I had the honor of being interviewed by journalist Anna Medaris from Health & Lifestyle about ADHD/ADD in Athletes and wanted to share!
What is ADHD/ADD?
From a neurological perspective, ADHD is a complex condition that is believed to result from a combination of factors including brain functioning, genetics, and environmental influences. Individuals with ADHD are hypothesized to have decreased size and functioning of the prefrontal cortex and limbic system, as well as reduced release of dopamine and norepinephrine in the prefrontal cortex.
In addition to these biological factors, environmental variables such as multigenerational family trauma, disruptive social conditions, and a society filled with distractions and stress may contribute to the manifestation of ADHD symptoms.
The prefrontal cortex is responsible for regulating attention, emotion, and behavior in all individuals. Within this region, the cortico-limbic structures including the amygdala, nucleus accumbens, and hippocampus play a crucial role in processing complex audio-visual stimuli, as well as regulating motivation and emotions. In individuals with ADHD, it is believed that the prefrontal cortex exhibits weaker function and structure, leading to dysregulation of attention, behavior, and emotion. Proper functioning of the prefrontal cortex relies on the availability of norepinephrine and dopamine, which has implications for the use of medications in ADHD treatment.
The default mode network (DMN) within the brain's medial frontoparietal network is another important component. It consists of the medial prefrontal cortex and other structures such as the posterior cingulate cortex, precuneus, and angular gyrus. The DMN is active when we are awake but not engaged with our immediate surroundings, such as during daydreaming or mind-wandering, social thinking, introspection, or planning for the future. Optimal functioning of the prefrontal cortex allows us to exercise good judgment, gain insight, and make sound executive decisions, enabling effective planning and organization while inhibiting responses to distractions. The delicate nature of the prefrontal cortex makes it vulnerable to genetic and environmental stress, requiring a precise balance for optimal functioning.
How does ADHD potentially benefit athletes?
From a perspective of how ADHD may potentially benefit athletes, it is important to understand that ADHD symptoms, including inattention, hyperactivity, and selective attention, can be seen as problematic traits. However, it is crucial to note that these symptoms exist on a continuum and are not exclusive to individuals with ADHD. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) categorizes ADHD into different types, including inattentive, hyperactive, impulsive, combined, and unspecified.
While traditional educational structures and societal expectations may not suit individuals with ADHD, competitive sports can often provide a more stimulating and goal-oriented environment that attracts individuals with ADHD.
One potential benefit that individuals with ADHD may experience is periods of hyperfocus. Although limited research exists on this phenomenon and its relationship to ADHD, it is believed to contribute to enhanced performance in sports. The ability to hyperfocus may be misconstrued as perfectionism in athletes.
Creativity, exceptional energy, spontaneity, and courage are also commonly observed traits among individuals with ADHD. These traits have their advantages in athletic pursuits as they contribute to problem-solving, communication skills, and a sense of humor. Furthermore, athletes with ADHD often exhibit heightened levels of self-awareness, which can lead to improved teamwork and leadership abilities.
Inattentiveness, often associated with ADHD, is rarely absolute, and individuals with ADHD can display hyperattentive focus. This nuanced attention to detail may be overlooked when diagnosing ADHD, as patients can demonstrate impressive attention under certain circumstances.
Athletes with ADHD may also possess a keen sense of observation, multitasking abilities, adaptability to chaotic situations, non-linear thinking, and adventurous spirits. These characteristics can be valuable in the sporting arena.
Impulsiveness is another trait associated with ADHD, manifesting as excessive risk-taking, interrupting others, or speaking before thinking. While this impulsiveness can present challenges, it can also add excitement and unpredictability to sporting events.
Psychological resilience, the ability to cope mentally and emotionally with crises or stressful experiences, is often seen in athletes with sustainable success. This resilience, combined with perseverant qualities, plays a vital role in competitive sports.
It is important to acknowledge that the impact of ADHD on athletes can vary greatly, and individual experiences may differ. Therefore, a tailored approach that addresses the specific strengths and challenges presented by ADHD is crucial for maximizing the potential benefits in athletic performance.
In what ways can ADHD hinder athletic performance?
Some of the symptoms or behaviors that may be seen in someone with ADHD can impair all individuals including athletes:
1. Difficulty focusing or paying attention to tasks or instructions
2. Impulsivity, such as acting without thinking
3. Restlessness or constant need for movement
4. Short attention span or difficulty staying on task
5. Forgetfulness or easily losing items
6. Poor organization skills or difficulty managing time
7. Difficulty following through on tasks or completing projects
8. Difficulty with impulse control or poor decision-making
9. Emotional reactivity or mood swings
10. Difficulty with self-regulation or managing emotions
11. Chronic procrastination or task avoidance
12. Low self-esteem or feelings of inadequacy
13. Tendency towards addictive behaviors or risk-taking
14. Tendency to be easily overwhelmed or stressed
15. Difficulty with long-term planning or goal setting.
Individuals with untreated ADHD may encounter challenges that hinder their athletic performance. Psychological issues like depression, anxiety, and emotional difficulties linked to ADHD can impact an athlete's ability to perform optimally. Additionally, athletes with ADHD may struggle with internal discipline, motivation, and require external structure and discipline to stay focused. Sports, with their variety, interest, and excitement, can provide a beneficial outlet for individuals with ADHD. However, if the athlete's interest in the sport wanes, it can result in increased distractions and inattentiveness. This is particularly observed in cases of sport specialization in young athletes.
Success in athletics relies on factors such as performance conditioning, attitude, and a growth mindset. Individuals with ADHD may experience negative experiences, leading to emotional reactivity and indecisiveness. Dwelling on mistakes can have a detrimental impact on an athlete's mental state. Engaging in sports and exercise can assist in managing ADHD symptoms, including enhancing focus, emotional regulation, and behaviors associated with ADHD. Additionally, sports and exercise can help athletes with ADHD manage restlessness and excess energy. However, when athletes with ADHD face injuries or prolonged periods away from sport, it can exacerbate ADHD symptoms.
How has your field's understanding of ADHD changed over the course of your career? What about the public discourse around it?
A few years ago, I had the opportunity to deliver a lecture at the American Medical Society of Sports Medicine, focusing on the misconceptions surrounding the use of stimulant medication in athletes with ADHD. Specifically, I addressed the notions of performance enhancement, weight loss, and academic advantage associated with stimulant use.
It was quite enlightening to examine the literature and evidence supporting the belief that stimulant medications have the potential to enhance athletic performance. However, I found that many of the studies were outdated, with small sample sizes, and utilized variables that were not applicable in real-life athletic settings.
One common concern is that stimulant use may lead to weight loss due to appetite suppression, thereby posing a risk of eating disorders or providing an advantage in certain sports such as wrestling or sailing. However, the evidence supporting these claims is weak as the research fails to assess body composition, leptin levels, or directly examine the athletic population. Any weight loss observed is often minimal and temporary.
In terms of academic performance, it is important to consider the analogy of providing glasses to a student who needs them to see the board. Just like glasses eliminate a visual disadvantage, medication can help individuals with ADHD achieve a baseline level of functioning similar to their peers. It is unjust to label this as an advantage when we already categorize ADHD as a disorder, dysfunction, or illness.
The use of prescribed stimulant medications among different sporting organizations needs to be reevaluated. Many organizations currently ban stimulants, even when used for diagnosed ADHD. These rules and regulations contribute to the stigma surrounding the diagnosis and treatment of ADHD.
The concern surrounding the potential cardiac risks associated with stimulant medications has long been debated within the sports and exercise medicine community. However, the majority of our recommendations are based on case reports and retrospective cohort studies, rather than rigorous randomized control trials. There is no evidence suggesting that stimulant medications are harmful. My greater concern lies with the irresponsible use of energy drinks, rather than prescribed stimulants. It is important to conduct cardiac screening, including additional testing for signs, symptoms, or positive family history, prior to initiating stimulant medication. However, the belief that stimulants pose a danger to the cardiovascular system in otherwise healthy athletes is unfounded.
What else is misunderstood about ADD?
It is important to acknowledge that ADHD is a complex condition that can be approached in multiple ways, including reversing or preventing its effects, or embracing it as part of one's identity. However, there are several misconceptions surrounding the treatment of ADHD and ADD that need to be addressed.
One key misconception is that individuals with ADHD must be treated. As a clinician, I believe in treating people, not just diagnoses. If someone with ADHD has a positive sense of self and is content with their life, there may be no need for intervention. Treatment for any condition should always be a personal choice based on individual circumstances.
Another misconception is that medication is the only way to treat ADHD. While medications can be beneficial, there are various other treatment modalities that can be equally or even more effective. Personalized and individualized care plans should be developed to address the specific needs of each person with ADHD.
Additionally, it is crucial to recognize that ADHD symptoms can manifest differently in individuals of different genders. The research on the topic of ADHD in female athletes is lacking, and it is essential to explore factors such as pregnancy, hormonal changes, body image, maturity, and societal expectations to better understand the unique challenges faced by women with ADHD.
Moreover, the current diagnostic manual for mental health conditions, the DSM-V, focuses primarily on symptom-based criteria and lacks consideration for genetic, environmental, and anatomical factors. As clinicians, we need to take into account various aspects of an individual's life, such as lifestyle, self-esteem, social relationships, psychological security, genetics, and other medical conditions, when addressing ADHD in athletes. Our approach should aim to support athletes in developing a holistic sense of self.
Unfortunately, limited data is available on how factors such as income, race, and culture influence the diagnosis and treatment of ADHD in adults. This research gap highlights the need to explore and understand these factors to ensure equitable access to appropriate care for individuals from diverse backgrounds.
Do you have any examples you can share from your practice of athletes (recreational or pro) who've sort of figured out how to use the condition to their advantage? Or, really any stories that come to mind related to this topic?
We are now recognizing that individuals with ADHD often turn to nicotine because they seek the stimulant effects it provides. It is important to note that untreated ADHD can lead to various negative outcomes, including depression, anxiety, low self-confidence, and impaired personal and professional relationships. In fact, research shows that young people with ADHD are 2-3 times more likely to smoke or vape nicotine products, possibly as a means of self-medication. Therefore, it is essential to inquire about an athlete's use of these products when discussing ADHD treatment.
I have had the opportunity to work with an athlete who struggled with tobacco and other illegal substance use as a way to cope with anxiety related to academics. By addressing and treating his ADHD, we were able to help him find healthier ways of managing his symptoms. Additionally, I have had the privilege of caring for a college football player who failed to perform academically and lost his athletic scholarship. Initially, he was mistakenly diagnosed with depression and prescribed an antidepressant. However, upon further evaluation, it became evident that his underlying condition was actually ADHD. The athlete had excelled athletically in high school and had not been held accountable for his academic performance. Upon starting college, where academic performance was crucial, he lacked a diagnosis and the necessary tools to function effectively in that environment.
By implementing lifestyle modifications and prescribing appropriate medications to treat his ADHD, this athlete has thrived and is now playing professionally in the NFL. This case highlights the importance of accurate diagnosis and targeted treatment for athletes with ADHD, as it can make a significant difference in their overall success and well-being in both their academic and athletic endeavors.
How can ADHD treatment (both pharmacological and otherwise) affect performance, for better and worse? Do some athletes worry that, in treating ADHD, they'll lose their edge?
I do observe that athletes may have concerns about treating their ADHD. The stigma associated with treatment can be a significant worry for some athletes. It can be challenging to navigate the perception of having an unfair advantage or needing accommodations, especially in competitive sports environments. Some clinicians may also have reservations about prescribing stimulant medications for athletes, as they may not fully understand the necessary documentation and protocols required by certain sporting organizations during competition. Additionally, finding the right medication and managing potential side effects can be a complex process for athletes, which can sometimes lead to discouragement or discontinuation of treatment.
While non-stimulant medications are available for ADHD treatment, stimulant medications generally tend to be more effective in reducing core symptoms and have been associated with greater positive outcomes in social and academic areas. However, stimulants can also have an impact on various aspects of an athlete's performance. They can affect energy levels, heat tolerance, appetite, and thirst perception, among other things. Some athletes may report feelings of anxiety or emotional blunting while on stimulant medications.
Understanding the mechanism of action behind stimulant medications for ADHD is important. These medications work by decreasing the activity of compounds such as dopamine, norepinephrine, and serotonin to a lesser extent. Stimulant medications, which are synthetic psychoactive sympathomimetic compounds, share similarities with other substances like caffeine, phentermine, nicotine, and some newer products called nootropics.
There are various types and formulations of stimulant medications available, and new options continue to emerge. For instance, instant-release forms of stimulants have a more rapid onset of action but do not have a lasting effect. This type of medication may be suitable for athletes who need to take it for academic purposes and want to avoid its impact on athletic performance. It is important for clinicians and athletes to be aware of the available options so that the most appropriate treatment can be provided.
Aside from pharmacological approaches, there are other non-pharmacological strategies for managing ADHD, such as psychotherapy, life coaching, and school accommodations. One particularly interesting treatment modality is Neurofeedback, which is based on the concept of neuroplasticity - the idea that the brain can change through frequent and intense practice. Neurofeedback can be used for a range of conditions, including ADHD, OCD, PTSD, sleep disorders, and cognitive enhancement. I have witnessed athletes achieve significant success with this treatment approach, as it allows them to retain their desired ADHD characteristics while minimizing undesirable symptoms.
Overall, treating ADHD in athletes requires careful consideration of the individual's needs, the specific demands of their sport, and any relevant regulations or policies. Working closely with healthcare professionals and incorporating a multimodal approach can lead to effective management of ADHD symptoms while maintaining optimal athletic performance.
Thank you, Anna for the opportunity to discuss such an important topic.
Anna Medaris I Health & Lifestyle Journalist
VP Communications, The Deadline Club
Writing Coach, The New York Writing Room