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Considerations in the Care of Athletes With Attention Deficit Hyperactivity Disorder

Pujalte, George G. A., MD, FACSM*; Maynard, Jennifer R., MD§; Thurston, McKennan J., MD§,†; Taylor, Walter C. III, MD§; Chauhan, Mohit, MBBS

Clinical Journal of Sport Medicine: May 2019 - Volume 29 - Issue 3 - p 245–256
doi: 10.1097/JSM.0000000000000508
General Review
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SDC

Objectives: Uncover literature pertaining to: (1) attention deficit hyperactivity disorder (ADHD) and how it impacts athletes; (2) ADHD medication effects; (3) regulations regarding ADHD medications; (4) approaches to conditions similar to, and occurring with, ADHD; and (5) use of stimulants.

Data Sources: MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Ovid interface.

Main Results: ADHD can have many effects on athletes and sports participation. Exercise has positive benefits on ADHD behaviors and players' attitudes. Athletes with ADHD can have worsened ADHD symptoms after concussions. Attention deficit hyperactivity disorder is a modifier of return to play; baseline ADHD symptoms should be used to guide management. Management should include medications, behavioral/psychosocial therapy, and academic accommodations. Behavioral therapy combined with medication is superior to behavioral treatment alone. Sustained exercise as ADHD treatment should be considered mainstay in management. Sports can increase thermogenic effects of stimulants, heat injury, and cardiac arrhythmias. Increased aggressiveness, improved pain tolerance, and decreased sense of fatigue are some attributes of stimulants that are presumed to impart some advantage to athletes, but evidence is uncertain. Attention deficit hyperactivity disorder medications may lead to myocardial infarctions, cerebrovascular accidents, paranoid psychoses, seizures, insomnia, tremors, anxiety, hypertension, and death.

Conclusions: Athletes' performance and quality of life can be negatively affected by ADHD. Risks exist for those who take ADHD medications. More research is needed on the implications ADHD may have in specific sports, and on possible advantages of medication use. Potential deleterious effects of these medications should be addressed.

*Sports Medicine, Department of Family Medicine, Mayo Clinic, Jacksonville, Florida;

§Department of Family Medicine, Mayo Clinic, Jacksonville, Florida;

Sports Medicine, Tanner Clinic, Layton, Utah; and

Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida.

Corresponding Author: George G. A. Pujalte, MD, FACSM, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 (Pujalte.george@mayo.edu).

G. G. A. Pujalte has received payment for lectures from American Medical Seminars and travel grants from USA Taekwondo outside of the submitted work. W. C. Taylor serves as the medical advisor to the Women's Tennis Association (WTA), for which Mayo Clinic is paid under contract. The WTA pays W. C. Taylor's travel to 2 to 3 tournaments/yr. W. C. Taylor also owns stock in Gilead Sciences, Inc, Pfizer, and Illumina, Inc, outside of the submitted work, but he has not sold them or received any money from them. No funding was received in support of the submitted work. The remaining authors report no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.cjsportmed.com).

Received December 23, 2016

Accepted July 22, 2017

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INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders. The National Survey of Children's Health in 2011 revealed that parents of 11% of children aged 4 to 17 years reported that their child had been diagnosed with ADHD, and males are diagnosed twice as often as females.1 ADHD is characterized by symptoms in 2 domains: inattention and hyperactivity-impulsivity. Symptoms from these domains can be present together or individually. Inattention presents as persistent difficulties with sustained attention and organization, where hyperactivity-impulsivity is marked by excessive motor activity and decision making without forethought. In recognizing advances in the understanding of ADHD, the Diagnostic and Statistical Manual of Mental Disorders fifth ed (DSM-5)2 made important changes to diagnostic criteria. The age at which symptoms must initially be observed was increased from 7 to 12 years, whereas the requirement that symptoms must have caused clinically significant impairment in functioning was also relaxed.3Table 1 shows the steps of how to diagnose ADHD. Table 2 lists the core symptoms of ADHD.The DSM-5 lists the symptoms required to make the diagnosis of ADHD in those older than 17 years.2,4

TABLE 1

TABLE 1

TABLE 2

TABLE 2

ADHD can cause impairment in academic achievement and social functioning. Untreated ADHD is also associated with oppositional behavior, substance use, and forms of anxiety and depression that often cause social disruption. The impact of ADHD on motor functioning is not well studied, but there is some evidence that children with ADHD have deficits in gross and fine motor functioning.5

Stimulant medications persist as the mainstay of treatment for ADHD. Medications have been shown to improve symptoms of inattention and hyperactivity. Children receiving behavioral therapy in combination with medications also show improvement in oppositional behavior and reading achievement.6 Physical activity has shown promise as an additive intervention for improving cognitive and behavioral outcomes for children with ADHD.5,7

Concerns have been raised about a possible increased risk of adverse cardiovascular effects due to the use of stimulant medications. Therapeutic dosages of stimulants have been shown to increase heart rate and blood pressure, and other adverse side effects include loss of appetite, insomnia, irritability, and headache. High dosages can cause psychosis and seizures.8 The misuse of stimulants for cognitive enhancement and recreation has been found to be a common and growing problem among college students, including athletes.8,9

Although the direct impact of ADHD on athletic performance has not been well studied, sustaining a minimum academic performance is often required for student athletes to maintain eligibility for athletic participation. Moreover, behavioral problems associated with ADHD can also impact participation and performance. The positive and negative impacts of stimulant use and misuse in athletes continue to be controversial.

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BACKGROUND

The primary purpose of this systematic review is to discover how ADHD impacts athletes and how ADHD symptoms are affected by sports and athletic activities. As with other domains of functioning, difficulties with sustained attention, organization, and conforming to structure during school sports participation can affect participation and performance. Even mild ADHD can have an impact on elite athletes due to a greater need for control both on and off the sporting arena. The medications used to treat ADHD are known to have potential side effects that may negatively affect the individuals taking them. Moreover, competitive athletes taking these medications may be perceived as having an unfair advantage due to the stimulant nature of the drug. Sports medicine physicians should routinely follow-up with affected athletes to assess appropriate use, effectiveness of treatment, and emergence of adverse effects. If the sports physician is the treating physician for the athlete's ADHD, they should follow-up with the athlete in a longitudinal manner with frequent contact. Abuse of stimulants for recreation and performance improvement is also a growing concern. Sports physicians need to know the current evidence regarding possible effects the medications may have on athletes during important phases in sports (ie, before or after practice, before or after games, etc). In this review, we will also evaluate the literature on which sports regulatory commissions base their decisions on prohibiting medications used to treat ADHD.

Misdiagnosis, delayed diagnosis, or improper management of care may also be harmful for athletes struggling with ADHD. Sports physicians should recognize when it is appropriate to enlist resources that can help athletes diagnosed with ADHD, such as, neuropsychologists, psychologists, and counselors. The medical care of these athletes will need to be balanced with consideration of their future scholastic or athletic careers; coaches, teachers, and athletic trainers will often rely on sports physicians to chart the management of their care in a holistic manner. There are other conditions that have characteristics, which may overlap with ADHD symptoms,10 and this review is intended to present any approaches that may help sports physicians distinguish similar conditions and manage them when treating athletes diagnosed with ADHD. This review aims to provide evidence-based best practices for diagnosis and management of athletes with ADHD.

Sports physicians must also gain a better understanding of the use of stimulant medications among school-aged athletes with ADHD because these treatments have implications on grades and school performance.

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METHODS

An experienced medical reference librarian developed and ran searches in the MEDLINE, Embase, PsycINFO, and Cochrane Database of Systematic Reviews (all through the Ovid interface). Search strategies were limited by excluding certain publication types and animal studies. There were no limits to language or publication date. Search terms included MeSH and Embase terms as well as keywords including sports, athletes, attention deficit, conduct disorder, and various pharmacologic or drug therapy terms. All searches were run on August 19, 2016. The full search strategies are available in Supplemental Digital Content 1 (see Appendix,http://links.lww.com/JSM/A157).

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RESULTS AND DISCUSSION

Overview of ADHD in Athletes

Athletics and physical activities in general play an integral role for the promotion of health and socialization throughout the lifespan. Participation in organized sports can be a challenge for children or adolescents with ADD/ADHD as they inherently lack the ability to focus on the task and to be attentive, patient, and organized. Anecdotally, however, some athletes report this impulsivity as an asset that may improve their quickness and ability to “trick” the opponent with their “unpredictability.” This is most commonly reported by players in certain positions who are required to make quick decisions, such as point guards in basketball or quarterbacks in American football.11 However, the vast majority of athletes, parents, and coaches concur that physical exercise and sports have positive benefits on ADHD behaviors, self-confidence, and the player's overall attitude.12

Population studies to define the true prevalence of ADHD in athletes have not been conducted; however, researchers may extrapolate that the rate mimics that of the general population.13 Based on a small study of a boys' gymnastics team, where 5 of 7 (71%) parents reported a current or previous diagnosis of ADHD, it is possible that the prevalence of ADHD may be higher in athletes at the collegiate and professional levels.14 One possible cause of the disproportionate number of ADHD in athletes may be due to the innate beneficial effect of exercise and positive reinforcement offered by team sports; children with ADHD may continue to participate in sports organizations longer than other children.11,15

As might be expected, children with predominance of hyperactive and impulsive behaviors are more likely to draw the attention of teachers and parents, and thus, are likely to be referred to clinicians earlier. However, some athletes may go undiagnosed until late adolescence or young adulthood.11,13 One possible reason is that some exceptional athletes may be “pushed along” despite poor school performance to be recruited to competitive athletic programs. It is also theorized that parental influence and structure in the grade school years provide the student athlete with compensatory mechanisms for academic success. Often, when the student athlete enters college, this external support is lost, and the demands of independent learning exceed the compensatory strategies. This “loss of scaffolding” may expose an underlying issue of inattention, disorganization, and distractibility and lead to poor academic achievement.11 Health care providers who treat athletes, especially in the collegiate setting, must be aware of the symptoms of ADHD to recognize, diagnose, and initiate treatment to improve their academic performance and overall quality of life. An accurate diagnosis is important to differentiate those who truly need treatment with stimulant medication from others who may be looking for opportunistic side effects of performance enhancement from a stimulant medication.16,17

Several studies have investigated how ADHD may influence motor coordination in children and adolescents. Some evidence indicates delayed motor coordination and movement in those with ADHD.5 In a study in Korea, Cho et al18 found significant deficits in strength, agility, and coordination in a sample of children with ADHD (mean age of 9) compared with a sample of controls. It is also suggested that poor early development of motor coordination may impact social acceptance, sports participation, and overall well-being. Cho recommends early intervention if motor dysfunction is recognized. Although abundant evidence exists on the benefits of stimulant medications on cognitive function, there is a paucity of research on the effects of pharmacologic treatment on motor function in children with ADHD.5

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Concussion and ADHD

It is well known that athletes are at a greater risk of sports-related concussions, especially in contact sports. Given the impulsivity and the lack of fear of consequences of athletes with ADHD,19 it may be postulated that there lies an inherent increased risk of sports-related injury. Studies also that suggest that athletes may, in fact, have a higher potential increased risk of injury, not specific to ADHD and mild traumatic brain injury (TBI), although strong reproducible evidence to this conclusion is lacking.20–22

Concussive cognitive symptoms of difficulty focusing, fogginess and memory concerns can mimic those of ADHD and perhaps even worsen in athletes with preexisting ADHD.21 The term “secondary ADHD” refers to athletes who are diagnosed after a TBI, as opposed to “primary/developmental ADHD” indicating a preinjury diagnosis.

The evaluation and management of concussion often includes neurocognitive testing. It has been reported anecdotally that those with preexisting ADHD who take a postconcussion computerized neurocognitive test may not return to their baseline scores. It is believed that the repeated testing may “lose its novelty” and fail to capture the interest of players long enough to reestablish their baseline level scores.11 Scores failing to reach the baseline level may lead to protracted time away from the sport, which may in itself have a detrimental effect on ADHD symptoms and overall mood. If a patient with known ADHD is taking stimulant medication for treatment of ADHD, and the medical provider is using computerized neurocognitive testing, both baseline and postconcussion testing should be performed after the patient has taken their typical stimulant medication to allow for consistent interpretation of the results.

A preexisting diagnosis of ADHD requires a specialized interpretation of neurocognitive testing. The 2012 Zurich Consensus Statement acknowledges ADHD and learning disabilities as “modifiers” in “return to play” consideration, possibly requiring a multidisciplinary approach.19 It is, therefore, important that the team physician be aware of an athlete's baseline ADHD symptoms and treatment to help guide management and return to play.

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ADHD Treatment

The management of ADHD in athletes includes a combination of treatment modalities including behavioral, psychological, and pharmacotherapy options. Much like other psychological illnesses in sports, a multidisciplinary approach with the involvement of psychologists, psychiatrists, and a team physician is an integral part in the diagnosis and management of ADHD. In addition, the parents, teachers, athletic trainers, and coaches play an important role in monitoring symptoms, medication side effects, and the academic/athletic performance in response to treatment.13

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Nonpharmacologic Treatment Options

A multifaceted approach to the treatment of the athlete with ADHD includes the use of medication and behavioral and psychosocial therapy, as well as potential academic accommodations. Although stimulant medications are considered the first-line treatment for ADHD,23 strong consideration for nonpharmacologic treatment is warranted, especially in athletes.13,24,25

From 2007 to 2011, ADHD medication use increased from 4.8% to 6.1%. Although there is definitely a role of pharmacotherapy in ADHD management, there is a paucity of behavioral therapy availability and usage thereof.1 There are 2 main categories of psychosocial treatment that have been proven effective: behavior management and training interventions. Behavior management can be subcategorized into the following 3 areas of focus: behavioral parent training; behavioral classroom management; and behavioral peer interventions. Behavioral treatments seek to change behavior by manipulating disruptive incidents in a specific environment (ie, home, school, peer groups, and sport teams). They use the positive reinforcement of desired behaviors and disregard of undesired behaviors with the goal of extinguishing them. In a study investigating dose–response effect, behavior modification was as effective in decreasing intrusive ADHD symptoms as a moderate dose of stimulant medication.25 A structured environment both at home and in school can aid the student athlete in developing coping strategies. Skills training for the parents, as well as for the athlete, in time management, social interaction, and problem solving are examples of psychosocial treatment.13,17,26 Academic accommodations should be discussed with the school's guidance counselor, and the possible implementation of an Individualized Education Plan or 504 plan. However, Pelham et al24 has also shown that adjunctive behavioral therapy combined with medication is superior to symptom improvement than behavioral treatment alone, reinforcing the effectiveness of stimulant medication. Training interventions seek to change behavior by improving the child's skill set and hoping for generalization across behavioral settings.27

Another well-studied intervention is physical activity. A physical activity program has shown enhanced cognitive performance and brain function during tasks requiring greater executive control. Although athletes may already be active, it is important as a team physician to encourage continued fitness as this form of treatment has very low risk, but a high potential for reward.5 For some individuals, the combination of psychosocial treatment modalities and medication is optimal.28 Berwid et al26 summarized a number of studies on animals and human adults that have “compelling evidence that aerobic exercise can enhance neural growth and development, and improve cognitive and behavioral functioning.” Therefore, a sustained routine of exercise as a form of nonmedication treatment for ADHD should be considered a mainstay in management.29

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Pharmacologic

Stimulant medications, including amphetamines (and combinations of its derivatives) and methylphenidate, are considered first-line treatment for ADHD. Atomoxetine was the first nonstimulant approved by the FDA for the treatment of ADHD in both children and adults. Clonidine and guanfacine are approved for use in the pediatric population (aged 6-17 years). Bupropion and tricyclic antidepressants are not approved by the FDA but may be used as alternatives.30,31

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ADHD Medication Side Effects

All pharmacologic treatments offer potential side effects that may adversely affect an athlete. For example, amphetamine-based medications are associated with central nervous system and cardiovascular stimulation. The demands of sports can increase the thermogenic effects of stimulants, resulting in heat injury, and can also trigger cardiac arrhythmias.30,31 Careful history taking and athlete screening is key to decreasing the potential for risk, paying particular attention to the following contraindications: hypertension, glaucoma, hyperthyroidism, symptomatic cardiovascular disease, structural heart disease, psychosis, stimulant hypersensitivity, history of drug dependence, and concomitant use of a monoamine oxidase inhibitor or St. John Wort.13 Blood pressure, exertional symptoms, and heart rate, should be noted before, and monitored periodically after, initiating medication. According to the American Heart Association, obtaining an electrocardiogram before initiating stimulant and nonstimulant medications should be considered. This same sentiment has not been adopted by the American Academy of Pediatrics, as there is no evidence of increased rates of sudden cardiac death in patients taking medications for ADHD.12,13

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Special Considerations for Team Physicians

Team physicians should be aware of the signs and symptoms of ADHD discussed above to recognize new cases that may not have been diagnosed. They should be familiar with the multidisciplinary resources in their community to help address and treat these athletes to help them succeed in both academics and sports.13 For those already diagnosed, the team physician should be aware of which athletes on their teams are currently treated with stimulant medication. Depending on how each athlete feels the medication affects them during play, athletes may take their medication in different patterns. Some only take medication for classroom activities and enjoy the impulsivity during sporting events, whereas others take their medication during sport activities because they need the extra concentration imposed by the medication, such as in the case of an athlete in the role of a baseball pitcher.17 There are 2 main side effects that warrant concern for athletes: risk of heat illness and cardiac arrhythmia.21 Because of potential performance-enhancing effects of stimulant medications, there are certain regulations, depending on the level of play, by which the athlete must abide by to take the field under the influence of these medications.

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ADHD Medications and Their Status in Sports

The potential harmful effects of stimulant medications are the motivation behind the recommendation of various sports medicine committees [eg, the National Collegiate Athletic Association (NCAA), Major League Baseball, International Olympic Committee (IOC), etc.] that athletes avoid taking these medications.30,32 Medications used for ADHD, however, have been shown to be clearly beneficial for this condition. Therefore, sports medicine physicians have to balance the need to have athletes medicated versus the need to protect them from known deleterious effects that may cause harm, especially during sports participation. Furthermore, studies have indicated that some ADHD medications may lead to advantages for athletes during competition or training.33 The evidence is uncertain, but it is a common belief that athletes may take such medications precisely to avail some advantage. Increased aggressiveness, improved pain tolerance, and a decreased sense of fatigue are a few of the attributes of some stimulants that are presumed to impart some advantage to athletes during training and competition.34,35 Other stimulants increase catecholamine activity, release free fatty acids from adipocytes, and increase lipid metabolism.12,33,36 The sympathomimetic property of some stimulants is believed to give athletes an unfair advantage, causing such stimulants to be banned (Table 3).33,37 Of note, however, is that excessive sympathomimetic stimulation can actually interfere with overall athletic performance.33 Still, some stimulants are accepted for use by athletes if the athletes have documented ADHD and used the correct processes [ie, therapeutic use exemption (TUE)] to inform the sports committees regarding their use of medications prescribed by trained professionals; in the elite levels, this verification is most likely through psychiatric evaluation.

TABLE 3-a

TABLE 3-a

TABLE 3-b

TABLE 3-b

ADHD stimulant medications are strictly regulated by many governing bodies in sports including the NCAA and IOC who require thorough documentation of diagnosis. In 1992, the IOC instituted the concept of a TUE which is a form that allows athletes to participate in sports using substances that might otherwise be banned if not for their given documented diagnosis. If athletes are taking ADHD medications, the governing body of their sport may require that they receive an exemption to be able to use this medication in and out of competition. To obtain this exemption, the athlete must submit a TUE to the appropriate authorities who will review the documentation as to why the athlete requires this treatment; based on this information it will be determined whether an exemption should be granted for a defined period of time. If the athlete is to be continued on the medication beyond the end date of that TUE, the athlete and their physician must reapply to continue the exemption. Organizations such as the NCAA, IOC, and World Anti-Doping Agency require stringent documentation and recommend yearly reviews in order for the athlete to continue the use of stimulants.12 A comparison of various regulations put forth by selected sports organizations is shown in Table 4.31,38,39

TABLE 4

TABLE 4

The Food and Drug Administration (FDA) is responsible for investigating adverse medication reactions in the United States.40 So far, incidents reported involving ADHD medications include adverse effects such as myocardial infarctions, cerebrovascular accidents, paranoid psychoses, seizures, insomnia, tremors, anxiety, arrhythmias, hypertension, and death.33,38 The FDA has placed dosage limits and black-box warnings, but sale of stimulants and ADHD medications continues to register in billions in the United States alone.41Table 5 lists the results of studies mentioned within this article which may be pertinent to the care of athletes with ADHD.

TABLE 5-a

TABLE 5-a

TABLE 5-b

TABLE 5-b

TABLE 5-c

TABLE 5-c

TABLE 5-d

TABLE 5-d

TABLE 5-e

TABLE 5-e

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CONCLUSIONS

The unique impact of ADHD on athletes is still relatively poorly understood, and must be followed by health professionals who have a solid understanding of the medications that such athletes may be prescribed, in addition to the influence of these medications on the athletes' overall health and athletic performance. Attention deficit hyperactivity disorder treatments may provide advantages in athletics. Accurate diagnosis, by careful history taking and screening, is the key to differentiating athletes needing treatment from those hoping for performance enhancement. Trained professionals should be engaged with athletes who manage ADHD, from diagnosis through treatment; psychiatric evaluation is likely needed, especially at more elite levels of sports. Sports physicians must also be aware of the regulatory guidelines of each athlete's particular sport and organization.

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          Keywords:

          ADHD; attention deficit; hyperactivity; stimulants; athlete; WADA

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