Applied Evidence

Addressing the unique issues of student athletes with ADHD

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The differential diagnosis for symptoms of inattention and hyperactivity is large (TABLE 1).1,3,4,6 Once underlying medical conditions have been ruled out, screen the patient for mental disorders, including depression and mood disorders, anxiety, and conduct disorders, before concluding that symptoms are likely due to ADHD. When compared with mood disorders, a patient with ADHD will have a persistent course of symptoms rather than periods of recurring and remitting symptoms.2 ADHD is a chronic condition that raises special health care concerns for children and adolescents.12 As many as two-thirds of children with ADHD have at least one coexisting neuropsychiatric condition, and symptoms may overlap, making for a significant diagnostic and management challenge.9 Difficult cases may necessitate consulting a specialist (psychiatrist, neurologist, or neuropsychologist) for guidance. Additionally, in ADHD youth the overall risk of developing a substance use disorder is twice that of children who do not have ADHD.2,15

Treatment: More than medication

Effective treatment for ADHD improves quality of life, decreases the rate of substance abuse, reduces errors when driving vehicles, and decreases the prevalence of comorbid psychological disorders.16,17 Pharmacologic and nonpharmacologic options are available. With athletes, it’s important to be aware of and consider alternatives to medication, particularly given the rules restricting the use of stimulant medication by the NCAA, International Olympic Committee (IOC), and the World Anti-Doping Agency (WADA). The IOC and WADA prohibit any use of stimulant medications, and the NCAA requires a therapeutic-use exemption (TUE) for athletes who take psychostimulant medications (detailed below).3,16

Nonpharmacologic treatment

Published guidelines on managing ADHD show greater agreement on pharmacologic treatment than on psychosocial interventions, based on strength of evidence.18 One evidence-based psychosocial intervention that has shown benefit is behavior therapy, which includes a broad set of specific interventions that modify physical and social environments to change behavior.19 Behavioral training, which primary care providers can introduce to parents, teachers, and coaches, involves the simple principles of reinforcing desired behavior through reward and ignoring undesired behavior to reduce or eliminate it. Consistent application of rewards or unresponsiveness helps patients increase attention to instructions, comply with rules, improve productivity, and decrease disruptive behavior.20

Accurate diagnosis is needed to distinguish a legitimate need for treatment from an unwarranted request for a stimulant.The athlete with ADHD will benefit from a structured environment and, depending on age and level of maturity, can be educated by coaches on self-management strategies such as time management, effective planning and organization, and avoidance of distractions.20 Exercise may help relieve subjective symptoms of ADHD and comorbid mood disorders, but evidence is insufficient to determine its direct impact on ADHD.

Pharmacologic treatment

Of the many available medications used to treat ADHD (TABLE 2),9,12,16,18,20,21 psychostimulants are most effective for reducing core symptoms of the disorder.22 It is estimated that 56% of patients with ADHD receive drug therapy, and most of these drugs are psychostimulants.16 These agents increase dopamine and norepinephrine concentrations in the brainstem, midbrain, and frontal cortex, which likely is responsible for increasing attention span and concentration.23 As judged by increased attention or decreased hyperactivity in a recent cohort-based study, the positive response rate to psychostimulants was 73.1%.24

Atomoxetine, a selective norepinephrine reuptake inhibitor, is the primary US Food and Drug Administration (FDA)-approved nonstimulant medication for the treatment of ADHD. In double-blind randomized trials, atomoxetine was roughly equivalent to psychostimulants in reducing target symptoms.21,25 Typically more expensive than psychostimulants, atomoxetine is an acceptable alternative and the more appropriate agent for the ADHD patient with a history of illicit substance abuse or the athlete whose sport bans the use of stimulant medications.

Medication adverse effects. Adverse effects common to psychostimulants are generally mild and include decreased appetite and sleep disturbances. Less common are nervousness, irritability, headache, and increased heart rate and blood pressure (BP).22 Overdose can result in drug-induced psychosis or cardiac arrest.26 Most of these effects are reversible or preventable through dose reduction, increasing the dosing interval, or changing time of dosing during the day. Linear growth rate deceleration in both height and weight may occur in children and adolescents, but this effect is thought to be small and reversible upon discontinuation of medication.27,28

Atomoxetine carries a black-box warning regarding suicidality in children and adolescents during the first month of treatment.Contraindications to using psychostimulant medications include symptomatic cardiovascular disease, structural heart disease, uncontrolled hypertension, hyperthyroidism, glaucoma, stimulant hypersensitivity, psychosis, and a history of drug dependence.29 Psychostimulants are Schedule II drugs, which means they pose a high potential for abuse and risk for development of physical dependence. The nonstimulant medications listed in TABLE 2 are not Schedule II drugs and, though not as efficacious, generally are safer and lack the adverse effects typically seen with psychostimulants. Atomoxetine, however, carries a black-box warning regarding the risk of suicidality in children and adolescents during the first month of treatment, and patients should be counseled accordingly. Long-term effects of ADHD medications, either adverse or positive, remain unknown; few studies have been done over a period longer than 24 months.25

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