Focus on athletes with ADHD

According to the Centers for Disease Control and Prevention (CDC), the number of children diagnosed with Attention-Deficit/Hyperactivity Disorder  (ADHD) in the United States since the start of the 2000s has increased almost 50%, with some surveys citing the incidence up to 11% in children 4 to 17 years-of-age(1,2). It seems likely, then, that the number of athletes with this disorder has grown too. How this impacts rehabilitation and injury is an area in need of further study. Therefore, a multi-center team recently reviewed the current literature to help identify the prevalence and impact ADHD has on athletes and recommend appropriate interventions.

A diagnosis of ADHD is based on reported symptoms of inattention, hyperactivity, and impulsivity, or a combination of both, that interfere with normal developmental expectations. Other comorbid conditions must be eliminated to arrive at a diagnosis of ADHD, such as depression, anxiety, substance abuse, and concussion. Interestingly the rate of diagnosis for boys compared to girls is 3:1, however, the fastest growing segment of newly diagnosed cases of ADHD is adult women(3).

Theoretically, the prevalence of ADHD among athletes may be higher than that of the community population. In 2018 Major League Baseball in the US reported 8.4% of their players filing for a therapeutic use exemption (TUE) for stimulants with the World Anti-Doping Agency (WADA)(2). This doesn’t take into account those diagnosed and treated with non-stimulants or not treated pharmacologically.

Why ADHD matters in rehab

Children with ADHD often have difficulty succeeding in an academic environment and therefore, are drawn to the sports field where they can excel. Some children may use sports as a way to manage their ADHD symptoms and thus naturally spend more time on the playing field. Individuals with impulsivity and novelty seeking behaviors may be more adept at ‘quick-thinking’ sports such as basketball or hockey. While those with the ability to ‘hyperfocus’ can block out distractions and keep a steady countenance which may help them succeed in sports such as golf and tennis.

It’s important to ask in a history intake questionnaire if an athlete is diagnosed with ADHD. While forms typically request a list of current medications, athletes may be reticent to reveal that they take stimulant medications. In addition, evidence suggests that only 70% of the population with ADHD in the US is treated with medication(4). While treatments have their own considerations (see below), ADHD alone may impact the rehabilitation outcomes of an athlete.

Individuals with ADHD are more likely to have deficits in explicit learning and memory. Explicit learning implies a conscious or deliberate attempt to master a skill, usually in response to specific instructions. Most coaching and training activities rely on explicit learning. For instance, when instructing an athlete post anterior cruciate ligament repair (ACLR) in executing a lunge, a clinician might tell them to keep their knee over their toes and not let it wobble side to side. For someone with ADHD, this type of learning requires intense focus and is quickly forgotten.

However, implicit learning seems to be more reliable and transferrable for those with ADHD(2). During implicit learning, the learner relies on internal and sensory feedback to execute a task, providing self-correction on an almost unconscious level. As Alicia Filley explains in her article on new thinking in the treatment of ACL injuries, providing a target for the knee in the post ACLR lunge improves outcomes, as the athlete is able to focus on internal feedback rather than the patter of verbal instruction.

Implications of pharmacological treatment

The pharmacological treatments for ADHD are divided into stimulants and non-stimulants. Physicians most commonly prescribe stimulants which, though not fully understood, improve attention and focus. The primary downside to stimulant treatment for elite athletes is the need to obtain a TUE from the WADA. Collegiate and competitive club organizations may have their own guidelines.

Secondly, the side effects of stimulants can include palpitations, irritability, and sweating. Often individuals treated with stimulants describe a lack of personality or creativity and decreased energy or sluggishness. Stimulant medications may decrease an athlete’s ability to tolerate heat, increase their heart rate, and decrease their threshold for cardiac arrhythmias. Therefore, take care when preparing an athlete taking stimulants for return to sport. They may need more frequent breaks or heart rate monitoring if they have been away from endurance activities for a while.

Another side effect of stimulants is loss of appetite. Athletes in weight-dependent sports may abuse this aspect of their treatment and under fuel. Decreased nutrition compromises healing and training as athletes return to sport after injury. Runners, gymnasts, skaters, cyclists, and wrestlers, in particular, are more vulnerable to underfeeding and suffering from relative energy deficiency in sport (RED-S). Alicia Filley’s article on the topic describes what every health professional should know about RED-S and its effects on rehabilitation and performance.

Stimulant use may also affect sleep patterns. Sleep is integral to healing from injury and recovery from intense training. Without proper recovery, the body may fatigue more quickly and be more susceptible to injury.

Clearly, individuals with ADHD benefit from and may excel at sport. Like any other athlete, they may also suffer injuries. Understanding the best approach for teaching these athletes may improve their rehabilitation outcomes. In addition, awareness of the consequences of stimulant treatment may impact the progression of their return to sport protocol.

References

1. www.cdc.gov/ncbddd/adhd/data.html
2. Br. J Sports Med. Epub ahead of print 2019;0:1-5
3. www.additudemag.com/statistics-of-adhd/
4. JAACAP. January 2014;Volume 53(1):14–16