Attention-Deficit Hyperactivity Disorder in Athletes


Attention-Deficit Hyperactivity Disorder (ADHD) is a chronic, biologically based condition. Its primary features are inattention, overactivity and impulsivity. ADHD causes problems for individuals when they are involved in structured situations or those that demand sustained attention such as school or sports activities. ADHD is a relatively widespread condition most prominent in adolescents with onset typically in childhood and with effects often extending into adulthood. Though the effects in the classroom have been extensively studied, little study has been done in the sports setting. As a consequence, little is known of its incidence and effects on athletic performance, nor have specialized treatment approaches been developed for sport training and competition. Therefore as a research study, we addressed ADHD in a naturally occurring population of interscholastic athletes. A survey with questions about ADHD symptoms, treatments and sport performance was completed by 870 interscholastic athletes in conjunction with a large scale pre-participation sport physical. The median age of the athletes was 15 years (50.2 percent were male and 49.7 percent were female). They resided in a mixed urban and rural community in Virginia and participated in a wide range of typically contested scholastic sports. A diagnosis of ADHD was directly reported by 64 of these athletes or 7.3 percent, which is consistent with conservative estimates of three to six percent in the general population. Of the athletes diagnosed with ADHD by health care professionals, 94 percent take medication. Of those on medication, 25 percent are under the effects of medication during sport participation. This raises concern because the medications typically taken (e.g., Ritalin and other stimulants) are banned by the International Olympic Committee (IOC) and the National Collegiate Athletic Association (NCAA). As a result of the survey/study, three main issues came to the forefront: 1. To what extent, treated or untreated, does ADHD influence sport performance? With proper treatment, ADHD-diagnosed athletes are able to participate effectively in a variety of sports. The study’s results indicate that ADHD adolescents are not self-selecting out of sport. The relatively low self-report of symptoms (indicating that proper treatment manages symptoms) and self-report scale ratings suggest that impact of the disorder on performance is minimal and allows these athletes to actively compete. Anecdotal evidence suggests that, when untreated, ADHD may limit fulfillment of an athlete’s potential. 2. Are ADHD-diagnosed athletes best suited for particular sports? The 18 athletic activities reported by survey participants fell into a bimodal distribution in regard to overall participation (<33 participants, 12 activities; >62 participants, six sports). The percentage of ADHD-diagnosed athletes (in the six larger participation sports) ranged from 4.4 percent for track and field to 17.5 percent for football. 3. What is in the best interest of all in regard to medication use for ADHD? Proper treatment enables ADHD-students to achieve at a level consistent with their underlying academic potential in the classroom. Proper treatment also provides ADHD-diagnosed scholastic athletes with the opportunity to participate in sport at a level commensurate with their ability and training, thereby providing access to sports benefits including fitness, socialization and personal development. Failure of athletes to receive proper treatment is likely to increasingly limit participation as the athlete matures and as the focus of sport shifts from an emphasis on participation to competitive excellence. The most commonly prescribed medications (stimulants) have a high abuse potential as recreational drugs. The stimulants are also considered to be performance enhancing by the NCAA and the IOC and are included in the list of banned substances. Difficult questions follow. Is the classroom performance of competitive athletes inadvertently undermined if they are required to abstain altogether from medically appropriate treatment in order to comply with doping requirements? May athletes use medications for training (and in the classroom), if they abstain from use during competition? Who is to determine when these medications need to be started and stopped in order to avoid use in competition per se and to avoid a positive drug test? Is this approach violating the “spirit of the law” by helping athletes avoid the consequences of a positive test? If stimulant medications are to be selectively available to ADHD athletes, how is this to be determined and monitored, given the relatively subjective nature of symptoms and ease with which they can be fabricated? Sport, Drugs and ADHD Drugs are an integral part of life in America ¯ for better and worse. Medical and recreational, legal and illegal drug use permeates society. For athletes who suffer ADHD, medicines and psychological treatment may bring tremendous benefits. The key issues are how to optimize athletes’ academic and athletic performance while avoiding the potential side effects of medicines and the possible pitfalls of a positive drug test for a banned substance. There are three key dimensions to drug use in sport: recreational, ergogenic (or performance enhancing) and medical. The prevalence of recreational drug use (e.g. alcohol, cocaine) is widely recognized in the media and through research studies. As one might expect, the pattern of recreational drug use seen in sport reflects those of society at large. Ergogenic drug use, which is unique to the world of sport, is prompted by the desire to excel. There are a wide variety of substances that have been identified which provide athletes with a competitive edge, and while some substances are illegal, others have established medical uses (such as anabolic steroids, used in the treatment of certain hormonal dysfunctions). In order to “level the playing field” and safeguard athletes’ health, a variety of medicines have been banned for use by competitive athletes. This has created a thorny situation because it is difficult to draw clear lines between ergogenic and medical uses. Medical use of stimulants in the treatment of ADHD reflects on all three aspects of recreational, ergogenic and medical drug use. A great deal of information regarding medical and psychological treatments of ADHD is available, but most is focused on school and home behavior. Very little information is available about enhancing athletic performance. Traits and Treatment of ADHD ADHD is typically identified in children between the ages of five and 11 years. The condition is more common in boys than girls and is conservatively estimated to occur in two to three percent of the school population. Symptoms persist into adolescence in as many as 80 percent of the children diagnosed with over 30 percent still suffering significant symptoms into adulthood. There are three different subtypes of ADHD including the Primarily Inattentive Type, the Primarily Hyperactive/Impulsive Type, and the Combined Type. Symptoms in the Inattentive Type include failure to give close attention to details with frequent careless mistakes, problems following through on instructions and susceptibility to distraction by extraneous events. Examples of overactive and impulsive behaviors include excessive talking, difficulty taking turns and being overenergized. Medication is the most commonly used treatment for ADHD. The two main types are stimulants and anti-depressants. The majority of those treated with stimulants show improvement. Anti-depressant medication has been shown to be of use only in limited cases, probably because of impact on co-existing psychological conditions such as anxiety and depression. For some time, many health professionals believed that stimulants only worked on individuals with ADHD; however, research data suggests that stimulant medication not only affects those with ADHD, but would likely improve most individuals’ ability to focus. The primary goal for using stimulant medication is to boost performance in the classroom environment by improving concentration and enhancing learning. It is for those same reasons that stimulants are beneficial to athletes when training and competing in sport; therefore, these are ergogenic drugs. This is the basis for including stimulants on the list of banned substances for competitive athletes. However, the situation is unique in that legitimate medical benefits are intertwined with ergogenic benefits. The best results in the treatment of ADHD are found with a combination of medication and psychological treatment. Even though medication usually brings about improvements in a variety of areas, the inclusion of psychological treatment significantly adds to gain in academic and social functioning. While medication may help the individual pay attention and control behavior, it does not teach self-control strategies or promote a positive attitude toward learning. A thorough psychological evaluation is useful in that it may uncover alternate reasons for the behaviors that have caused others to suspect ADHD. Learning disabilities, other psychological disorders and the presence of significant psychosocial stressors are examples of conditions that may alter behavior and cause the individual to be falsely diagnosed and treated for ADHD. The most simple and straightforward psychological intervention is education. One of the initial and most important steps when treating ADHD is to have parents, teachers and other significant persons, including the coach, educated, as there are many misconceptions about the disorder. Parents, counselors or health professionals should discuss the nature of ADHD with the diagnosed individual. It is noteworthy that for all the behavioral changes typically brought about by medicines, there are proven psychological techniques which can have the same effect. There are a wide variety of mental training methods designed to increase concentration, manage emotional intensity, improve decision making under stress and optimize performance under adverse conditions. These methods have been proven effective in the performance environment; however, there is virtually no research on the use of these interventions with the ADHD athlete. Optimizing Sport Performance The recommendations that follow combine general knowledge about ADHD, principles of sport psychology and grow from the fundamental assumption that the primary reason for sport participation is to enhance health and develop life skills. 1. Be sure that the coach is informed about ADHD and its treatment. The discerning eye of a well-trained coach is able to pick up subtle variations in performance; therefore, the coach is an important source of information in helping identify the right amount and combination of medication and psychological treatment. 2. Athletes must take medication exactly as prescribed. They should report any problems with medication to their medical doctor immediately. Also their medical doctor should know that they are a competitive athletes, and if it is appropriate provide the U.S. Anti-Doping Agency with information on prescribed medication. 3. Athletes should undergo psychological evaluation and consultation to optimize performance academically and athletically. This need not be ongoing, but should be sufficient to establish a set of strategies and methods for managing the challenges provided by ADHD. These principles and practices should be clearly understood and implemented routinely. 4. Athletes must identify their commitment level to sport in terms of time and level of training intensity. Based on the level of commitment, athletes must establish realistic competitive goals with a balance between the limits of ADHD and the inherent ability of committed athletes to overcome obstacles to success. 5. Assuming a moderate to strong commitment to sport, athletes should seek a sport psychology consultation with a goal of developing a mental training program to build skills in concentration, manage emotional intensity, decision making and preparation for competition. A sport psychologist can also help set realistic competitive goals. 6. In conjunction with their medical doctor, athletes with a strong commitment and high competitive goals must establish a practical strategy for when to use and not to use prescribed medicines. It should be done in a way that avoids putting him/her at risk for a positive drug test. The athlete needs to acclimate to competing relatively medication free. This requires participating in some training with the athlete abstaining from medications for a time sufficient to allow a clean drug test. He/she should also undertake a specialized sport psychology mental training program with a goal of transferring the psychological state facilitated by medication use to situations where medicines are not used. Conclusion ADHD presets a formidable challenge to competitive athletes, but with ingenuity and precise training performance skills can be developed and refined in a way that contributes to competitive excellence and excellence in living. By Drs. John Heil, David Hartman, Greg Robinson, and Lisa Teegarden Lewis-Gale Clinic, Department of Psychological Medicine Editor’s Note: This article is based on a technical report prepared under the direction of the United States Fencing Association Sport Medicine & Science Committee. It has been adapted for athletes of all sports. The authors wish to thank the Lewis-Gale Foundation for their support of the research noted in this report. To view the full report, visit the U.S. Fencing Association’s web site at www.usfencing.org.

online pharmacy map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html map.html