertension, diaphoresis, tremors, and nausea. Anxiety may also manifest in cognitive functioning, affecting thought processes and causing worry, dread, confusion, inattention, and forgetfulness among other symptoms. Behavioral symptoms are the outward manifestation of anxiety, and may involve pacing, becoming withdrawn, fidgeting, and avoiding eye contact (16). A more complete list of signs and symptoms can be found in Table 1 (9). The symptoms experienced by each athlete will vary, and the severity may range from mild to debilitating. In severe cases, the anxiety may be so debilitating that the athlete loses control over previously mastered movements (16).

Theoretical constructs and neural mechanisms

Performance anxiety may be a byproduct of state or trait anxiety. State anxiety is a temporary feeling in response to a perceived threating situation, whereas trait anxiety is considered a stable component of personality and is an inherent tendency towards anxiety that is not necessarily provoked by external stimuli (13). In athletes with low cognitive state anxiety, under increased pressure, the resulting increased arousal initially facilitates performance to an optimal point, after which additional pressure and arousal will lead to gradual decline. This pattern is termed the “Inverted-U Hypothesis” by Yerkes and Dodson (17). In athletes with high cognitive state anxiety, an alternative “Catastrophe Theory” postulates that performance rapidly deteriorates in an abrupt decline when pressure exceeds optimal arousal (18). The point at which the increased anxiety leads to performance deterioration differs between athletes, as it is heavily dependent on the athlete’s self-efficacy, skill level, team environment, and motivational profile (19).

Recent studies have elucidated the neural mechanisms of performance anxiety. Ganesh et al. found performance anxiety affected the motor action sequences, even in professional musicians and athletes (20). Specifically, in times of increased anxiety, activity in the dorsal anterior cingulate cortex (dACC) was noted to increase significantly. The dACC is a region of the brain involved in formulating executive control, motor control, and emotion—anxiety, in particular, is connected to dACC activity (21). Ganesh et al. demonstrated that activity in the dACC is not only correlated, but casual, to performance deterioration.

Additionally, Masaki et al. (22) investigated the relationship between performance anxiety and neural responses to errors. They studied two groups of competitive university athletes, one group high in performance anxiety, the other low. They studied the groups using EEG, monitoring for event-related potentials, which negatively deflect following an error—error-related negativity (ERN). The athletes were studied in both a control setting and during performance evaluation. Interestingly, the ERN was significantly larger in the evaluation condition than in the control condition for the high performance anxiety group, but not for the low performance anxiety group. Thus, the results indicate the value assigned to errors become exaggerated under testing conditions in athletes with high performance anxiety.

Clinical evaluation

Performance anxiety is a clinical diagnosis and is straightforward to identify based on patient self-reported behavioral symptoms or that of knowledgeable informants like parents or coaches. Typically, athletes wait to seek help until their anxiety negatively impacts their performance (9). Pediatricians aware of psychosocial issues related to sport participation may more effectively identify this concern before it causes marked impairment. Annual pre-participation sports physicals present the ideal opportunity to screen for mental health problems, including performance anxiety. Mental health screening during sports physicals is a recommendation of the United States National Collegiate Athletic Association (23).

The mainstay of evaluation is a thorough history, mental status assessment and physical examination. Pediatricians should assess the following areas during sports physicals: type of sport (i.e., team or individual), team environment, motivation to participate, level of competition, and history of any sport-related injuries. The presence of any symptoms of somatic, cognitive, and/or behavioral anxiety before, during, and/or after competition should also be queried. If positive, conducting a functional behavioral assessment can help identify precipitating and maintaining factors of the individual’s anxiety and form the basis of a treatment plan (24).

To aid in identification and diagnosis, there are many standardized questionnaires designed to evaluate performance anxiety in athletes (see Table 2). The two most referenced in the literature are the Sport Anxiety Scale, 2nd Edition (SAS-2) (25) and the Competitive State Anxiety Inventory, 2nd Edition (CSAI-2) (26). Based on this initial clinical evaluation, some athletes may require psychological evaluation by a clinical psychologist with experience in sport psychology. This is not typically necessary if only performance anxiety is suspected but may be beneficial if it appears to be comorbid with other mental health concerns.

Differential diagnoses

When considering a diagnosis of sports performance anxiety, it is important to keep physiologic pathologies that present with anxiety symptoms among the differential diagnoses. For example, exercise-induced bronchoconstriction (EIB) and vocal cord dysfunction (VCD) are the most common medical conditions mistaken with anxiety disorders in athletes. EIB occurs during physical exertion and involves a narrowing of the airway, producing symptoms of dyspnea, cough, and chest tightness. EIB occurs in 40% to 90% of persons with asthma and up to 20% of those without asthma (31). VCD is the paradoxical adduction of the vocal cords during inhalation. It imitates asthma and is frequently misdiagnosed. Both conditions frequently cause high anxiety during sport competitions due to the dyspnea that begins shortly after the onset of exercise. They also affect the performance, and the athlete may have difficulty recognizing the source of their anxiety (32). In addition to EIB and VCD, other medical conditions that should be considered in the differential diagnoses include epilepsy, hyperthyroidism, hyperparathyroidism, hypoglycemia, mitral valve prolapse syndrome, pheochromocytoma, porphyria and vestibular dysfunction.

Sport-related anxiety may be comorbid with other mental disorders such as other anxiety disorders or mood disorders. Screening for other mental disorders may identify these comorbidities, and is also necessary for differential diagnosis. For example, generalized anxiety disorder, panic disorder, agoraphobia, separation anxiety disorder, specific phobias, selective mutism, major depressive disorder, body dysmorphic disorder, delusional disorder, autism spectrum disorder, and avoidant personality disorder are all disorders which may present with some degree of discomfort in social settings and/or avoidance of social settings. Additionally, panic attacks may be present in performance anxiety, but can be differentiated from panic disorder by the setting in which the attacks occur (i.e., athletic performance versus “out of the blue”). Social anxiety disorder, although contextually similar to sport-related anxiety, should be differentiated to it. Social anxiety disorder involves an intense fear of social situations in which one is exposed to the possible scrutiny or judgment of others. The critical distinction is whether the anxious symptoms are present broadly across all social situations or are specific to situations in which the individual is performing in front of others (e.g., singing, acting, speaking, engaging in a sport).

Management

Psychotherapeutic interventions

Psychological interventions should be considered the primary treatment for performance anxiety, particularly state anxiety (16,33). Psychotherapies, and especially cognitive behavioral therapy (CBT), have high acceptability and effectiveness as a first line treatment of anxiety in children and adolescents (34-39). Unfortunately, the literature on application of psychotherapeutics in the treatment of mental health disorders in athletes specifically is lacking in general (40), and so too would it seem in pediatric populations. Key findings suggest that classical CBT continues to dominate the treatment literature, and there has been more research into third-wave CBT interventions based in mindfulness and acceptance. There have also been some technological adaptations of evidence-based treatments (41). Specific treatment approaches and components will be highlighted here. The supporting literature includes intervention studies conducted with a range of ages typically seen by pediatricians, from school-age children to college athletes. In any of these interventions, consideration of the athlete’s age and developmental level is imperative in selecting a suitable intervention.

CBT

As in the management of other anxiety disorders, CBT continues to be a treatment mainstay for performance anxiety (9,16). CBT is a collaborative, goal-oriented, and time-limited therapy. Compared to some other, insight-oriented talk therapies, CBT is focused on helping individuals acquire and apply new skills. The core assumptions of CBT are that psychological problems are based, in part, on faulty or unhelpful ways of thinking and learned patterns of unhelpful behavior. Engagement in CBT teaches individuals to recognize the relationships between their thoughts, actions, and emotions. Through CBT, individuals learn to recognize unhelpful patterns in their ways of thinking and behaving, which may cause and maintain their emotional distress and functional impairment.

Through CBT, individuals are taught various strategies to change unhelpful thoughts and behaviors, leading to symptom alleviation and improvement in functioning. CBT includes psychoeducation about the precipitating and maintaining factors in the development of anxiety, including the role of emotional and behavioral avoidance. Individuals in CBT learn to challenge their cognitive distortions and automatic negative thoughts, rather than accepting them at face value. For example, a young athlete engaged in CBT could identify that every time they make a mistake during competition, they automatically think, “I’m the worst player on the team”, or, “that mistake is going to cost us the game”. Countering these statements with a realistic thought could include practicing self-statements like, “anyone could make that mistake”, or, “it’s unlikely that one mistake will cost us the game”. The athlete may also come to realize how often they magnify their mistakes and how little they celebrate their successes.

Limiting avoidance behaviors is also an important component of CBT. Avoidance behaviors are shaped up through negative reinforcement. In the short-term, avoidance of an anxiety-provoking situation alleviates uncomfortable emotional and physical feelings. In the long term, however, continued avoidance perpetuates feelings of anxiety because the individual never learns to overcome these feelings to participate and build their confidence. For example, a young athlete may skip important practices or competitions due to the fear of making a mistake in front of others. Their parents and coaches may consider encouragement of any approach behavior, such as including them in the competition for short periods of time, and limiting avoidance by requiring participation.

In some cases, anxious feelings may be attributed to an automatic physiological reaction associated with specific settings, as in classical (Pavlovian) conditioning. For example, a young athlete may experience tachycardia and perspiration every time they walk onto the field during a competition. These symptoms may simply be markers of competition-related psychophysiological arousal and activation of a response that may benefit performance. The athlete perceives these sensations and cognitively interprets them as threatening, instead of an adaptive stress response. The athlete then goes on to associate the setting with the uncomfortable emotional, cognitive, and physiological response. Through strategies like systematic desensitization or interoceptive exposure, they start to break this association and experience the arousal without distress. Core treatment components of CBT are outlined in Table 3.

Acceptance and mindfulness-based therapies

“Classical” CBT emphasizes the interrelation of thoughts, behaviors, and emotions. Many of the skills in CBT involve recognizing and changing distorted thoughts to alleviate unwanted symptoms. For the last few decades, third-wave CBT interventions have placed greater emphasis on acceptance of unwanted thoughts and symptoms. Individuals learn to accept their negative thoughts, feelings, and emotions, changing their relationship to these components rather than working to control or reduce them as in traditional CBT. An important aspect of this is mindfulness, which has shown some promise as an intervention for performance anxiety in athletic competition (42). In mindfulness interventions, attention is directed and held on bodily sensations, perceptions, emotions, and thoughts, with an emphasis on acceptance and compassion rather than judgment and reactance (43).

There are some studies to support the use of acceptance- and mindfulness-based interventions in pediatric populations. Brief intervention has the capacity to reduce participants’ endorsement of pre-performance anxiety (44) and psychological distress (45). Numerous studies have also shown both a reduction in psychological symptoms and improvement to performance following mindfulness intervention (46-48). There is even some preliminary evidence from a randomized controlled trial that mindfulness interventions outperform traditional CBT in the treatment of sports performance anxiety (49). Further research should employ larger sample sizes in randomized controlled trials (RCTs) with active control groups to compare mindfulness interventions to CBT with this specific population.

Psychological skills training (PST)

Much of the literature on interventions within the pediatric population focuses on the development of performance-enhancing psychological skills. These interventions may be broadly categorized as PST. PST was developed within the CBT framework, and is most often applied in performance settings such as athletics or performing arts (49). The focus of PST is to teach athletes how to monitor and control their thoughts, actions, and emotions. PST may be used to enhance athletic performance by reducing performance anxiety, enhancing attention, and improving confidence (50). PST has been employed among pediatric athletes experiencing performance anxiety (51-57). While reviews largely conclude that PST can enhance athletic performance, many studies are of low quality, necessitating further research to definitively determine the efficacy of PST (58).

PST encompasses a wide array of techniques, most commonly self-talk, imagery, goal-setting, and arousal regulation. Self-talk is the internal dialogue/verbalization that athletes repeat to themselves before or during skill execution. The goal of self-talk is to replace unhelpful and negative thoughts with more helpful and positive messages. Self-talk can be instructional (e.g., thinking through a sequence of actions) and/or motivational (e.g., using encouraging language to enhance performance). Imagery involves the vivid and deliberate simulation of events in the mind through imagining the input from each of the five senses, helping the athlete to mentally rehearse their actions during competition. In goal-setting, three types may be considered: outcome goals, performance goals, and process goals. Outcome goals are defined as the final result of a competition (i.e., rank, winning, or losing). Performance goals are based on an athlete’s individual execution compared with the current performance. Process goals break down how a specific skill is carried out and what actions must be taken to optimally perform the skill. Finally, arousal regulation pertains to increasing or decreasing physiological arousal, for example, through breathing techniques or relaxation (59).

Special considerations for young athletes

For younger athletes, the involvement of parents/caregivers, coaches, and other relevant adults in treatment is imperative. They can set an atmosphere facilitative of enjoyable engagement or one of pressure (60,61). In young children especially, keeping the focus on participation “for the fun of it” results in better outcomes (4). For young children especially, the role of caregivers in maintaining anxious avoidance also deserves unique attention. For example, during competition children may engage in avoidance or escape behaviors such as crying, freezing, clinging, or refusing to participate which removes them from the anxiety-provoking situation (negative reinforcement); at the same time these behaviors may result in adult attention and reassurance (positive reinforcement). Intervention involves teaching caregivers and coaches to reinforce desirable behaviors and ignore/not give reinforcement to undesirable behaviors (62). Young children may be rewarded with attention, praise, or other desirable outcomes for engaging in “brave” behaviors [see for example, Puliafico’s Coaching Approach behavior and Leading by Modeling (CALM) intervention] (63).

Innovations in intervention delivery

It is generally recommended that psychological interventions be delivered by clinicians who have experience working with athletes and the unique stressors they face, and are trained in evidence-based treatments. Unconventional delivery methods may also be explored. For example, there is some evidence that coaches can be trained to deliver brief but effective mindfulness interventions to whole teams which could increase the reach of these interventions (64). Future research could continue to explore alternate ways for young athletes to access evidence-based interventions given some unique barriers they face in accessing services (65). Athletes with severe mental health concerns should be referred to a clinical psychologist for evaluation and treatment.

Psychopharmacologic treatment

Behavioral and psychological interventions are the mainstay of treatment for sport-related performance anxiety. There is no evidence-based guidance specifically for the use of psychopharmacologic drugs for the treatment of sport-related performance anxiety (66). Furthermore, the potential for side effects may make athletes more likely to first pursue behavioral treatments over medication (33). Therefore, use of drugs should be considered on an individual basis. Nevertheless, an overview of drugs used for anxiety disorders in general is provided here to guide the practitioner if drug treatment is a consideration (67-71).

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs and serotonin norepinephrine reuptake inhibitors are widely used and recommended for the treatment of anxiety disorders (72-77). However, their use for episodic, acute, or short-term treatment of sports-related performance anxiety has not been clearly elucidated. Their use is more appropriate for long-term treatment of specific chronic anxiety disorders.

Propranolol

Propranolol has been used with some reported effectiveness to prevent and treat competitive or performance anxiety in athletes. For prevention of anticipated anxiety, a single dose taken approximately 60 minutes prior to an anticipated sport event has been shown to ameliorate or prevent anxiety symptoms (66,67,78,79). For a short duration regular use, an initial recommended dose is 10–20 mg once daily, which is gradually increased to an optimal dose of 20–40 mg daily, given divided twice daily (67).

Propranolol is a non-selective beta-adrenergic receptor blocker. The mechanism of action of propranolol in reducing anxiety symptoms has not been clearly elucidated. Reduction in somatic symptoms associated with anxiety is believed to be due to a reduction in neuronal sympathetic outflow and peripheral autonomic tone by propranolol (66,67,78,79).

Commonly reported side effects propranolol include rash, dizziness, fatigue, low heart rate, low blood pressure and gastrointestinal upset (78,79). The occasional or short-term use of propranolol in young, otherwise healthy athletes is generally not associated with serious side effects; however, some of the less frequent but significant side effects include bronchospasm, heart failure and emergence of Raynaud phenomenon (78,79). Prior to starting propranolol an electrocardiogram is generally recommended; regular follow up should include monitoring of heart rate, blood pressure, fasting blood glucose, liver function tests, and blood electrolytes (67,68,72,74,78,79). Any consideration of using propranolol in an athlete with any underlying cardiovascular, endocrine or neuromuscular disorder would require careful medical assessment and specialist consultation (67,68,72,74,78,79).

Conclusions

Medical and mental health providers have a role to play in the evaluation and management of competition-related anxiety in pediatric patients. In addition to causing significant psychological distress, anxiety can lead to significant deterioration of athletic performance during competitions, and may cause athletes to prematurely drop out of their sport. Performance anxiety may be identified and differentiated from other conditions through gathering a thorough history, conducting a mental status and physical examination, and administering a published measure specific to anxiety in the setting of sports competition. Once identified, psychological interventions are the mainstay of treatment for this condition. The emphasis of this treatment is on limiting avoidance behaviors, and teaching relaxation and cognitive restructuring in the service of reducing distress and impairment. Often this is achieved through CBT, and there should be additional considerations for teaching athletes mindfulness and involving parents and coaches for the youngest athletes. There is generally not a role for SSRIs in the treatment of performance anxiety, however in some cases there can be a role for adjunct treatment with propranolol, hydroxyzine, or a benzodiazepine.

Acknowledgments

The authors would like to thank Juli McCarroll, Assistant Professor and medical librarian at Western Michigan University Homer Stryker MD School of Medicine, for her assistance with the literature search.

Funding: None.

Footnote

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-24-258/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-24-258/coif). D.R.P. serves as a Deputy Editor-in-Chief of Translational Pediatrics from January 2023 to December 2024. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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