Attention-deficit/hyperactivity disorder (ADHD) is a relatively common neurobehavioral disorder, affecting up to 11% of the population worldwide.1–5 ADHD is more common among men than women6 and is presumed to be more prevalent among athletes.1,2,5 Diagnosis of ADHD remains largely subjective; an evidence-based, standardized diagnostic tool should be used. Management strategies for ADHD are multifaceted, ranging from behavioral therapy to pharmacologic management and physical activity.1–5,7–10 Prescribing physicians should be vigilant for potential unfair performance advantages because of stimulant use, differentiating these from changes in performance because of appropriate treatment of ADHD. It is noteworthy that ADHD treatment may have unique direct and indirect impacts on an athlete's performance. In addition, the risks of unfair performance advantages from using stimulants and their adverse effects, especially regarding heat-related illnesses, must be deliberated.11
The primary purpose of this position statement is to evaluate current evidence on the proper diagnosis and management of ADHD among athletes at different competition levels, providing guidance for sports medicine practitioners that leverages scientific evidence for clinical utility. This study updates and expands on the 2011 American Medical Society for Sports Medicine (AMSSM) position statement.12
Writing Team Selection Process
A call for a lead author was sent to all AMSSM members; although AMSSM has an international reach, its activities are focused mainly within the US. The lead author was chosen by the AMSSM Board of Directors, at which time a separate call for coauthors was sent. The AMSSM Board of Directors and the lead author reviewed responses. Coauthors were chosen with the goal of a writing team that represented the diverse membership of AMSSM, including sex, clinical specialty, focus of expertise, geographic region, and race and ethnicity.
American Medical Society for Sports Medicine is a multidisciplinary organization of sports medicine physicians dedicated to education, research, advocacy, and care of athletes of all ages. Most AMSSM members are board-certified primary care physicians with fellowship training in sports medicine who combine their practice of sports medicine with their primary specialty. AMSSM includes members who specialize solely in nonsurgical sports medicine and serve as team physicians at the youth level, secondary schools, National Collegiate Athletic Association (NCAA), National Football League, Major League Baseball, National Basketball Association, Women's National Basketball Association, Major League Soccer, and National Hockey League, and with Olympic and Paralympic teams. By nature of their training and experience, sports medicine physicians are ideally suited to provide comprehensive medical care for athletes, sports teams, or active individuals looking to maintain a healthy lifestyle.
Studies were identified by a health sciences librarian by developing and running searches in the following databases: MEDLINE (1946-Present), Embase (1974-Present), Cochrane Central Register of Controlled Trials (1991-Present), and Cochrane Database of Systematic Reviews (2005-Present) via the Ovid interface, and Science Citation Index Expanded (1975-Present) and Emerging Sources Citation Index (2015-Present) via the Web of Science interface. There were no limits to language or publication dates, a strength of this review. Filters to remove editorials, letters, conference posters, and proceedings were included, and filters to remove animal studies, a possible limitation. Search strategies were created using a combination of keywords and standardized index terms. Search terms included standard NLM Medical Subject Headings and Emtree terms, and keywords, such as “attention deficit disorder with hyperactivity,” “ADHD,” “athletes,” “sports,” and concepts for each specific aim. The search strategy for all specific aims was completed between September 20, 2021, and October 18, 2021, resulting in 8142 unique articles. Full search strategies are available on request.
Specific aims of the article were developed through periodic meetings. The writing team was divided into subgroups (Table 1). Consensus on article inclusion and draft content was reached within each subgroup before the full group content meeting. This article is not a primer on ADHD diagnosis and treatment, but rather focuses on issues most pertinent to the competitive athlete with ADHD.
TABLE 1. -
Division of Work for Members of the Writing Team by Section
| Diagnosis and management of ADHD
| ADHD mimics: Pattern identification for differentiation
| ADHD and issues related to diversity, equity, and inclusivity
||Callender, King, Pujalte, Wolf
| Medication adverse effects
| The role of exercise in the treatment of ADHD
| Effects of ADHD on sports participation
||Kane, Liebman, Logan
| Effects of ADHD medications on athletic performance
| The relationship between ADHD and concussions
| Regulatory issues
Diagnosis and Management of ADHD
Diagnosing ADHD principally warrants comprehensive input (eg, interviews or assessment tools) from the patient and their parents, caregivers, and teachers. Other conditions that resemble ADHD (eg, depression, anxiety, posttraumatic stress disorder) should be assessed through diagnostic evaluation. Table 2 presents diagnostic criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.13 Neuroimaging and laboratory evaluation are rarely necessary to diagnose ADHD, especially when no other etiologies are being considered.14
TABLE 2. -
Criteria for the Diagnosis of ADHD
|Persistent Pattern of Inattention And/Or Hyperactivity-Impulsivity that Interferes with Functioning or Development
|Six or more symptoms of inattention in children up to 16 years old, or 5 or more in adolescents aged 17 years or older and adults. Symptoms have been present for at least 6 months and are inappropriate for the person's developmental level:
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
• Often has trouble holding attention to tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (eg, loses focus, is sidetracked)
• Often has trouble organizing tasks and activities
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework)
• Often loses things necessary for tasks and activities (eg, school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones)
• Is often easily distracted
• Often forgetful in daily activities
|Six or more symptoms of hyperactivity-impulsivity in children up to 16 years old, or 5 or more in adolescents aged 17 years or older and adults. Symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level:
• often fidgets with or taps hands or feet, or squirms in seat
• Often leaves a seat in situations where remaining seated is expected
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
• Often unable to play or take part quietly in leisure activities
• Is often “on the go” or acting as if “driven by a motor”
• Often talks excessively
• Often blurts out an answer before a question has been completed
• Often has trouble waiting for their turn
• Often interrupts or intrudes on others (eg, “butts into” conversations or games)
|The following conditions must also be met:
|• Several inattentive or hyperactive-impulsive symptoms present before 12 years old
• Several symptoms present in 2 or more settings (eg, at home, school, or work; with friends or relatives; in other activities)
• Clear evidence that symptoms interfere with or reduce the quality of social, school, or work functioning
• Symptoms not better explained by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, or personality disorder)
• Symptoms do not happen only during the course of schizophrenia or other psychotic disorder
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; DSM-V, diagnostic and statistical manual of mental disorders, Fifth Edition.
A team approach that includes the athlete is preferred.1,3,4 The primary members of this team (ie, health care professionals, athlete, family members) need to participate in discussions about short- and long-term treatment plans along with coping and management strategies. Teachers who work closely with athletes should also be incorporated into the intervention and management team.
Cognitive behavioral therapy and social skills training alone are not sufficient for ADHD management.15 The most effective treatment for ADHD is a multidisciplinary approach that combines pharmacotherapy with cognitive and social therapies. Left untreated, ADHD can negatively impact performance in school, job stability,16 self-esteem,17 relationships, substance use disorder,6 and mood (eg, anxiety).18
Of the various medication options (Table 3), stimulants are considered the first-line treatment with selected nonstimulants prescribed less frequently.19 Family and personal histories of cardiovascular diseases should be examined before prescribing stimulant medications for ADHD.20
TABLE 3. -
Commonly Used Medications for ADHD
and Known Pharmacology
||Increases norepinephrine and dopamine release and prevents reuptake
| Dextroamphetamine-amphetamine salts
||Increases norepinephrine and dopamine release and prevents reuptake
||Increases norepinephrine and dopamine release and prevents reuptake
||Inhibits GABA release, possible α1 agonist
||Norepinephrine reuptake inhibitor
||Norepinephrine and dopamine reuptake inhibitor
||Selective α2A agonist
||Norepinephrine and dopamine reuptake inhibitor
Norepinephrine and dopamine reuptake inhibitor
Norepinephrine and dopamine reuptake inhibitor
Norepinephrine and dopamine reuptake inhibitor
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; GABA, γ-aminobutyric acid.
It is essential to educate coaches, families, and other sports personnel working with athletes with ADHD about this disorder. Privacy of the patient should be maintained throughout these interactions. The patient and their parents (if applicable) need to document their approval to involve other individuals. The extent of the team's involvement should be detailed in the medical record by the physician when appropriate.
ADHD Mimics: Pattern Identification for Differentiation
There are various medical conditions that can mimic the signs and symptoms of ADHD. Appropriate diagnosis and treatment of ADHD is paramount, particularly in athletes, because there are potential adverse effects of pharmacologic treatment and restrictions placed by various sports organizations regarding the use of stimulant medications.21
Difficulty concentrating, inattentiveness, and impulsivity can be presenting symptoms of several other psychological conditions, including, but not limited to major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, bipolar disorder, and obsessive-compulsive disorder.22 ADHD symptoms are often instigated by external stimuli and are constant, whereas symptoms of mood disorder are more commonly episodic.23 Use of condition-specific screening tools, such as Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale, can help differentiate between ADHD and other psychologic disorders, although the diagnoses are not mutually exclusive (Table 4).
TABLE 4. -
Psychological Conditions that May Lead to ADHD
-like Symptomatology, and Corresponding Assessments
| Intellectual disability
||Intelligence quotient tests
• Cognitive assessment system
• Kaufman assessment battery for children
• Stanford–Binet intelligence scale
• Wechsler adult/Children intelligence scale
| Language communication disorders
||Sequenced inventory communication development
| Autism spectrum disorders
||Modified checklist for autism in Toddlers (18 and 24 months)
Child development review (18-60 months)
Pervasive developmental disorders screening
Autism screening questionnaire
Eyberg Child behavior inventory
| Depression disorder
• Children's depression inventory
• Reynolds Child depression scale
• Reynolds adolescent depression scale
| Anxiety disorder
||Generalized anxiety disorder scale
Short health anxiety inventory
Beck anxiety scale
| Oppositional defiant disorder
||Freely available scales
• National institute for Children's health quality Vanderbilt assessment scale
• Swanson, Nolan and pelham, version IV, teacher and parent rating scale
Fee for use
• Connors 3
• Child behavior checklist
| Obsessive compulsive disorder
Florida obsessive-compulsive inventory
• Yale–Brown obsessive-compulsive scale
||PTSD screening checklist
Startle, physiologic arousal, anger, numb score
| Substance abuse
National institute on alcohol abuse and alcoholism quantity and frequency questionnaire
Drug abuse screening test
United States preventive services task force–recommended screening tools
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; AUDIT, alcohol use disorders identification test; BDI, beck depression inventory; CES-D, center for epidemiologic studies depression scale; PHQ-9, Patient Health Questionnaire-9; PTSD, posttraumatic stress disorder.
Acronym: Cutting down; Annoyed by criticism, Guilty feeling, Eye-opener.
Behavioral dysfunction and outbursts are common among populations with autism spectrum disorders, oppositional defiant disorder, some personality disorders, substance use or abuse, and ADHD.22,24 Persons with autism spectrum disorders often exhibit an inability to tolerate alterations in their environment, whereas features of impaired behavioral composure are more common in ADHD.25,26
Medical conditions, such as lead poisoning,27,28 malnutrition-related deficiencies,29 cardiovascular pathologies,20,30 sleep disorders,31,32 and endocrine disorders33 can be distinguished from ADHD through history, physical examination, and other distinctive tests (Table 5).
TABLE 5. -
Physiological Conditions Mimicking or to Be Considered as Differential Diagnosis for ADHD
||Additional Information and Further Testing
||Fragile X syndrome, fetal alcohol syndrome
|Motor coordination disorders
||Cerebral palsy, muscular dystrophies
||Genetic testing, muscle biopsy
|Hearing or visual impairment
||Congenital versus acquired causes
||Vestibular/vision testing, audiometry; referral to ophthalmologist, neuro-ophthalmologist, audiologist, or otorhinolaryngologist
|Central nervous system conditions (infectious, trauma)
||Encephalitis, meningitis, neurosyphilis, CVA, sickle cell CVA, traumatic brain injury, concussion
||Brain imaging: MRI, magnetic resonance angiography, functional MRI, quantitative EEG
Cerebrospinal fluid testing
|Iron deficiency with or without anemia
||Chronic blood loss, decreased production or dietary intake, chronic kidney disease, malabsorption
||Complete blood count, iron studies
||Epilepsy, absence or myoclonic seizures
||EEG, referral to neurology
||Measure blood levels
||Thyroid disease, hyper/hypothyroidism, thyrotoxicosis, diabetes mellitus, exogenous ingestion of insulin
||Thyroid studies, hemoglobin A1c, insulin, C-peptide level
||Electrocardiography, echocardiography, cardiology referral
||Malabsorptive disorders (celiac disease, inflammatory bowel disease), eating disorders, low energy availability Vitamin deficiency
||Assess growth parameters
Dual-energy X-ray absorptiometry, eating disorder screening questionnaires, laboratory testing (prealbumin, leptin, erythrocyte sedimentation rate)
||Sleep apnea, narcolepsy, restless leg syndrome, parasomnias
||Polysomnography, ferritin levels
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CVA, cerebrovascular accident; EEG, electroencephalography; MRI, magnetic resonance imaging.
Central nervous system trauma or infection can mimic ADHD. Similar to ADHD, sports-related injuries, such as concussions, can lead to mood disturbances, cognitive dysfunction, reduced attention, and somatic idiosyncrasies.3,34,35 History of multiple head injuries, central nervous system infection, cerebral vascular disease, or brain tumor suggests a diagnosis other than ADHD.36,37
Conditions affecting the vestibular-visual system simulate ADHD symptoms and can be assessed with vestibular, visual, and audiologic testing and referral to suitable specialists (ie, audiologist, ophthalmologist, or otorhinolaryngologist).38,39
It has also been reported that psychosocial factors, such as social media, can lead to impaired attention, memory, information processing, and problem-solving (Table 6).40,41 Effects of stress or considerable fluctuations in the athlete's environment, including school absence, disorientation, and changes in mental health, can mimic ADHD.42 Moreover, the dynamics of caregiver relationships, specifically inadequate or corrective parenting and parental psychopathology, may result in childhood ADHD-like behaviors that can persist into adulthood.43–45
TABLE 6. -
Psychosocial/Environmental Scenarios that May Lead to ADHD
-like Symptomatology, and Corresponding Testing
||Additional Methods of Testing
|Stress or distraction by external stimuli
||Occurring in multiple environments (eg, school, home, work, social media)
||• Vanderbilt ADHD diagnostic teacher and parent rating scales, Brown attention-deficit disorder symptom assessment scale, Conners abbreviated symptom questionnaire
• HEADSS psychosocial interview
||Inadequate or corrective parenting
Parental psychopathology (eg, substance abuse, psychological disorder)
|• Mental health assessment of caregivers
• Child protective services involvement
|Child abuse or neglect
||• Skeletal survey radiography, head imaging
• Abdominal trauma: Liver function tests, lipase/amylase, urinalysis, fecal occult blood test
• Coagulation studies: Complete blood count, platelets, prothrombin time, partial thromboplastin time
• Urine toxicology
|Adverse childhood experiences
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; HEADSS, home, education/employment, peer group activities, drugs, sexuality, suicide/depression.
Attention-deficit/hyperactivity disorder is a complex issue that may be too challenging for a single health care professional to manage. As ADHD can imitate or coincide with other diagnoses, understanding these parallels and distinguishing them from ADHD will promote appropriate diagnosis and management of athletes with ADHD. We are advocating a team approach that is comprised of clinicians with specific expertise for adequate clinical management (Tables 4–6).
ADHD and Issues Related to Diversity, Equity, and Inclusivity
Globally, ADHD is more prevalent in boys than girls.46 However, diagnosis of ADHD in girls is often delayed. Social norms for behavior among girls may disguise ADHD-related dysfunction and delay observation of ADHD symptoms.
Boys are more likely to be referred for hyperactive symptoms, whereas girls are more likely to be referred for learning problems.47 This might affect the treatment rates for ADHD.48 Because of the frequency of disruptive classroom behavior, boys are often presumed to exhibit gender-correlated behavioral patterns compared with girls. However, girls tend to have their ADHD behaviors overlooked and are diagnosed with generalized anxiety disorder.49 When expulsion and suspension are a school's primary means of handling behavioral problems, boys are more likely to have ADHD behaviors misinterpreted as conduct issues.50 In contrast, although girls receive school suspension less often, this does not mean that girls with ADHD are not impaired and do not need referral for treatment.51
More research is warranted to examine the contributing risk factors for ADHD and the components of socioeconomic status.52 Compliance with medications and other treatments correlate well with the socioeconomic background of the child's family. When receiving behavioral and pharmacologic treatments, children from low socioeconomic backgrounds do not experience substantial improvement and are less likely to adhere to treatment.53 Parental engagement may be the primary determinant, making it even more important that clinicians actively address cultural competencies to aid in communication with families about their child's ADHD treatment.54,55
Children from marginalized communities are less likely to receive an ADHD diagnosis than the most represented groups.56 Black people are about two-thirds less likely to be recognized as having ADHD than White people. In one study, Black children were diagnosed with ADHD less often than White children despite more symptoms of distractibility and hyperactivity.57 Children of marginalized communities diagnosed with ADHD are less likely to use their prescribed medication and have a higher drop-out rate from treatment. There are different hypotheses explaining these disparities: 1) less health care access for those in marginalized communities; 2) poor ability to pay for health care; 3) communication and language barriers; and 4) known ADHD stigma and negative views toward disability.58
Children and adolescents with parents born in traditionally non–English-speaking countries are less likely to be treated with stimulants.59 For immigrant children, ADHD medication is prescribed less frequently, and the children are less likely to take the medication. This increases with the concentration of foreign-born children in the geographic area around the child's home.60
The COVID-19 pandemic has likely led to specific risks for individuals with ADHD, especially those who are vulnerable to distress caused by physical distancing measures. Loss of social structure because of school closures, distance from hobbies and friends, and anxiety related to isolation may cause behavioral disruptions in children and adolescents with ADHD, in addition to worsening their sleep issues. Preexisting disparities because of factors discussed above may have worsened during the COVID-19 pandemic. More research is required to analyze the pandemic's impact in this regard.61
Each drug has its own special considerations when used by athletes. Table 3 lists medications currently approved by the US Food and Drug Association (FDA) for ADHD. Medications used to treat ADHD are categorized as stimulants or nonstimulants; most published research addresses norepinephrine and dopamine pathways.62,63 Stimulants remain first-line medications; nonstimulant medications may be considered when stimulants fail, are poorly tolerated, or are contraindicated.64,65 Stimulants for ADHD treatment include methylphenidate, dextroamphetamine-amphetamine salts, modafinil, and dextroamphetamine; most are available in short- and long-acting formulations.66,67 Nonstimulant medications include atomoxetine, tricyclic antidepressants (TCAs), clonidine, guanfacine, and viloxazine.1,12,68,69 Adverse effects of TCAs may make them less tolerable to athletes. Bupropion is prescribed for off-label use and is typically an adjunct to first-line therapy.12,70,71
Medication Adverse Effects
Medication class and mechanism of action often determine the adverse effects observed in athletes treated for ADHD.1 When discussing possible adverse effects, it is important to understand the mechanism of action of each drug class. Common adverse effects of any stimulant include decreased appetite, gastrointestinal upset, sleep disturbances, irritability, headache, elevated heart rate, and increased blood pressure.2,5,11,66,70
Sudden cardiac death in athletes is a concern and has been reported in those using stimulants to manage their ADHD.3,11 It is currently believed that stimulant use does not increase the risk of sudden cardiac death in patients without underlying cardiovascular disease.1,3,11,72 However, dextroamphetamine-amphetamine salts carry a warning for cardiovascular events and sudden death with misuse. Therefore, stimulants should not be prescribed for athletes at risk for cardiovascular disease. Current evidence does not support ordering electrocardiography routinely because of starting stimulant medications in children.73–75 Although stimulant medications may cause elevations in heart rate and blood pressure, there seems to be no increased incidence of sudden cardiac death with the judicious, proper use of stimulant medications for the treatment of ADHD.76,77 Routinely ordering electrocardiography before initiating stimulant medications has not been shown to add benefit in preventing sudden cardiac events78,79 and may result in treatment delay and increased or unnecessary anxiety. Detailed family history and physical examination are therefore crucial before initiation of stimulants, because these will be the main determinants of whether electrocardiography is needed. All children started on stimulant medications for ADHD should be monitored for palpitations, chest pain, high blood pressure, and tachycardia.80,81 Clinicians must also remember that stimulants can theoretically increase the risk of arrhythmias.82
Athletes taking stimulants have an elevated core body temperature with physical activity that can increase the risk of exertional heat illness.83 In athletes whose sports require considerable exertion or occur in hot or humid environments, clinicians must understand this increased risk of heat illness when prescribing stimulants for ADHD. Of note, clinically relevant hyperthermia, rhabdomyolysis, and hypertension after therapeutic use of stimulants for ADHD has not been reported.84–86 Risk for these effects is theoretical and extrapolated from data on use of ephedra as a performance enhancer and improper stimulant use or abuse.86–88 More studies are needed to observe whether proper use of stimulant medications in athletes with ADHD can lead to such adverse effects. Based on current evidence, it is likely that properly dosed stimulants can be safely used without clinically significant risk.89,90 Treatment need not be delayed, because benefits can outweigh the theoretical risks as long as monitoring begins with the initial prescription of the stimulant.
Atomoxetine is one of the most commonly prescribed nonstimulant medications for ADHD.5 Its adverse effects include gastrointestinal disturbance, weight gain, liver toxicity, and hypertensive crisis.1,3,91 Clonidine and guanfacine, both α2 agonists, are also nonstimulant options with common adverse effects of dizziness, sedation, bradycardia, hypotension, and QT prolongation.1,3 TCAs are another off-label option, but the potential adverse effects (eg, weight gain, dry mouth, fatigue, cardiac dysrhythmia) often prevent their use in athletes.3 Of note, suicidal tendency is among the top 20 reported adverse effects of nonstimulant medications.91 Suicidal ideation and mania are serious potential adverse effects of viloxazine; less serious adverse effects include elevated blood pressure and heart rate, headache, and fatigue.92
The Role of Exercise in the Treatment of ADHD
Despite being the most commonly diagnosed pediatric psychiatric disorder,93 the prevalence of ADHD may be disproportionately represented in athletes because of the attention-activating effects of physical activity.3,11,12,14,94–98 Athletes, families, and caregivers who are apprehensive about the mainstream treatment with psychostimulant medications may seek exercise as an alternative therapeutic option.3,11,93 Sports participation may help develop physical skills and control in young athletes with ADHD by building motor coordination and static-dynamic balance and improving their psychosocial skills. More research is needed to demonstrate whether the prevalence of ADHD is overrepresented in athletes because of attention-activating effects of physical activity, or because those with ADHD gravitate toward pursuits that require attention activation.
Athletic participation and regular exercise serve as emotional and physical outlets and offer positive reinforcement in a venue where impulsivity can be an advantage.11,95,96,99 Evidence suggests that intense exercise is beneficial for major symptoms observed in children with ADHD (ie, lack of attention, hyperactivity, and impulsive behaviors).93 Although only a minimum volume of exercise is needed to attain meaningful symptom improvement, physical activity past the minimum may further improve symptoms.100 More studies are needed to determine whether a ceiling effect exists with exercise in this regard.
Research suggests that exercise positively affects ADHD symptoms without adverse events.9 Chuang et al101 found that 30 minutes of continuous moderate aerobic exercise resulted in significantly improved reaction time in a cognitive task suggesting improvement in attention. Medina and colleagues102 reported that 30 minutes of intermittent exercise (2 minutes work to 1 minute recovery) improved response times, stabilized impulsivity, and increased attention. There is also evidence that exercise enhances the effects of medications.103
Moderate-to-intense aerobic activity and varied sport tasks are independently effective in mitigating cognitive, behavioral, and physical symptoms of ADHD.70 Immediate single-exercise tasks and repeated regular exercise positively affect symptoms of ADHD over time, specifically inattention and impulsivity. Therefore, exercise should be a regular component of a treatment strategy for those with ADHD, and programs should be designed to provide opportunities that combine cognitive training and behavioral education.100 Although more research is needed, current findings suggest that exercise programs are helpful for behavior problems and obesity9 and, therefore, should be recommended as adjuncts to ADHD management. Children with ADHD are themselves at increased risk for becoming physically inactive and obese. Physical activity, which reduces the risk for inattention symptoms later in adolescence, can be recommended as a unique approach to treating ADHD.104
Effects of ADHD on Sports Participation
It is uncertain whether ADHD has a direct effect on participation in organized sports. Gross motor skills are frequently impaired in patients with ADHD, which could hinder participation in sports and lead to reduced social interaction.105,106 Stimulant use during exercise can lead to higher core temperatures and heart rates without an awareness of increased effort.83,107,108 Research also shows that patients with ADHD perform poorly and less efficiently in motor regulation than their neurotypical peers.109 Gait abnormalities resulting from attempts to improve the base of support, such as exaggerated out-toeing and increased step rate,110 could certainly influence comfort and performance in an athletic setting. Children with ADHD are more likely to have low levels of physical literacy, which may affect physical performance.111 However, more research is needed to determine how low physical literacy directly affects attention and impulsivity. Lack of a cohesive understanding of what, if any, influence an ADHD diagnosis has on sport participation rates presents a worthwhile investigative opportunity.
Effects of ADHD Medications on Athletic Performance
Athletes with ADHD may favor stimulant medication use because of perceived competitive benefits despite potential adverse effects.112,113 Improvements in concentration and attention with stimulant use are assumed to occur because of the activation of dopaminergic and noradrenergic systems.5,21,35,96 However, stimulation of these systems can also lead to tachycardia, hypertension, increased heart rate and blood pressure, stroke, myocardial infarction, loss of appetite, gastrointestinal impairments, rhabdomyolysis, headache, tremor, nausea, agitation, psychosis, and changes in sleep patterns,114–117 all of which can negatively affect athletic performance. Studies have shown that methylphenidate has fewer motor and systemic effects and more cognitive actions compared with amphetamines.35 The dosage, timing, duration, and type of stimulant medications can be adjusted to decrease the probable adverse effects.
The potential effects of improved endurance, anaerobic performance, reaction time, and alertness and reduced feelings of exercise fatigue with stimulants have led to their use as a performance-enhancing substance by athletes.3,118 Even if stimulant cessation is required before competition, its use may still be beneficial to athletes outside of competition by enhancing training outcomes.3,116 Use of stimulant medications as appetite suppressants is also appealing to some athletes who participate in weight-restricted (eg, boxing, wrestling and other combative sports, lightweight rowing) or aesthetics sports (eg, diving, figure skating, dance, cheerleading) given the assumption of improved performance with weight loss.119,120 Although studies have shown an improvement in variables associated with success in sport (eg, acceleration, anaerobic capacity, strength, time to exhaustion, reaction time),101,121 evidence suggesting competitive performance benefits through stimulant use in athletes is limited by sample size, dosage, novelty, consistency, and study design.5,122,123 Unfortunately, many conclusions have been based on subjective reports, hypothetical extrapolations, limited research designs, and other nonvalidated protocols. Furthermore, studies assessing performance effects may be biased in that most were not conducted exclusively on an athletic population confirmed to have ADHD.124,125
Theoretically, improvements in working memory, motor performance, attentiveness, judgment, and obedient behavior observed in athletes treated for ADHD offer an advantage in sport performance through enhanced coachability and focus on training and competition.5,21,126 For some sports positions, inattention may be particularly difficult or problematic (eg, baseball outfielder), whereas in other sports positions, impulsivity may be beneficial (eg, point guard). Presumably, treating ADHD in diagnosed athletes allows for equalization of performance compared with athletes without ADHD. Clinicians must examine the influence that the symptoms of untreated ADHD can have on performance. Although untreated ADHD in athletes may impair performance because of reduced concentration, oppositional behavior, impaired self-esteem, and labile mood, it is also possible that the unstructured or impulsive behavior of untreated athletes with ADHD may lead to advantages with their athletic performance. There is inadequate research on the performance effects of ADHD medications in the athletic population; additional quality investigations are needed to confirm performance-enhancement claims.124,127
Off-label nonpharmacologic treatment for ADHD, besides lifestyle modifications, focuses on caffeine and supplements with a high ratio of omega-3 fatty acids and eicosapentaenoic acid (EPA) to docosahexaenoic acid. Omega-3 supplementation is often discussed as a complementary intervention for ADHD with studies showing improvement when baseline EPA levels are low.96,128 Evidence suggests potential performance advantages with caffeine and EPA supplements because of reduction in delayed-onset muscle soreness and maintenance of muscle function after eccentric exercise-induced muscle damage.129–131 It is unknown whether such results occur in those with ADHD. There is a growing trend toward the use of caffeinated beverages to improve cognitive performance among individuals with ADHD with recent studies suggesting benefits when used as an adjuvant therapy to stimulants.132
Frequently prescribed nonstimulant ADHD medications include bupropion (norepinephrine and dopamine reuptake inhibitor), atomoxetine (serotonin-norepinephrine reuptake inhibitor), and α2 agonists clonidine and guanfacine, in extended-release formulas.5,116,133,134 The results of smaller trials suggest that bupropion use may decrease perceived exertion and thermal increase during exercise, thereby elevating athletes' thresholds for exercise cessation.135,136 Atomoxetine is an FDA-approved drug for ADHD treatment in children and adults. Clonidine and guanfacine are approved for use in the pediatric population, whereas bupropion and TCAs are not FDA-approved but can still be used.137
The Relationship Between ADHD and Concussions
Risk, Incidence, and Prevalence
Review of the literature for concussion prevalence by age, sex, and diagnosis of ADHD revealed some interesting trends. For example, the overall frequency of at least one diagnosed concussion is lowest in elementary school children without ADHD (3.2%) versus those with ADHD (7.2%).138 About 11% of middle school children without ADHD report at least one concussion, whereas 24% of their classmates with ADHD have experienced one or more concussions.139 In high school, 17% of students report at least one concussion, whereas 24% to 25% of those with ADHD report one or more concussions.140,141 Just over 22% of college-age students without ADHD report a history of at least one concussion, whereas 35.2% of those with ADHD report having suffered one or more concussions.142 At younger ages, children with ADHD are about twice as likely to have suffered at least one concussion over their neurotypical peers.138,139 In adolescent to college-age individuals, those with ADHD are about 1.6 times more likely to report at least 1 concussion.140,141,142 In general, concussion frequency is higher in boys than girls with differences ranging from 0.4%138% to 5.5%141 for those with ADHD and from 1.0%142% to 6.4%141 for those without ADHD.
Symptom Load and Duration
There are mixed data on the interaction between ADHD and concussion duration. Older studies reported that ADHD does not affect clinical outcomes after concussion, including prolonged recovery time (>1 month).143 More recent data, however, suggests that ADHD may affect clinical outcomes for specific populations. For example, children and adolescents with ADHD have longer recovery times for return to school and physical activity after concussion compared with youth without ADHD.144,145 In contrast, older collegiate athletes with ADHD do not seem to have longer recovery times compared with their peers without ADHD.146 Still other studies have found that older age, female sex, and the presence of an internalizing disorder (eg, depression, dysthymia, bipolar disorder) are predictors of worse outcomes after concussion for people with ADHD.147 Overall, there is no clear consensus on how age affects concussion duration for patients with ADHD.
Patients with ADHD who sustain concussions experience higher concussion symptom load, in severity and number of symptoms, compared with their unaffected peers.143,145,148,149 This is likely because ADHD symptoms mimic concussion symptoms even in the absence of injury.150 High school and collegiate athletes with ADHD are known to have higher rates of concussion-like symptoms on their preconcussion baseline assessments and return-to-play initiation assessments.143,151–153 Furthermore, ADHD is associated with worsened vestibular and oculomotor dysfunction and increased visual symptoms, at baseline and after concussions.149,154,155 Neurocognitive measures, including the Immediate Post-concussion Assessment and Cognitive Test (UPMC) and other postconcussion evaluations, indicate greater impairment in those with ADHD.138,143,149,151,152,155–159 Notably, neurocognitive testing for school-age children with ADHD is more likely to be invalid when performed in a group setting.153
Impact of Stimulant Medications
Young athletes with ADHD who take stimulants have a lower incidence of concussion when compared with their peers without ADHD and those with ADHD not taking stimulants.160 This protective effect is theoretically because of lower impulsivity and improved executive functioning. Research examining how stimulant medications affect neurocognitive impairment on postconcussion testing has yielded mixed results with some studies saying stimulants improve test performance,158,161,162 whereas others report no effect or mixed results.163,164 Similarly, stimulant medications may have no effect or may shorten concussion recovery time,145,146 but whether this is because of some physiologic mechanism or symptom masking is difficult to discern.35,160 The effects of stimulants on athletes require periodic evaluations, including after concussions. The individualized decision regarding continuation or dosage changes needs to be made after such evaluations and may reflect, as with most medications, changes in efficacy or worsening adverse effects noted in each clinic visit.
Stimulant medications have the potential to operate not only as ergogenic aids, potentially benefiting any athlete, but also as appetite suppressants, beneficial to athletes participating in sports with restrictive weight classifications, such as wrestling.4 Because of these potential performance enhancements, stimulant medications without appropriate documentation and approval are banned for athletes in competition by numerous athletic regulatory agencies. For example, the World Anti-Doping Agency requires that athletes taking medically necessary banned substances under physician supervision, such as stimulants for ADHD, must have a therapeutic use exemption (TUE) approved before competition. Approval can be obtained after review of the ADHD checklist165 and the TUE by 2 independent consultants.166 TUE approval for a new diagnosis or medication can be granted for 1 year; if the medication and dose remain constant, subsequent TUE approval may be granted for up to 4 years. Any change in medication or dosage requires resubmission of the TUE.167
The NCAA also allows the use of stimulant medications with submission and approval of their ADHD-specific medical reporting form.168 Documentation required by the NCAA includes the following: (1) description of the evaluation process which identifies the assessment tools and procedures; (2) statement of the diagnosis, including when it was confirmed; (3) history of ADHD treatment; (4) statement that a non-banned ADHD alternative has been considered; and (5) statement regarding follow-up and monitoring visits.169 These documents and the results of the annual preparticipation evaluation are required to be updated yearly. Clinical evaluation must include a full report of family history and previous ADHD treatment in addition to ADHD rating scale scores. To ensure eligibility in the event of a positive test, the student athlete should immediately report initiation or change in medications to the institution. The institution is obligated to maintain a medical file with a record of the clinical evaluation to provide to the NCAA if needed.168
Other professional athletic organizations have created individual policies regarding diagnosis, management, and documentation requirements for ADHD and use of stimulant medications in their sport. Health care professionals involved in the care of these athletes need to consult the appropriate governing body to ensure compliance with current guidelines. A summary of current organizational policies can be found in Table 7.86,170
TABLE 7. -
League- and Organization-specific Rules Related to Therapeutic Use Exemption or Pharmacologic Treatment of ADHD
|League or Association
||Written Policy Explicit to Stimulants for ADHD?
||Independent Examiner Required?
||Recertification Frequency and Other Documentation
|MLB-certified clinician or review by expert panel
||Yearly, pharmacy records
||Petition to the medical director of the antidrug program; medical information and valid prescription
||History, physical examination, and testing: Neurologic evaluation, concussion history (with imaging or neuropsychiatric testing, if indicated); evaluation for mental health disorders; laboratory tests; neurocognitive testing; interviews with player and family; DSM-V criteria; ACDS; BFIS; management plan
||Yearly; must provide documentation of follow-up visits
||PES program committee can review, consider, and act on a player's application
||In case of appeal, 2 arbitrators (1 appointed by the PGA tour and 1 selected by the player); these 2 select a third
||Yes (follows WADA directives)
||Follows WADA directives
||Through USADA, VADA, or WADA
||Voluntary program, VADA- or WADA- administered, depending on commission and competition; VADA: Medical history/examination; laboratory results (if indicated); imaging (if indicated); WADA: DSM-V criteria; second opinion, if new diagnosis at >18 years old
||USADA/WADA; DSM-V criteria; second opinion if new diagnosis at >18 years old
Abbreviations: ACDS, Adult ADHD Clinician Diagnostic Scale v1.2; ADHD, attention-deficit/hyperactivity disorder; ATP, association of tennis professionals; BFIS, barkley functional impairment scales; DSM-V, diagnostic and statistical manual of mental disorders, Fifth Edition; MLB, major league baseball; MLS, major league soccer; MMA, mixed martial arts; NASCAR, National Association for Stock Car Racing; NBA, national basketball association; NFL, national football league; NHL, national hockey league; PES, performance-enhancing substance; PGA, professional golf association; TUE, therapeutic use exemption; USADA, US Anti-Doping Association; VADA, Voluntary Anti-Doping Association; WADA, World Anti-Doping Association.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for ADHD are vital for accurate diagnosis. Clinicians who care for athletes with ADHD should be aware of best practices regarding diagnosis and clinical management. Knowledge of medications used for ADHD is essential specifically regarding possible adverse effects and the rules governing their use in organized sports. Clinical recommendations for managing individuals diagnosed with ADHD are presented in Table 8.171 Clinicians also need to know that stimulant medications are banned by numerous athletic regulatory organizations (when used without appropriate documentation and approval) and that athletes may seek stimulants for perceived performance benefits.
TABLE 8. -
Key Clinical Recommendations
|Use the diagnostic criteria listed in the DSM-V to diagnose ADHD.
|Aim for a multidisciplinary approach for the treatment of ADHD, combining pharmacotherapy with cognitive and social therapies.
|Be aware of the potential effects of stimulants, their likelihood of performance-enhancing effects in athletes, and the possibility of abuse/misuse for intended benefits.
|Leverage thorough history, assessment scales, physical examination, cognitive tests, lab tests, and neuroimaging to rule out mimics of ADHD.
|Identify athletes with ADHD who are at risk for cardiovascular disease and consider nonstimulant approaches to their management.
|Adjust the dosage, timing, duration, and type of stimulant medication to address any adverse effects.
|Ensure appropriate documentation and approval processes are followed for athletes on stimulants for ADHD competing in sports under the various athletic regulatory organizations including, but not limited to the IOC, WADA, and the NCAA.
|Consider the interaction of ADHD and concussion, and how adequate management of 1 may positively affect outcomes/symptomatology of the other.
|Be mindful of likelihood and unintended tendencies to underdiagnose and undertreat ADHD in girls, women, and minorities.
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; DSM-V, diagnostic and statistical manual of mental disorders, Fifth Edition; IOC, international olympic committee; NCAA, national collegiate athletic association; SORT, strength of recommendation taxonomy; WADA, World Anti-Doping Association.
This position statement is not intended as a clinical practice guideline or legal standard of care and should not be interpreted as such.
Jason Matuszak, MD, and Lauren Simon, MD, MPH, helped guide the group in terms of what information is clinically useful and reminded us of the AMSSM template. David Olsen, MD, made contributions towards formulating ideas at the planning stage for the article. Tara J. Brigham, MLIS, AHIP, and Victoria L. Clifton, MLIS, developed and conducted the literature search. Andy Meyer assisted the writing team and helped with formatting this document. Mohit Chauhan, MBBS, a Mayo Clinic psychiatrist with special interest in Sport Psychology, reviewed the article and made wording suggestions. Donald T. Kirkendall, ELS, a contracted medical editor, helped prepare the document for submission. The Scientific Publications staff at Mayo Clinic provided copyediting, proofreading, administrative, and clerical support.
1. Ciocca M. Attention deficit hyperactivity
disorder in athletes
. Clin Sports Med. 2019;38:545–554.
2. Garner AA, Hansen AA, Baxley C, Ross MJ. The use of stimulant medication to treat attention-deficit/hyperactivity
disorder in elite athletes
: a performance and health perspective. Sports Med. 2018;48:507–512.
3. Han DH, McDuff D, Thompson D, et al. Attention-deficit/hyperactivity
disorder in elite athletes
: a narrative review. Br J Sports Med. 2019;53:741–745.
4. MacLean L, Prabhakar D. Attention-deficit/hyperactivity
disorder and sports: a lifespan perspective. Psychiatr Clin North Am. 2021;44:419–430.
5. Pujalte GGA, Maynard JR, Thurston MJ, et al. Considerations in the care of athletes
with attention deficit hyperactivity
disorder. Clin J Sport Med. 2019;29:245–256.
6. Faraone SV, Banaschewski T, Coghill D, et al. The World federation of ADHD
international consensus statement: 208 evidence-based conclusions about the disorder. Neurosci Biobehav Rev. 2021;128:789–818.
7. Chan YS, Jang JT, Ho CS. Effects of physical exercise in children with attention deficit
disorder. Biomed J. 2021.
8. Halperin JM, Berwid OG, O'Neill S. Healthy body, healthy mind?: the effectiveness of physical activity to treat ADHD
in children. Child Adolesc Psychiatr Clin N Am. 2014;23:899–936.
9. Ng QX, Ho CYX, Chan HW, et al. Managing childhood and adolescent attention-deficit/hyperactivity
) with exercise: a systematic review. Complement Ther Med. 2017;34:123–128.
10. Xie Y, Gao X, Song Y, et al. Effectiveness of physical activity intervention on ADHD
symptoms: a systematic review and meta-analysis. Front Psychiatry. 2021;12:706625.
11. Stewman CG, Liebman C, Fink L, Sandella B. Attention deficit hyperactivity
disorder: unique considerations in athletes
. Sports Health. 2018;10:40–46.
12. Putukian M, Kreher JB, Coppel DB, et al. Attention deficit hyperactivity
disorder and the athlete: an American Medical Society for Sports Medicine position statement. Clin J Sport Med. 2011;21:392–401.
13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, D.C.: American Psychiatric Assocation; 2013.
14. Wolraich ML, Hagan JF Jr., Allan C, et al. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity
disorder in children and adolescents. Pediatrics. 2019;144:e20192528.
15. Bodison SC, Parham LD. Specific sensory techniques and sensory environmental modifications for children and youth with sensory integration difficulties: a systematic review. Am J Occup Ther. 2018;72:7201190040p1–7201190040p11.
16. Fuermaier ABM, Tucha L, Butzbach M, et al. ADHD
at the workplace: ADHD
symptoms, diagnostic status, and work-related functioning. J Neural Transm (Vienna). 2021;128:1021–1031.
17. Cook J, Knight E, Hume I, Qureshi A. The self-esteem of adults diagnosed with attention-deficit/hyperactivity
): a systematic review of the literature. Atten Defic Hyperact Disord. 2014;6:249–268.
18. Grogan K, Bramham J. Demographic, developmental and psychosocial predictors of the development of anxiety in adults with ADHD
. Atten Defic Hyperact Disord. 2016;8:35–44.
19. Shellenberg TP, Stoops WW, Lile JA, Rush CR. An update on the clinical pharmacology of methylphenidate: therapeutic efficacy, abuse potential and future considerations. Expert Rev Clin Pharmacol. 2020;13:825–833.
20. Torres-Acosta N, O'Keefe JH, O'Keefe CL, Lavie CJ. Cardiovascular effects of ADHD
therapies: JACC review topic of the week. J Am Coll Cardiol. 2020;76:858–866.
21. Perrin AE, Jotwani VM. Addressing the unique issues of student athletes
. J Fam Pract. 2014;63:E1–E9.
22. Tarazi FI, Sahli ZT, Pleskow J, Mousa SA. Asperger's syndrome: diagnosis, comorbidity and therapy. Expert Rev Neurother. 2015;15:281–293.
23. Wozniak J, Biederman J, Richards JA. Diagnostic and therapeutic dilemmas in the management of pediatric-onset bipolar disorder. J Clin Psychiatry. 2001;62(suppl 14):10–15.
24. Mao AR, Findling RL. Comorbidities in adult attention-deficit/hyperactivity
disorder: a practical guide to diagnosis in primary care. Postgrad Med. 2014;126:42–51.
25. Schottle D, Schimmelmann BG, van Elst LT. ADHS und hochfunktionale Autismus-Spektrum-Störungen [ADHD
and High-Functioning Autism Spectrum Disorders]. Nervenheilkunde. 2019;38:632–644.
26. Taurines R, Schwenck C, Westerwald E, et al. ADHD
and autism: differential diagnosis or overlapping traits? A selective review. Atten Defic Hyperact Disord. 2012;4:115–139.
27. Lin Y, Huang L, Xu J, et al. Blood lead, bone lead and child attention-deficit-hyperactivity
-disorder-like behavior. Sci Total Environ. 2019;659:161–167.
28. Nigg JT, Knottnerus GM, Martel MM, et al. Low blood lead levels associated with clinically diagnosed attention-deficit/hyperactivity
disorder and mediated by weak cognitive control. Biol Psychiatry. 2008;63:325–331.
29. Demirci K, Yildirim Baş F, Arslan B, et al. The investigation of symptoms and diagnoses of adult-attention deficit
disorder in women with iron deficiency anemia. Noro Psikiyatr Ars. 2017;54:72–77.
30. Liang EF, Lim SZ, Tam WW, et al. The effect of methylphenidate and atomoxetine on heart rate and systolic blood pressure in young people and adults with attention-deficit hyperactivity
): systematic review, meta-analysis, and meta-regression. Int J Environ Res Public Health. 2018;15:1789.
31. McWilliams S, Zhou T, Stockler S, et al. Sleep as an outcome measure in ADHD
randomized controlled trials: a scoping review. Sleep Med Rev. 2022;63:101613.
32. Surman CBH, Walsh DM. Understanding the impact of stimulants
on sleep in ADHD
: evidence from systematic assessment of sleep in adults. CNS Drugs. 2022;36:253–260.
33. Muskens JB, Velders FP, Staal WG. Medical comorbidities in children and adolescents with autism spectrum disorders and attention deficit hyperactivity
disorders: a systematic review. Eur Child Adolesc Psychiatry. 2017;26:1093–1103.
34. Cook NE, Huang DS, Silverberg ND, et al. Baseline cognitive test performance and concussion-like symptoms among adolescent athletes
: examining differences based on medication use. Clin Neuropsychol. 2017;31:1341–1352.
35. Coris EE, Moran B, Sneed K, et al. Stimulant therapy utilization for neurocognitive deficits in mild traumatic brain injury. Sports Health. 2022;14:538–548.
36. Snell LB, Bakshi D. Neurological adverse effects of methylphenidate may be misdiagnosed as meningoencephalitis. BMJ Case Rep. 2015;2015:bcr2014207796.
37. Wait JW, Stanton L, Schoeman JF. Tuberculosis meningitis and attention deficit hyperactivity
disorder in children. J Trop Pediatr. 2002;48:294–299.
38. Corwin DJ, McDonald CC, Arbogast KB, et al. Visio-vestibular deficits in healthy child and adolescent athletes
. Clin J Sport Med. 2022;32:376–384.
39. Moran RN, Wallace J, Murray NG, Covassin T. Effects of attention deficit hyperactivity
disorder and learning disability on vestibular and ocular baseline concussion assessment in pediatric athletes
. Appl Neuropsychol Child. 2021;10:276–282.
40. Alageel AA, Alyahya RA, Bahateq YA, et al. Smartphone addiction and associated factors among postgraduate students in an Arabic sample: a cross-sectional study. BMC Psychiatry. 2021;21:302.
41. Liang SH, Lee YC, Kelsen BA, Chen VC. Health-related quality of life in mothers of children with attention deficit hyperactivity
disorder in Taiwan: the roles of child, parent, and family characteristics. Res Dev Disabil. 2021;113:103944.
42. Wofford JR, Ohrt JH. An integrated approach to counseling children diagnosed with adhd
, odd, and chronic stressors. Fam J Alex Va. 2018;26:105–109.
43. Chang CC, Chen YM, Hsiao RC, et al. Affiliate stigma in caregivers of children with attention-deficit/hyperactivity
disorder: the roles of stress-coping orientations and parental child-rearing styles. Int J Environ Res Public Health. 2021;18:9004.
44. Galloway H, Newman E, Miller N, Yuill C. Does parent stress predict the quality of life of children with a diagnosis of ADHD
? A comparison of parent and child perspectives. J Atten Disord. 2019;23:435–450.
45. Mulligan A, Anney R, Butler L, et al. Home environment: association with hyperactivity
/impulsivity in children with ADHD
and their non-ADHD
siblings. Child Care Health Dev. 2013;39:202–212.
46. Levy F, Hay DA, Bennett KS, McStephen M. Gender differences in ADHD
subtype comorbidity. J Am Acad Child Adolesc Psychiatry. 2005;44:368–376.
47. Slobodin O, Davidovitch M. Gender differences in objective and subjective measures of ADHD
among clinic-referred children. Front Hum Neurosci. 2019;13:441.
48. Sciutto MJ, Eisenberg M. Evaluating the evidence for and against the overdiagnosis of ADHD
. J Atten Disord. 2007;11:106–113.
49. Quinn PO. Treating adolescent girls and women with ADHD
: gender-specific issues. J Clin Psychol. 2005;61:579–587.
50. Bauermeister JJ, Shrout PE, Chávez L, et al. ADHD
and gender: are risks and sequela of ADHD
the same for boys and girls?. J Child Psychol Psychiatry. 2007;48:831–839.
51. Bauermeister JJ, Shrout PE, Ramírez R, et al. ADHD
correlates, comorbidity, and impairment in community and treated samples of children and adolescents. J Abnorm Child Psychol. 2007;35:883–898.
52. Russell AE, Ford T, Russell G. Socioeconomic associations with ADHD
: findings from a mediation analysis. PLoS One. 2015;10:e0128248.
53. Rieppi R, Greenhill LL, Ford RE, et al. Socioeconomic status as a moderator of ADHD
treatment outcomes. J Am Acad Child Adolesc Psychiatry. 2002;41:269–277.
54. Bailey RK. Diagnosis and treatment of attention-deficit/hyperactivity
) in African-American and Hispanic patients. J Natl Med Assoc. 2005;97:3s–4s.
55. Kim M, King MD, Jennings J. ADHD
remission, inclusive special education, and socioeconomic disparities. SSM Popul Health. 2019;8:100420.
56. Morgan PL, Staff J, Hillemeier MM, et al. Racial and ethnic disparities in ADHD
diagnosis from kindergarten to eighth grade. Pediatrics. 2013;132:85–93.
57. Epstein JN, Willoughby M, Valencia EY, et al. The role of children's ethnicity in the relationship between teacher ratings of attention-deficit/hyperactivity
disorder and observed classroom behavior. J Consult Clin Psychol. 2005;73:424–434.
58. Eiraldi RB, Mazzuca LB, Clarke AT, Power TJ. Service Utilization among ethnic minority children with ADHD
: a model of help-seeking behavior. Adm Pol Ment Health. 2006;33:607–622.
59. Yang KG, Flores MW, Carson NJ, Cook BL. Racial and ethnic disparities in childhood ADHD
treatment access and utilization: results from a national study. Psychiatr Serv. 2022;73:1338–1345.
60. Lehti V, Chudal R, Suominen A, et al. Association between immigrant background and ADHD
: a nationwide population-based case-control study. J Child Psychol Psychiatry. 2016;57:967–975.
61. Behrmann JT, Blaabjerg J, Jordansen J, Jensen de López KM. Systematic review: investigating the impact of COVID-19 on mental health outcomes of individuals with ADHD
. J Atten Disord. 2021;26:959–975.
62. Braun S, Russo L, Zeidler J, et al. Descriptive comparison of drug treatment-persistent, -nonpersistent, and nondrug treatment patients with newly diagnosed attention deficit
disorder in Germany. Clin Ther. 2013;35:673–685.
63. Graham J, Banaschewski T, Buitelaar J, et al. European guidelines on managing adverse effects of medication for ADHD
. Eur Child Adolesc Psychiatry. 2011;20:17–37.
64. Pliszka SR. Non-stimulant treatment of attention-deficit/hyperactivity
disorder. CNS Spectr. 2003;8:253–258.
65. Pliszka SR. Pharmacologic treatment of attention-deficit/hyperactivity
disorder: efficacy, safety and mechanisms of action. Neuropsychol Rev. 2007;17:61–72.
66. Greenhill LL, Pliszka S, Dulcan MK, et al. Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002;41:26s–49s.
67. Greenhill LL, Pliszka S, Dulcan MK, et al. Summary of the practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2001;40:1352–1355.
68. Lamb YN. Viloxazine: pediatric first approval. Paediatr Drugs. 2021;23:403–409.
69. White RD, Harris GD, Gibson ME. Attention deficit hyperactivity
disorder and athletes
. Sports Health. 2014;6:149–156.
70. Verbeeck W, Bekkering GE, Van den Noortgate W, Kramers C. Bupropion for attention deficit hyperactivity
) in adults. Cochrane Database Syst Rev. 2017;10:Cd009504.
71. Wilens TE, Haight BR, Horrigan JP, et al. Bupropion XL in adults with attention-deficit/hyperactivity
disorder: a randomized, placebo-controlled study. Biol Psychiatry. 2005;57:793–801.
72. Schneider BN, Enenbach M. Managing the risks of ADHD
treatments. Curr Psychiatry Rep. 2014;16:479.
73. Aggarwal V, Aggarwal A, Khan D. Electrocardiogram before starting stimulant medications: to order or not? Cardiol Young. 2016;26:216–219.
74. Becker SD, Rochelson E, Lienhard M, et al. Screening electrocardiograms have low utility in medical clearance before pediatric inpatient psychiatric admission. Pediatr Emerg Care. 2022;38:e393–e397.
75. Conway J, Wong KK, O'Connell C, Warren AE. Cardiovascular risk screening before starting stimulant medications and prescribing practices of canadian physicians: impact of the Health Canada advisory. Pediatrics. 2008;122:e828–e834.
76. Knight M. Stimulant-drug therapy for attention-deficit disorder (with or without hyperactivity
) and sudden cardiac death. Pediatrics. 2007;119:154–155.
77. Wilens TE, Prince JB, Spencer TJ, Biederman J. Stimulants
and sudden death: what is a physician to do? Pediatrics. 2006;118:1215–1219.
78. Leslie LK, Cohen JT, Newburger JW, et al. Costs and benefits of targeted screening for causes of sudden cardiac death in children and adolescents. Circulation. 2012;125:2621–2629.
79. Vetter VL, Elia J, Erickson C, et al. Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit
disorder [corrected]: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation. 2008;117:2407–2423.
80. Hammerness PG, Perrin JM, Shelley-Abrahamson R, Wilens TE. Cardiovascular risk of stimulant treatment in pediatric attention-deficit/hyperactivity
disorder: update and clinical recommendations. J Am Acad Child Adolesc Psychiatry. 2011;50:978–990.
81. Vitiello B. Understanding the risk of using medications for attention deficit hyperactivity
disorder with respect to physical growth and cardiovascular function. Child Adolesc Psychiatr Clin N Am. 2008;17:459–474.
82. Akasaki Y, Ohishi M. Cerebrovascular and cardiovascular diseases caused by drugs of abuse. Hypertens Res. 2020;43:363–371.
83. Roelands B, Hasegawa H, Watson P, et al. The effects of acute dopamine reuptake inhibition on performance. Med Sci Sports Exerc. 2008;40:879–885.
84. Ciccarone D, Shoptaw S. Understanding stimulant use and use disorders in a new era. Med Clin North Am. 2022;106:81–97.
85. Docherty JR, Alsufyani HA. Cardiovascular and temperature adverse actions of stimulants
. Br J Pharmacol. 2021;178:2551–2568.
86. Matuszak J. Attention deficit
). In: Hong ES, Rao AL, eds. Mental Health in the Athlete: Modern Perspectives and Novel Challenges for the Sports Medicine Provider. Cham, Switzerland: Springer Nature Switzerland AG; 2020:69–84.
87. Gutiérrez-Hellín J, Varillas-Delgado D. Energy drinks and sports performance, cardiovascular risk, and genetic associations; future prospects. Nutrients. 2021;13:715.
88. Mahendru D, Kumar S, Prakash A, Medhi B. Drugs in sport: the curse of doping and role of pharmacologist. Indian J Pharmacol. 2019;51:1–3.
89. Coghill D, Banaschewski T, Cortese S, et al. The management of ADHD
in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD
Guidelines Group (EAGG). Eur Child Adolesc Psychiatry. 2021:1–25.
90. Farhat LC, Flores JM, Behling E, et al. The effects of stimulant dose and dosing strategy on treatment outcomes in attention-deficit/hyperactivity
disorder in children and adolescents: a meta-analysis. Mol Psychiatry. 2022;27:1562–1572.
91. Pang L, Sareen R. Retrospective analysis of adverse events associated with non-stimulant ADHD
medications reported to the United States food and drug administration. Psychiatry Res. 2021;300:113861.
92. Nasser A, Liranso T, Adewole T, et al. A phase III, randomized, placebo-controlled trial to assess the efficacy and safety of once-daily SPN-812 (viloxazine extended-release) in the treatment of attention-deficit/hyperactivity
disorder in school-age children. Clin Ther. 2020;42:1452–1466.
93. Villa-González R, Villalba-Heredia L, Crespo I, et al. A systematic review of acute exercise as a coadjuvant treatment of ADHD
in young people. Psicothema. 2020;32:67–74.
94. Broshek DK, Freeman JR. Psychiatric and neuropsychological issues in sport medicine. Clin Sports Med. 2005;24:663–679.
95. Gökçen C, Unal A, Alpak G, et al. Is there any relationship between ADHD
symptoms and choosing sports education at the university? Int J Psychiatry Med. 2013;46:169–178.
96. Parr JW. Attention-deficit hyperactivity
disorder and the athlete: new advances and understanding. Clin Sports Med. 2011;30:591–610.
97. Shaw P, Eckstrand K, Sharp W, et al. Attention-deficit/hyperactivity
disorder is characterized by a delay in cortical maturation. Proc Natl Acad Sci U S A. 2007;104:19649–19654.
98. Wolraich M, Brown L, Brown RT, et al. ADHD
: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity
disorder in children and adolescents. Pediatrics. 2011;128:1007–1022.
99. McKune AJ, Paultz J, Lombard J. Behavioural response to exercise in children with attention-deficit/hyperactivity
disorder. S Afr J Sports Med. 2003;15:17–21.
100. Neudecker C, Mewes N, Reimers AK, Woll A. Exercise interventions in children and adolescents with ADHD
: a systematic review. J Atten Disord. 2019;23:307–324.
101. Chuang L-Y, Tsai Y-J, Chang Y-K, et al. Effects of acute aerobic exercise on response preparation in a Go/No Go Task in children with ADHD
: an ERP study. J Sport Health Sci. 2015;4:82–88.
102. Medina JA, Netto TL, Muszkat M, et al. Exercise impact on sustained attention of ADHD
children, methylphenidate effects. Atten Defic Hyperact Disord. 2010;2:49–58.
103. Hoza B, Martin CP, Pirog A, Shoulberg EK. Using physical activity to manage ADHD
symptoms:the state of the evidence. Curr Psychiatry Rep. 2016;18:113.
104. Khalife N, Kantomaa M, Glover V, et al. Childhood attention-deficit/hyperactivity
disorder symptoms are risk factors for obesity and physical inactivity in adolescence. J Am Acad Child Adolesc Psychiatry. 2014;53:425–436.
105. Emck C, Bosscher RJ, van Wieringen PC, et al. Psychiatric symptoms in children with gross motor problems. Adapt Phys Activ Q. 2012;29:161–178.
106. Havmoeller SR, Thomsen PH, Lemcke S. The early motor development in children diagnosed with ADHD
: a systematic review. Atten Defic Hyperact Disord. 2019;11:233–240.
107. Pelham WE, McBurnett K, Harper GW, et al. Methylphenidate and baseball playing in ADHD
children: who's on first? J Consult Clin Psychol. 1990;58:130–133.
108. Wade MG. Effects of methylphenidate on motor skill acquisition of hyperactive-children. J Learn Disabilities. 1976;9:443–447.
109. Dahan A, Ryder CH, Reiner M. Components of motor deficiencies in ADHD
and possible interventions. Neuroscience. 2018;378:34–53.
110. Simmons RW, Taggart TC, Thomas JD, et al. Gait control in children with attention-deficit/hyperactivity
disorder. Hum Mov Sci. 2020;70:102584.
111. Fortnum K, Furzer B, Reid S, et al. The physical literacy of children with behavioural and emotional mental health disorders: a scoping review. Ment Health Phys Act. 2018;15:95–131.
112. Griswold KS, Aronoff H, Kernan JB, Kahn LS. Adolescent substance use and abuse: recognition and management. Am Fam Physician. 2008;77:331–336.
113. McDuff D, Stull T, Castaldelli-Maia JM, et al. Recreational and ergogenic substance use and substance use disorders in elite athletes
: a narrative review. Br J Sports Med. 2019;53:754–760.
114. Martinez-Quintana E, Saiz-Udaeta B, Marrero-Negrin N, et al. Androgenic anabolic steroid, cocaine and amphetamine abuse and adverse cardiovascular effects. Int J Endocrinol Metab. 2013;11:e8755.
115. Pumariega AJ, Rodriguez L, Kilgus MD. Substance abuse among adolescents: current perspectives. Addict Disord Their Treat. 2004;3:145–155.
116. Reardon CL, Factor RM. Considerations in the use of stimulants
in sport. Sports Med. 2016;46:611–617.
117. Stark JG, Engelking D, McMahen R, Sikes C. A randomized crossover study to assess the pharmacokinetics of a novel amphetamine extended-release orally disintegrating tablet in healthy adults. Postgrad Med. 2016;128:648–655.
118. Eichner ER. Ergolytic drugs in medicine and sports. Am J Med. 1993;94:205–211.
119. Ferguson JH. National institutes of health consensus development conference statement: diagnosis and treatment of attention-deficit/hyperactivity
). J Am Acad Child Adolesc Psychiatry. 2000;39:182–193.
120. Rast JE, Anderson KA, Roux AM, Shattuck PT. Medication use in youth with autism and attention-deficit/hyperactivity
disorder. Acad Pediatr. 2021;21:272–279.
121. Chandler JV, Blair SN. The effect of amphetamines on selected physiological components related to athletic success. Med Sci Sports Exerc. 1980;12:65–69.
122. Chang CJ, Putukian M, Aerni G, et al. Mental health issues and psychological factors in athletes
: detection, management, effect on performance, and prevention: American medical society for sports medicine position statement. Clin J Sport Med. 2020;30:e61–e87.
123. Kreher JB. Attention deficit
) in athletes
. Int J Athl Ther Train. 2012;17:15–19.
124. Benson K, Flory K, Humphreys KL, Lee SS. Misuse of stimulant medication among college students: a comprehensive review and meta-analysis. Clin Child Fam Psychol Rev. 2015;18:50–76.
125. Lakhan SE, Kirchgessner A. Prescription stimulants
in individuals with and without attention deficit hyperactivity
disorder: misuse, cognitive impact, and adverse effects. Brain Behav. 2012;2:661–677.
126. Kaufman KR, Bajaj A, Schiltz JF. Attention-deficit/hyperactivity
) in gymnastics: preliminary findings. Apunts Med de l'Esport. 2011;46:89–95.
127. Searight HR, Nahlik JE, Campbell DC. Attention-deficit/hyperactivity
disorder: assessment, diagnosis, and management. J Fam Pract. 1995;40:270–279.
128. Chang JP, Su KP, Mondelli V, et al. High-dose eicosapentaenoic acid (EPA) improves attention and vigilance in children and adolescents with attention deficit hyperactivity
) and low endogenous EPA levels. Transl Psychiatry. 2019;9:303.
129. Black KE, Witard OC, Baker D, et al. Adding omega-3 fatty acids to a protein-based supplement during pre-season training results in reduced muscle soreness and the better maintenance of explosive power in professional Rugby Union players. Eur J Sport Sci. 2018;18:1357–1367.
130. Kim J, Lee J. A review of nutritional intervention on delayed onset muscle soreness. Part I. J Exerc Rehabil. 2014;10:349–356.
131. Lewis EJ, Radonic PW, Wolever TM, Wells GD. 21 days of mammalian omega-3 fatty acid supplementation improves aspects of neuromuscular function and performance in male athletes
compared to olive oil placebo. J Int Soc Sports Nutr. 2015;12:28.
132. Franke AG, Gränsmark P, Agricola A, et al. Methylphenidate, modafinil, and caffeine for cognitive enhancement in chess: a double-blind, randomised controlled trial. Eur Neuropsychopharmacol. 2017;27:248–260.
133. Davis E, Loiacono R, Summers RJ. The rush to adrenaline: drugs in sport acting on the beta-adrenergic system. Br J Pharmacol. 2008;154:584–597.
134. Faraone SV, Glatt SJ. Effects of extended-release guanfacine on ADHD
symptoms and sedation-related adverse events in children with ADHD
. J Atten Disord. 2010;13:532–538.
135. Onus K, Cannon J, Liberts L, Marino FE. Acute effects of a dopamine/norepinephrine reuptake inhibitor on neuromuscular performance following self-paced exercise in cool and hot environments. J Therm Biol. 2016;60:60–69.
136. Roelands B, Watson P, Cordery P, et al. A dopamine/noradrenaline reuptake inhibitor improves performance in the heat, but only at the maximum therapeutic dose. Scand J Med Sci Sports. 2012;22:e93–e98.
137. Daviss WB, Patel NC, Robb AS, et al. Clonidine for attention-deficit/hyperactivity
disorder: II. ECG changes and adverse events analysis. J Am Acad Child Adolesc Psychiatry. 2008;47:189–198.
138. Cook NE, Karr JE, Iverson GL. Children with ADHD
have a greater lifetime history of concussion: results from the ABCD study. J Neurotrauma. 2022;39:86–92.
139. Iverson GL, Kelshaw PM, Cook NE, Caswell SV. Middle school children with attention-deficit/hyperactivity
disorder have a greater concussion history. Clin J Sport Med. 2021;31:438–441.
140. Iverson GL, Atkins JE, Zafonte R, Berkner PD. Concussion history in adolescent athletes
with attention-deficit hyperactivity
disorder. J Neurotrauma. 2016;33:2077–2080.
141. Iverson GL, Wojtowicz M, Brooks BL, et al. High school athletes
and learning difficulties have a greater lifetime concussion history. J Atten Disord. 2020;24:1095–1101.
142. Gunn BS, McAllister TW, McCrea MA, et al. Neurodevelopmental disorders and risk of concussion: findings from the national collegiate athletic association department of defense grand alliance concussion assessment, research, and education (NCAA-DOD CARE) consortium (2014-2017). J Neurotrauma. 2022;39:379–389.
143. Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51:941–948.
144. Aggarwal SS, Ott SD, Padhye NS, Schulz PE. Sex, race, ADHD
, and prior concussions as predictors of concussion recovery in adolescents. Brain Inj. 2020;34:809–817.
145. Martin AK, Petersen AJ, Sesma HW, et al. Learning and attention deficit
disorders as risk factors for prolonged concussion recovery in children and adolescents. J Int Neuropsychol Soc. 2022;28:109–122.
146. Broglio SP, McAllister T, Katz BP, et al. The natural history of sport-related concussion in collegiate athletes
: findings from the NCAA-DoD CARE consortium. Sports Med. 2022;52:403–415.
147. Lambert M, Marshall C, Holahan MR. Predictors of concussion outcomes in individuals with ADHD
. J Head Trauma Rehabil. 2021;36:120–127.
148. Houck Z, Asken B, Bauer R, Clugston J. Predictors of post-concussion symptom severity in a university-based concussion clinic. Brain Inj. 2019;33:480–489.
149. Iaccarino MA, Fitzgerald M, Pulli A, et al. Sport concussion and attention deficit hyperactivity
disorder in student athletes
: a cohort study. Neurol Clin Pract. 2018;8:403–411.
150. Cook NE, Sapigao RG, Silverberg ND, et al. Attention-deficit/hyperactivity
disorder mimics the post-concussion syndrome in adolescents. Front Pediatr. 2020;8:2.
151. Brett BL, Kuhn AW, Yengo-Kahn AM, et al. Risk factors associated with sustaining a sport-related concussion: an initial synthesis study of 12,320 student-athletes
. Arch Clin Neuropsychol. 2018;33:984–992.
152. Nelson LD, Guskiewicz KM, Marshall SW, et al. Multiple self-reported concussions are more prevalent in athletes
and learning disability. Clin J Sport Med. 2016;26:120–127.
153. Vaughan CG, Gerst EH, Sady MD, et al. The relation between testing environment and baseline performance in child and adolescent concussion assessment. Am J Sports Med. 2014;42:1716–1723.
154. Babicz MA, Woods SP, Cirino P, et al. Vestibular/Ocular motor screening is independently associated with concussion symptom severity in youths. Clin J Sport Med. 2022;32:40–45.
155. Kaye S, Sundman MH, Hall EE, et al. Baseline neurocognitive performance and symptoms in those with attention deficit hyperactivity
disorders and history of concussion with previous loss of consciousness. Front Neurol. 2019;10:396.
156. Brooks BL, Silverberg N, Maxwell B, et al. Investigating effects of sex differences and prior concussions on symptom reporting and cognition among adolescent soccer players. Am J Sports Med. 2018;46:961–968.
157. Elbin RJ, Kontos AP, Kegel N, et al. Individual and combined effects of LD and ADHD
on computerized neurocognitive concussion test performance: evidence for separate norms. Arch Clin Neuropsychol. 2013;28:476–484.
158. Gardner RM, Yengo-Kahn A, Bonfield CM, Solomon GS. Comparison of baseline and post-concussion ImPACT test scores in young athletes
with stimulant-treated and untreated ADHD
. Phys Sportsmed. 2017;45:1–10.
159. Merritt VC, Meyer JE, Cadden MH, et al. Normative data for a comprehensive neuropsychological test battery used in the assessment of sports-related concussion. Arch Clin Neuropsychol. 2017;32:168–183.
160. Ali M, Dreher N, Hannah T, et al. Concussion incidence and recovery among youth athletes
taking stimulant-based therapy. Orthop J Sports Med. 2021;9:23259671211032564.
161. Hawk LW Jr., Fosco WD, Colder CR, et al. How do stimulant treatments for ADHD
work? Evidence for mediation by improved cognition. J Child Psychol Psychiatry. 2018;59:1271–1281.
162. Littleton AC, Schmidt JD, Register-Mihalik JK, et al. Effects of attention deficit hyperactivity
disorder and stimulant medication on concussion symptom reporting and computerized neurocognitive test performance. Arch Clin Neuropsychol. 2015;30:683–693.
163. Manderino LM, Zachman AM, Gunstad J. Novel ImPACT validity indices in collegiate student-athletes
with and without histories of ADHD
or academic difficulties. Clin Neuropsychol. 2019;33:1455–1466.
164. Mautner K, Sussman WI, Axtman M, et al. Relationship of attention deficit hyperactivity
disorder and postconcussion recovery in youth athletes
. Clin J Sport Med. 2015;25:355–360.
165. World Anti-Doping Agency. Checklist for Therapeutic Use Exemption (TUE) Application - Attention Deficit Hyperactivity
). World Anti-Doping Agency; 2021. Available at: https://www.wada-ama.org/en/resources/therapeutic-use-exemption/checklist-therapeutic-use-exemption-tue-application-attention
. Accessed March 2, 2022.
166. World Anti-Doping Agency. The Prohibited List; 2021. Updated. https://www.wada-ama.org/en/prohibited-list
. Accessed November 11, 2021.
167. World Anti-Doping Agency. Therapeutic Use Exemption; 2021. Available at: https://www.wada-ama.org/en/therapeutic-use-exemptions
. Accessed November 11, 2021.
168. National Collegiate Athletic Association. Medical Exceptions Procedures; 2021. Available at: https://www.ncaa.org/sport-science-institute/medical-exceptions-procedures
. Accessed November 11, 2021.
169. National Collegiate Athletic Association. NCAA Medical Exception Documentation Reporting Form to Support the Diagnosis of Attention Deficit Hyperactivity
) and Treatment with Banned Stimulant Medication. National Collegiate Athletic Association; 2021. Available at: https://ncaaorg.s3.amazonaws.com/ssi/substance/2021-22/2021-22SSI_ADHDMedicalExceptionsReportingForm.pdf
. Accessed March 2, 2022.
170. Major League Baseball. Major League Baseball's Joint Drug Prevention and Treatment Program. New York: Major League Baseball; n.d.
171. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69:548–556.