Attention-deficit/hyperactivity disorder is one of the best researched disorders in medicine. The symptom cluster that defines this disorder was first identified in children, and subsequently in adolescents and adults.
Attention-deficit/hyperactivity disorder (ADHD) is currently diagnosed using criteria established by the American Psychiatric Association (APA) and delineated in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision.1 The diagnostic criteria have changed over time, yet the basic tenets of the diagnosis (attentional difficulties, poor impulse control, and overly active behavior that is not easily inhibited) have remained relatively unchanged.
Clinical practices in sports psychiatry have evolved to treat athletes who have this psychiatric disorder. This article identifies three distinct developmental phases for the athlete with ADHD: the child athlete; the adolescent or near-elite athlete; and the adult or elite athlete. Specific ADHD-related challenges and treatment strategies are discussed for each phase, including the evidence of sport and exercise as treatment for ADHD symptoms.
The Child Athlete
A child’s exercise and sporting experience may begin as unstructured games and challenges with peers in the neighborhood or at school. If the child has fun, plays with friends, and feels supported and competent, he or she likely will continue in the sporting activity. On the other hand, if a child feels belittled, criticized, or confused about his or her role in a particular sporting activity, he or she is unlikely to continue in that sport.2
Just as in parenting and teaching, successfully coaching a child with ADHD symptoms may require understanding of the disorder and possibly a different coaching strategy.3 ADHD-affected athletes are more easily distracted and may miss instructions from his or her coach, particularly if the coach speaks for long periods of time or does not have an engaging style or personality.
Impulsivity and Cognitive Impairment in Sports
In addition, the ADHD-affected child athlete will tend to be more impulsive and lack behavioral inhibition. They may have flares of temper that result in fouls or disqualification from play and bring on the wrath of negative, punitive, or critical coaches, as well as parents and spectators. Coaches who provide immediate positive feedback and set developmentally attainable goals help all child athletes, particularly the ADHD-affected child athlete.3
Children with ADHD often have specific cognitive difficulties that impair their functioning in both school and sport. Commonly, these children have a deficit in working memory.4 They struggle to hold a thought in memory while proceeding to the next thought; hence, they seem to forget what they were told and may seem oppositional. Rehearsing skills repetitively helps the child to develop motor memory and behavioral habits so that they do not need to rely as much on working memory.
Highly structured practices and games help the child by adding a predictable routine, decreasing the number of coaching instructions to manage the practice. Approximately half of all ADHD-affected child athletes will have a concurrent learning disorder — usually a language-based learning disorder that impairs a child’s ability to interpret and understand verbal commands quickly or accurately.4
The coach who can explain techniques through multiple sensory modalities will be most effective. Children with ADHD often are trial-and-experience learners in that they try every possible strategy until they find a behavioral strategy that works. Often this leads to many mistakes that try the patience of their adult coaches who wonder why these children “always learn the hard way.” Combining verbal, visual, kinesthetic, and experiential teaching is probably most effective for all athletes, but particularly helpful for those athletes with ADHD and learning disorders.
Other common cognitive deficits associated with ADHD include response inhibition, aversion to delay, difficulty modulating behavior and response to a reward and punishment cue, response inconsistency, and overall slow processing speed.4
Importance of Activity and Environment
One challenge that parents often report is their difficulty in finding a positive athletic experience for their ADHD-affected child. Commonly, parents may choose to enroll their children in athletic activities similar to those the parents enjoyed as children. Alternatively, they may choose activities in which the child’s friends or classmates participate.
There is little scientific guidance to direct parents in choosing activities for their children. One study found that the children with ADHD who participated in three or four sporting activities a year displayed fewer symptoms of anxiety and depression than those who participated in fewer than three sports.5
One unpublished survey of experienced child psychiatrists found that sports emphasizing large muscle groups, such as swimming and running, were most highly recommended for the AD-HD-affected athlete while high-skill sport positions (baseball catcher, hockey goalie, and soccer goalie) were viewed as the least-appropriate activities.6
It may not really matter which sport a child plays if the child experiences success and enjoys physical activity and a sense of mastery in the sport.
Just as in school where the teacher’s skill and style may dramatically affect the ADHD-affected child’s learning experience, the same is true with the youth coach either for an individual sport or a team sport. The coach who helps the child or team to work for a specific attainable goal may be ideal for the AD-HD-affected athlete.3
A child’s environment potentially can affect ADHD symptoms as well. One small, single-blind, controlled trial found that children diagnosed with ADHD performed significantly better on tests of attention after a 20-minute walk in a park, whereas there was no improvement after 20-minute walks in a neighborhood or downtown area.7 If experiencing a natural environment actually decreases ADHD symptoms, then outdoor sports such as mountain biking, skiing, trail running, and cycling in a natural setting might be good choices for children with ADHD.
Active participation in a sporting activity may be more important for children with ADHD than non–ADHD-affected children. Kim and colleagues8 found that children with ADHD who were not taking stimulant medication demonstrated increased risk for obesity for boys (24.9% vs. 21.6%) and for girls (21.9% vs. 16%). Their study noted that those children with ADHD receiving medication treatment had a higher prevalence rate for depression than those with ADHD that did not take the medication (boys 29.5% vs. 26.3%; girls 30.9% vs. 23.6%).8
This study seemed to challenge common beliefs that children with ADHD are always active and constantly burning off excess calories. It seems that in reality, children with ADHD may have more risk for obesity than non-ADHD children for many reasons, one of which could be lack of participation in sport. Hence, efforts to accommodate to children with ADHD in positive youth sporting experiences can decrease that risk.
Exercise and Brain Development
Exercise is important for brain development and can help ameliorate ADHD symptoms.8 One recent study demonstrated that daily exercise in rats with ADHD had the same effect as methylphenidate in decreasing their hyperactivity and improving spontaneous learning.8 The investigators examined brains of ADHD and non-ADHD rats and found that levels of tyrosine hydroxylase (TH) in the substantia negra, and brain-derived neurotrophic factor (BDNF) in the hippocampus, were reduced in the ADHD rats. However, when ADHD rats were either given methylphenidate or exercise, the TH and BDNF levels increased to levels of the non-ADHD rats.9
Three international groups have assessed the impact that exercise can have on the symptoms of children with ADHD. The first study, from Brazil, found that after intensive exercise, performance significantly improved the ADHD-affected child’s response time, impulse control, and vigilance measures, regardless of whether or not the child was taking methylphenidate.10
The second study, from Taiwan, studied the effect of acute aerobic exercise on the executive functioning of children with ADHD. Researchers found that the nonexercise control group demonstrated no change in functioning between the pre- and post-experience measures, whereas the exercise group demonstrated significant improvement in decreasing impulsive errors on neuropsychological tests immediately following exercise.11
The third study, performed in South Korea, studied whether using sport as exercise therapy could improve the attention span, cognitive capacity, and “sociality” in children with ADHD. They found the sports/exercise group improved in neuropsychological measures and parent report of ADHD symptoms, as well as social skills; the performance by the control group was not significantly changed on any of these measures.12
The evidence that physical activity has beneficial effects on cognition was recently reviewed by Gapin and colleagues;13 the authors concluded that the limited scientific literature generally supports the thought that physical activity decreases ADHD symptoms.13
Treatment of ADHD requires education, behavioral therapy, school accommodation and, frequently, pharmacologic treatment.14 There are several well-accepted treatment guidelines for ADHD for physicians and parents. Psychopharmacological treatment for moderate to severe ADHD is essential. Discussion of pharmacological treatment for ADHD is beyond the scope of this article but can be found elsewhere.6,15
The Adolescent Athlete
The gifted adolescent athlete may be pushed onto more competitive teams. For those in individual sports, success leads to opportunity to perform on a state/national or even international level. Although this may be seen as a positive experience, it can also be very expensive and disruptive for the adolescent’s family and social life.
Unlike child athletes, adolescent athletes competing on the national or international level may be subject to anti-doping rules and regulations, which are of particular concern to ADHD-affected athletes treated with psychostimulants, since all of these medications are listed as prohibited substances by the World Anti-Doping Agency.
Sports psychiatrists must be keenly aware of anti-doping rules because of the potential risks of pharmacologic treatment, as well as the risks of not using medications in the treatment regimen.6 Adolescent athletes often experience challenges in managing optimal nutrition and sleep patterns.
Use of Psychostimulants
Adding psychostimulants may negatively affect nutrition and sleep. Stimulants can lead to over-focus and lack of spontaneity, which may impair performance in some sports positions (eg, a basketball point guard, or soccer striker).16 On the other hand, stimulants may improve the ADHD-affected athletes focus and attention to coaching instructions during practice and competitions. Adolescent athletes also may need medication for successful academic performances, even if they prefer not to use medication during sport.
ADHD-affected athletes treated with stimulants should be monitored for any serious medical complications. Recently, there has been a concern over whether electrocardiogram (ECG) screenings are necessary. The consensus is that there is significant need to identify and manage any underlying cardiovascular pathology, particularly structural cardiac defects, and evaluate carefully.17 Onset of possible cardiac events such as syncopal episodes should be evaluated completely. Irregular or increased heart rate or blood pressure should also be monitored.17
Several studies have suggested that stimulants may diminish the perception of fatigue and thermal stress in an athlete; hence, putting that athlete at risk of a heat-related illness during exercise.18 The intensely training adolescent and adult athletes, especially if treated with stimulants, must take care to hydrate adequately and monitor for signs of heat stress.
The Adult or Elite Athlete
Athletes training at the highest level may be more susceptible to injury or over-training and may be much more vulnerable to stress and depression.19 Even mild depression and anxiety in a professional or elite athlete can significantly impair performance.
In the author’s experience, ADHD-affected adult athletes may enjoy success in their chosen sport but may have difficulty functioning in other aspects of their life. They may require others to organize them, accommodate to them, or manage their schedule and finances. They may be impulsive in their communications with the media and with coaches or other athletes, causing team conflicts and risking public ostracism or loss of income from marketing opportunities (Conant-Norville, personal observation).
Post-Sports Career Adaptation
While the ADHD-affected elite athlete may have overcome ADHD symptoms during sport, the athletic career will end, usually earlier than the athlete wishes. The successful ADHD-affected athlete is able to develop a support team and utilize the team’s support. This athlete is able to understand and prepare for life after sport and to build skills that fit the athlete’s natural skill set outside of athletics.
The author has observed that often ADHD-affected adults are excellent in intense, one-on-one situations. Sales positions, broadcast media roles, or positions in which they focus intensively on a project or activity can be successful options; ADHD-affected adults do not do as well in executive, administrative, or meeting-oriented positions. Many professional sports leagues have developed post-retirement support groups for retiring athletes.
Stimulant and nonstimulant medications that have proven effective for children and adolescents have also proven effective for the adult with ADHD.20 Monitoring a pulse and blood pressure is recommended for adult athletes treated with stimulants. More high-quality studies are needed to assess the response of adult athletes with ADHD to stimulant medications.21
Case: An Adhd-Affected Elite Cyclist
The patient reports that as early as he can remember, he was an active, energetic child. He states, “I was the kind of kid who was dancing on tables yelling and waving. In school, I had a hard time sitting still in class and being quiet. I knew I had a good heart, but I was running everywhere and just couldn’t stop.”
He grew up an only child in Los Angeles, where both of his parents were in the entertainment industry. His parents divorced amiably when he was age 6 years. Both parents remained involved in his life and observed that he was hyperactive, always getting into trouble at school.
In third grade, a “great teacher” suggested the patient be evaluated for ADHD because of his difficulty participating in class. His parents sought medical consultation and the patient was diagnosed with ADHD, combined type, and Tourette’s disorder. Of note, the patient’s mother was subsequently diagnosed with ADHD.
The patient reports that as a child, he was never that interested in sports. His parents encouraged him to participate in community-based organized sports activities and he remembers playing soccer when he was 5 years of age. He believed he was “fairly good,” but would forget which goal to go to and always was teased for scoring in the wrong goal.
He went to sports camps to try many different sports, but he did not like it. He states he tried baseball, but it “just wasn’t right” for him. He never was too interested in basketball and felt he could not compete with others who were “in love” with the sport. He tried karate, but became bored and felt too enclosed within four white walls. He had a skate-board, but he never really was interested, and he actually gave it away to someone. He never tried swimming or football. He was never interested in running.
“I was on five medicines during the next 3 years,” the patient reports, although he states he did not want to take pills. This was during grades 3 through 5. He reports that he was treated initially with risperidone up to 0.5 mg daily for his tics, but he became more agitated. He then was treated with clonazepam 0.5 mg daily, which seemed to help some of the tics, but he became “tired and cranky.”
Subsequently, he was treated with amantadine 100 mg twice daily, but he did not like the “rubbery pills.” When it was given to him as a liquid, he began having racing, disorganized thoughts. He was subsequently started on various doses of the clonidine transdermal patch (ranging from ¼ of a TTS-1 patch to 2 and ½ TTS-1 patches). This led to excessive sedation during his third-grade year.
In fifth grade, he remembers being given some sort of paste that he would rub on the inside of his wrist. This was helpful, although neither he nor his mother remembers exactly what was in the medication. In sixth grade, the patient went to his mother’s psychiatrist who started him on an amphetamine salts extended-release capsule, 20 mg each morning. While there was some improvement with his attention span, the patient was frustrated with school and had “given up on medication.”
Age 13 was a turning point for the patient. His mother arranged for him to have an Individual Education Plan because he was getting Ds and Fs in school. With some extended time for testing and assignments, he began to experience some success despite his decision to stop all ADHD medications. He had some additional support in a school resource room and felt that he had someone to advocate for him in school. His classes were selected for him based on which teachers would be the “best match.”
As the patient was beginning to experience some academic improvement, his father simultaneously encouraged the patient to try cycling; the father had cycled previously as a teenager and wanted to get back into the sport as an adult. The patient states, “The minute I walked into the Encino Velodrome I fell in love with the sport.” He reports that he loved the oval track with three lines on it and that track cycling was simple, since it was forward motion only.
The races were relatively short and intense, which accommodated his attention span. He began to race and experience success on the cycling track. He enjoyed racing as a 13-year-old novice, and by the end of eighth grade, at age 14, he was California state champion in his age group. Eventually, he took second place in a national competition for the 13- to 14-year-old age group.
Prior to this, the patient had difficulty with social interactions because of his impulsivity and awkwardness. He had always enjoyed being around adults but had struggled with peer friendships. With his sports success, however, he experienced improvement in social contacts as well.
The patient notes that when he was always identified as a child with ADHD, he felt helpless. He felt like a “guinea pig” and was discouraged by the various medications and the lack of support in school. Now, he enjoyed the exhilaration and success of the racetrack, and the complexity of the technology involved.
At age 15 years, he was traveling with a national cycling team. The patient realized that being busy was a benefit to him. He had a very full schedule, traveling and training for cycling, and then doing his regular schoolwork. He states, “I loved being busy. I found myself married to my work.” He states, “If I wasn’t as busy, I didn’t function as well.”
As a sophomore, he became the producer and director for the high school weekly news program. He states he would put in long days at school and would train 6 days a week for 1 to 6 hours per day. Cycling was year-round. He was road racing in the spring and summer, indoor track racing in the fall and winter, and also in the winter he would do preparation in the gym with weight-training, plyometrics, and core strengthening.
As an adolescent, the patient enjoyed making his own choices. He did not feel like others were controlling him or criticizing him when he made a mistake. He notes that his time management skills improved markedly because of his busy schedule and his high motivation to experience success in many realms.
He traveled internationally as a cyclist, which required him to think on his feet and problem-solve. He also realized that it was important to help his teachers to understand what he was doing and to involve them in his life and success: “People need to feel involved in order to help your program...”
His parents required that he get good grades if he wanted to bike-race, which further fueled his desire to take high school seriously. The common interest in cycling helped build a relationship with his father, who helped him with training and was there at competitions to cheer him on. The patient realized his travel for cycling made him “mature more quickly.”
After high school, the patient tried community college for one semester but found it was not a motivating educational environment. At age 19 years, he states it was at that point that he chose to be a professional cyclist when he realized he was an adult elite athlete. The patient continues to race for the US national cycling team and is involved in sports marketing.
The patient reports that he has met many cyclists who have been diagnosed with ADHD, and yet this is not a big discussion topic for professional cyclists. “In retrospect, cycling and especially track racing, were perfect for a racer with ADHD. It’s a short race. It’s exciting. It’s fun. It starts quickly and is over quickly.”
ADHD is a commonly identified psychiatric disorder that affects children, adolescents, and adults, and tends to be continuous throughout the life cycle. This disorder is present in athletes at every level of competition. The child athlete with ADHD seems to respond best to opportunities for activity that are focused on enjoyment, success, and positive regard or reward. Education and pharmacologic treatment can be helpful to improve the child’s sporting experience. Children with ADHD may also benefit directly from exercise and sport in decreasing their ADHD symptoms.
Adolescent athletes may take undue risks and may show intense engagement with sport above all else. Coaches and parents tread a fine line in being supportive and directive while not becoming overly controlling or expecting secondary gain from the adolescent athlete’s success.
The adult or elite athlete has all of the challenges of adulthood usually squeezed into a fairly short timeframe. The challenge for the adult athlete is to realize that their window of opportunity for elite sporting performance is limited. They must intensely focus on their sport while preparing for life after elite sport. The informed sports medicine physician and sports psychiatrist can be very helpful in assisting the ADHD-affected athlete at all developmental levels in customizing an effective treatment plan that assists the athlete experience success in all aspects of the athlete’s life.
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