Applied Evidence

Addressing the unique issues of student athletes with ADHD

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The student athlete participating in events sanctioned by WADA or IOC must be aware that use of psychostimulant medication is prohibited in competition. The only FDA-approved ADHD medication allowed for use in competition by all governing bodies is atomoxetine. Encourage student athletes to check governing organization Web sites to review current restrictions on use of psychostimulants in competition. Psychostimulants are banned in all professional sports, though many allow a TUE (except the National Hockey League). The process of obtaining a TUE is rigorous, and Major League Baseball requires a second opinion.2,9,16,33

Specific health concerns for student athletes treated for ADHD

Sudden cardiac death (SCD) is rare among athletes and most often associated with congenital abnormalities affecting heart structure and electrical conduction.16 Although there have been reports of cardiac arrhythmias related to the use of psychostimulants, no compelling clinical evidence has demonstrated a higher incidence of SCD in pediatric ADHD patients treated with psychostimulants compared with the general population.34

The American Academy of Pediatrics, in a policy statement subsequently endorsed by the American Medical Society for Sports Medicine, does not support the routine use of electrocardiograms before initiating psychostimulant therapy.16,34

In light of the cardiovascular side effects of psychostimulants, it remains prudent to obtain a thorough cardiovascular history before starting medication. If no preexisting cardiac disease is identified, psychostimulants can be safely prescribed for the ADHD athlete without worry about the risk of SCD.34

Psychostimulants can confer risk of heat injury

Endurance ADHD athletes on psychostimulants may be at increased risk of heat injury when exercising in warm conditions. Evidence suggests that psychostimulants can increase core temperature while also masking signs and symptoms of fatigue, allowing for a longer duration of exercise and delayed time to exhaustion in the presence of elevated core temperature and heart rate.35

In one placebo-controlled trial of exercise under warm conditions, core temperature measurements in athletes taking 20 mg of methylphenidate often exceeded 104˚F, and the athletes experienced no change in their perception of effort or thermal stress.36 These factors raise concerns for increased risk of heat-related injury in the ADHD athlete taking psychostimulant medication. Close monitoring is required.

Anticipating and addressing the misuse of psychostimulants

Psychostimulant medication, with its direct actions and adverse effects, has great potential for misuse, and the past 10 years have seen a surge in nonprescription stimulant use among adolescents and young adults.26 The reason most commonly given for using a stimulant is to enhance academic performance through improved alertness and sharpened focus.

Adderall is the psychostimulant most in demand as a “study drug.” Among college students, evidence suggests the individual most likely to misuse Adderall is white, male, affiliated with a formal fraternity, and more likely to use other illicit substances.26 Adding to the perpetuation of this phenomenon is that it is relatively stigma-free: Public opinion does not consistently condemn the use of Adderall for academic means, effectively legitimizing nonprescription use.

Very few universities have an academic policy associating nonprescription use of psychostimulants with cheating. The result is an unprecedented demand for psychostimulant medications,37 which are increasingly obtained through diversion by profiteering peers or from clinicians under false pretenses.26

To help curb the problem of misuse, consider stigmatizing such behavior and stress that, in addition to significant health risks associated with inappropriate use, the vast majority of evidence shows no cognitive enhancement with stimulants when compared with placebo in healthy individuals. Given that psychostimulant misuse is more common with an immediate-release formulation, one means of prevention is to restrict legitimate prescriptions to long-acting formulation as much as possible.38-40

Your role as the primary care provider

An optimal treatment plan for the ADHD athlete, especially one using a psychostimulant medication, should always be individualized. Many factors come into play: the nature of impairing symptoms, presence of comorbidities, and prior response to medication.

How the psychostimulant is taken also can vary depending on an athlete’s preference and the nature of the sport. For example, some athletes will take the medication only for academic purposes (studying, testing). Other athletes feel their sport performance improves while on psychostimulants (eg, a baseball catcher who requires game-long concentration), while yet others prefer not to take it during an event so they can remain unfocused, move randomly, and maintain spontaneity (as with a basketball point guard).

If psychostimulants are to be used while playing, it is wise not to initiate therapy during a high-stress event, such as a championship game. In addition, it is important to know when to withhold medication, as in the case of an endurance athlete competing in hot weather.

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