Abstract
There are a very limited number of sport-specific mental health and sport performance interventions available for athletes of color. This study examined The Optimum Performance Program in Sports (TOPPS) in a biracial adolescent athlete who was diagnosed with Agoraphobia and Social Anxiety Disorder. A multiple-baseline across behaviors case trial design was used to evaluate outcomes. A battery of psychological measures specific to mental health and sport performance was administered at baseline, post-intervention, and a 3-month follow-up. Social skill sets (i.e., positive assertion and negative assertion) were systematically targeted sequentially in a virtual format using HIPAA compliant video-conferencing technology to safeguard against contracting COVID-19. Results demonstrated improvement in negative and positive assertion skills when targeted by the intervention. Severity of concurrent symptoms associated with Social Anxiety Disorder and Agoraphobia Symptoms, general psychiatric functioning, relationships with coaches, teammates and family, and factors interfering with sports performance improved from pre- to post-intervention. These improvements were maintained at the 3-month follow-up. Athlete ratings indicated their satisfaction with TOPPS was high, and intervention components were implemented with high integrity.
1. Theoretical and Research Basis for Treatment
Anxiety disorders affect more than 30% of adolescents between the ages of 13–17 years (Kessler et al., 2012). Black children may be particularly vulnerable to the negative impact of anxiety disorders because they are underserved regarding mental health services (Alegria et al., 2010), and few studies have examined whether evidenced based intervention are effective for reducing anxiety in Black youth. Ginsburg and Drake (2002) reported that CBT for anxiety disorders implemented in school settings effectively reduced anxiety symptoms in low-income Black adolescents. They suggest integration into school settings increased access to services. Ferrell et al. (2004) found that Black and White youth benefitted equally from a behavioral approach to treat anxiety from pre- to post-treatment and at 6-month follow-up. Small sample size, which limits generalizability of findings from these studies, was at least in part due to difficulty engaging the participants and their families in treatment. Neal and Turner (1991) suggest persistent racial prejudice and financial hardship influence how Black families conceptualize anxiety (i.e., an adaptive response to stress) and their decision to engage in treatment. These findings underscore the importance of developing culturally sensitive and engaging treatments.
Integrating culturally sensitive evidence-based interventions with sport may be one way to increase engagement in treatment for a number of reasons. Some athletes may respond better to treatment when it is framed within the context of performance optimization rather than treatment of a “disorder” (Donohue et al., 2018). Also, cognitive behavioral therapies may be well suited for within the context of sports, given the range of inherent components that overlap with sport: structure, direction, practice (homework), goal setting, and self-reliance (Ginsburg & Drake, 2002; Walton et al., 2021). Further, adolescent athletes may be more interested in CBT interventions that address sports performance (Schinke et al., 2017), which may encourage greater interest in practicing therapeutic skill sets in a real-world context. Stillman et al. (2016) also emphasized the importance of family therapy for youth athletes, citing the role of parents in their child’s support or stress. Therefore, given the benefits of sports activities for Black adolescent athletes, a sports-specific intervention aimed at optimizing sports performance and mental health, as well as the inclusion of significant others, may be beneficial to increasing Black adolescent athletes’ engagement and accessibility.
The Optimum Performance Program in Sports (TOPPS) is a sport-specific intervention adapted from Family Behavioral Therapy (FBT; Azrin et al., 1994) to concurrently address athletes’ sports performance and mental health (Donohue et al., 2021) through cognitive behavioral skills (Donohue et al., 2018). TOPPS includes significant others (e.g., peers, family, coaches, and teammates) who provide insights, encourage goal setting, model skills, and reinforce optimal thinking and behaviors. Significant improvements in collegiate athletes’ relationships with coaches, family and teammates and psychiatric functioning, and decreases in alcohol and illicit drug use and interferences with sports performance have been observed up to 8 months post-intervention in TOPPS clinical trials (Chow et al., 2015; Donohue et al., 2020; Donohue et al., 2015; Galante and Donohue, 2019; Gavrilova et al., 2017; Pitts et al., 2014), and in one randomized controlled trial, as diagnostic severity increased TOPPS became increasingly effective relative to campus counseling in collegiate athletes who were assessed for various mental health disorders; most often evidencing substance use, anxiety, and mood disorders (Donohue et al., 2018). TOPPS has demonstrated similar improved outcomes in an uncontrolled case trials involving racially diverse adolescent athletes presenting with social anxiety, depression, and oppositional defiant disorder (Donohue et al., 2021; Phrathep et al., 2021, 2022) up to 1-month follow-up. The present study examined the initial efficacy of TOPPS for improving mental health, athletic performance, and relationship outcomes for a biracial adolescent athlete diagnosed with social anxiety disorder and agoraphobia. TOPPS was provided via video-conferencing to decrease transmission of COVID-19 from the provider to client.
2. Case Introduction
The participant is a 14-year old Black and White cisgender male middle school club baseball player who was referred to TOPPS by his head coach due to his “shyness” during baseball practices. He met the following inclusion and exclusion criteria: (a) participating in organized sports, (b) between 12 and 17 years of age, (c) enrolled in a middle or high school in the United States, (d) not involved in counseling, and (e) not diagnosed with schizophrenia.
3. Presenting Complaints
During the intake assessment, Cedric (not his real name) reported struggling with shyness in school, sport, and family settings. Cedric reported a frequent inability to speak for himself, which negatively impacted his performance in school, sports, and ability to build relationships with new peers. In sports, Cedric said that he had difficulty asking for help from coaches and connecting with his teammates due to his shyness. Similar to his difficulty asking for help from his coaches, he also mentioned having trouble asking for help in school on assignments. He stated that because of these issues, he became reliant on his mother or other authority figures to speak for him or accompany him in situations where he would be left alone. He reported being aware of how his shyness was negatively impacting his academics, athletic performance, and relationships and emphasized wanting to increase his confidence and assertiveness in social interactions.
4. History
At the time of intake, Cedric was living with his mother and younger sister. His father is a traveling laborer who often relocates for months, while his mother is a stay-at-home mom. Cedric’s mother reported that her son experiences extreme shyness in various settings (e.g., sports, school, and public). She stated that his shyness might be modeled after her and Cedric’s father’s anxieties about social interactions. His mother also said that Cedric has never had any mental health treatment in the past and that such issues were typically managed within the family. Cedric discussed his experiences with shyness, which included being unable to ask a librarian to assisting in locating a book, walking from the car to the baseball field alone, asking for an item at the grocery store, and asking a teacher for assistance with an assignment.
5. Assessment
Diagnostic Assessment
Primary Outcome Measures
A trained assessor administered a comprehensive assessment battery 1 week before intervention (baseline), 4 months post-baseline (post-intervention), and 7 months post-baseline. A sub-set of measures were administered consistent with the multiple-baseline across behaviors methodology (Barlow & Hersen, 1988). The assessment battery included:
Secondary Measures
Pre-intervention Assessment Results
Pre-, Post- and Follow-up Assessments of Mental Health.
Note. SCL-90-R = symptom check-list-90-revised; BDI-II = beck depression inventory-II. Reliable Change Index (RCI) > 1.96 is considered significant. Significant RCIs are signified with an asterisk*.
Pre, Post-, and Follow-up Assessments of Factors Interfering with Sport Performance.
Study Design
A multiple-baseline across-behaviors experimental design was used to assess the effects of specific intervention components related to Cedric’s anxiety-related symptoms and positive and negative assertion skills (Barlow & Hersen, 1988). Behaviors were monitored immediately before each meeting using probe assessments (see Appendix) and subscales from the SCL-90-R were administered at each probe (Figure 1). It was predicted that Cedric’s positive assertion skills (i.e., requesting something desired), as assessed in probe sessions, would improve once targeted in week three, while his positive assertion skills (i.e., responding to an aversively perceived situation) would demonstrate minimal improvements. Cedric’s negative assertion skills were predicted to improve once this skill set was targeted in week six and his positive assertion skills would be maintained throughout his negative assertion skills training. Lastly, Cedric’s symptoms assessed by the SCL-90-R were predicted to improve across time. Role-play assessment for social skills.
6. Case Conceptualization
Cedric’s experiences of worry and fear of being judged in social situations were conceptualized as contributing to his maladaptive behaviors (e.g., avoidance of fearful situations, having adults speak for him). He also reported maladaptive thinking patterns related to social situations (e.g., “I don’t want to embarrass myself,” “I don’t know what to say,” “I’m unable to speak for myself,” and “I’m too shy”) which, when combined with his lack of communication skills, undermined his confidence in interacting with others, especially new people, despite wanting to talk to others. In addition to social anxiety, Cedric described fears related to being in crowds, walking to a location alone, and being left at home alone. Maladaptive behaviors related to these fears included avoiding fearful situations or always being accompanied by an adult. Cedric experienced maladaptive thoughts (e.g., “Something bad is going to happen to me if I’m alone” and “I feel helpless if something happens when I’m alone”). Cedric and his mother reported onset of these symptoms during elementary school and they impair his athletic performance, academic performance, and interpersonal relationships. His mother reported “stepping in” for him when he avoided conversations, thus inadvertently negatively reinforcing his avoidance behavior (Frick et al., 1992). These behaviors and thinking patterns were consistent with diagnoses of social anxiety disorder and agoraphobia (American Psychiatric Association, 2013).
7. Course of Treatment and Assessment of Progress
Anxiety Hierarchy with Pre-Assignment and Post-Assignment Ratings.
Cedric, his mother, and the provider also developed a hierarchy of progressively greater anxiety provoking situations. The least anxiety provoking situation was asking his sister if she would like help with her homework, and the greatest anxiety provoking situation was asking the librarian for a book. Also, he ranked the situations in the hierarchy on an anxiety scale from 1 to 10 (1 = not anxiety provoking, 10 = extremely anxiety provoking). Each week he attempted to participate in one of the situations, and during the subsequent week he reported to the provider his thoughts and actions before, during, and after completing the respective assignment. He reported his thoughts and actions that were optimally performed during the assignment completion (based on his skills, resources, and task demands at the time). These reviews occurred during the mental wellness domain of Dynamic Goals and Rewards. The provider sometimes challenged Cedric to “optimize” thoughts and actions.
1. 2. 3. The provider and significant others offer descriptive praise for Cedric’s effort and the strategies he utilized and brainstormed to maintain goal progress after TOPPS. The provider commented on Cedric’s desire to maintain optimal relationships with others and utilize his goals worksheet to monitor his goal accomplishment. His mother commented that others had noticed improvements in Cedric’s social skills, including his coach, grandparents, father, and teachers. Both the provider and his mother commended Cedric for his positive attitude and desire to continue optimizing his sports performance, academics, and relationships. 4. The provider, Cedric, and significant others exchanged what they loved, admired, respected, or appreciated about Cedric’s optimization process. Cedric’s mother began by emphasizing Cedric’s qualities of loyalty, compassion, and willingness to learn. The provider reinforced the positive characteristics that Cedric’s mother highlighted and added Cedric’s courage and positive attitude as things that were admired about Cedric’s optimization process. Cedric and his mother expressed their gratitude to the provider for his persistence, knowledge, and mentorship in assisting Cedric in moving toward optimization in all areas of his life. Lastly, the provider and Cedric commented on his mother’s dedication and love for him to help him throughout the whole program. Cedric said that his participation in TOPPS “improved his confidence, motivation, and skills” by providing him with the tools to overcome present and future challenges. In addition, both Cedric and his mother expressed gratitude for the opportunity to learn skills relevant to sports performance, mental health, and relationships, with his mother stating that the program “could not have come at a better time in Cedric’s life.”
Intervention Integrity
Strategies employed to ensure implementation integrity included documentation of techniques used during each session, participant ratings of engagement and progress towards goals, ongoing clinical supervision by a licensed psychologist, structured agendas and detailed protocol checklists to guide intervention and measure protocol adherence, reviews of audio recordings by independent raters to evaluate protocol adherence and measure inter-rater reliability, and participant ratings of helpfulness with each intervention component during each session. Intervention integrity scores were calculated in a two-step process: 1. The overall percentages of intervention protocol steps completed based on the provider self-report were computed, thus serving as validity estimates for protocol adherence. 2. Independent raters randomly selected 10% of session audiotapes and rated the number of steps implemented. Inter-rated agreement was determined by comparing independent rater and provider ratings with 70% protocol adherence considered satisfactory.
Controlled Evaluation of Positive and Negative Assertion
8. Complicating Factors
Cedric was initially non-compliant with his homework assignments related to engaging in his exposure tasks for the week. To address this, the provider had Cedric rehearse the task during the meeting to provide him an opportunity to practice while descriptively praising him for the optimal behavior rehearsal skills demonstrated in the session. Additionally, the provider, Cedric, and his mother re-adjusted his exposure list to increase likelihood that he would be able to complete his homework in following weeks. Cedric was then able to complete his homework and desensitize himself to anxiety provoking situations. See Table 3 for the exposure tasks Cedric listed as goals, along with his pre- and post-treatment exposure ratings for each task.
9. Access and Barriers to Care
Video-conferencing was used to reduce risk of COVID-19 exposure. Other benefits of video-conferencing included that it facilitated access to care through limited travel time, allowed Cedric and the provider to search for resources on the internet during meetings, and allowed inclusion of significant others who would not have been able to attend performance meetings. Additionally, video-conferencing may be used to assist TOPPS service provision for athletes who frequently travel or reside in locations outside the service provider’s area. (e.g., athletes traveling for club sports).
10. Follow-Up (Post-Intervention and 3-Month Follow-Up)
The reliable change index (RCI; Jacobson & Truax, 1991) was used to help determine if changes on the SCL-90-R were significant beyond the standard error of measurement, with RCI scores greater than 1.96 reflecting meaningful changes across time. RCI scores indicated meaningful improvement in the SCL-90-R Global Severity Index, phobic anxiety, anxiety, and somatization scales from pre- to post-intervention and from pre-intervention to 3-month follow-up (see Table 1). SCL-90-R scores were improving prior to Probe 1 which limits causal inferences between the TOPPS intervention and the SCL-90-R. The stable baseline for Cedric’s social skills is evidence of the interventions effect on those outcomes. Post-intervention KSADS conducted by a rating blind to prior diagnosis indicated no current clinically significant social anxiety disorder and agoraphobia symptoms after the 3-month follow-up. Eyeballing procedures (Byrne, 2017) used to estimate magnitude of effect for all secondary measures (SIC, TLFB, YSR, SPS, SARI, Overall Happiness with Coaches, Teammates, and Family) from pre- to post-test and from pre-test to 3-month follow-up indicated improvements on these measures (see Tables 1 and 2).
11. Treatment Implications of the Case
This case study provides preliminary evidence supporting the efficacy of TOPPS for treatment of Social Anxiety Disorder and Agoraphobia in a biracial adolescent athlete. Cedric also expressed improvement in sports performance. Cedric 100% attendance at scheduled sessions, high ratings of the program, and the involvement of his family members and other significant others in sessions provides preliminary support that TOPPS’s sports-specific component may be an effective strategy of engagement for athletes and families that have been previously reported to not engage in treatment (Neal & Turner, 1991). Finally, the video-conferencing format was effective for delivering TOPPS interventions while simultaneously addressing barriers to care that contribute to lack of access to and engagement in mental health treatment.
12. Recommendations to Clinicians and Students
The TOPPS intervention components can handle multiple cognitive and behavioral problems associated with Social Anxiety Disorder and Agoraphobia. However, in choosing the individual treatment plans and modifying interventions to address the presenting diagnostic symptoms, the treatment provider must develop a treatment plan that optimally meets the client’s treatment goals. Therefore, the treatment provider should emphasize the client’s respective disorder. Also, when multiple diagnoses are present, as in the current case, it is prudent to include scenarios for the relevant diagnostics in each intervention component. For instance, because TOPPS focuses on goals in both sports and life, the provider was able to teach Cedric skills that could be applied in life outside of sports (e.g., communication skills with teachers or potential employers). To promote significant other involvement, treatment providers are also recommended to provide psychoeducation on how involving various significant others (e.g., coaches) in treatment is beneficial to program outcome (Gavrilova et al., 2022). For instance, involving coaches in meetings allows them to recommend relevant practice scenarios for the athlete in and outside of sessions, develop goals, model and reinforce skills, and provide encouragement.
Additionally, TOPPS was able to be delivered fully through video-conferencing, which was consistent with Boelen et al.’s (2020) recommendations. This indicates that TOPPS is adaptable and effectively minimizes the risks of contracting COVID-19 (Zhou et al., 2020). However, the lack of mental health interventions available for ethnic/racial minority and low-income youth athletes demonstrates a continued need for intervention development to address this healthcare disparity (Donohue et al., 2021). Additionally, an emphasis is placed on the fact that mental health providers can implement TOPPS interventions with a variety of training backgrounds (e.g., clinical social workers, counseling psychologists, clinical psychologists, and licensed mental health counselors). Therefore, creating opportunities for mental health providers from diverse backgrounds to learn TOPPS interventions may be useful in addressing the service gap for diverse youth athletes (Donohue et al., 2020). Lastly, these preliminary results support the need to examine TOPPS in randomized clinical trials (Rounsaville et al., 2001).
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Appendix
Role Play Assessment Prompts 1. You want to ask your coach to spend extra time with you after practice to help you with your fielding. Imagine I’m the coach, and I come up to you and say, “Hey, how’s it going?” 2. You want to ask your classmate to assist you in locating information about scholarships at the library. I’m one of your classmates at the library, and I say, “Have you been here a while?” 3. You want to ask a relative to drive you to the grocery store. One of your adult relatives who drives comes up to you and says, “Hey, what have you been up to?” 4. You make an error in a game. Imagine I’m the coach and I say “what happened out there? It looked like you weren’t even paying attention.
(wait for a response) “I don’t know, maybe take more repetitions at practice, stay to work with me after, ask a teammate for help, or watch the older guys play.”
(wait for a response) “I don’t know, what do you think?”