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What do you need to know about ADHD medication and sport?



ADHD medication can impact an athlete physically, emotionally, and psychologically. This can affect both sport performance and mental health. This post will discuss the additional considerations required when working with athletes with ADHD. These considerations are key for a coach (and others in the sporting support network) to understand so that the mental health and performance of athletes with ADHD can be best supported. These key considerations to understand include:

  • ADHD medication and side effects

  • Certain ADHD medications as a prohibited substance in sport

  • Stigma surrounding the use of ADHD medications

  • Increased risk of mental health issues

Before you read this blog, have you read the previous two blog posts in the series on ADHD and athletes? The first blog post explained: what ADHD is, misunderstandings of the condition, and the benefits of sport and exercise for ADHD. The second blog post discussed: the benefits of ADHD in a sporting environment, challenges faced by athletes with ADHD in sport, and offered practical tips and recommendations to support ADHD athletes. You will find it helpful to read these before this blog.


Medication to treat ADHD


Many individuals with ADHD take medication to manage their symptoms. Medications are grouped into: stimulants and non-stimulants.


The approach to medication is very individualized and depends upon several factors including: symptoms experienced, age and weight. Therefore, medication doses and type will likely vary over an individual's lifetime which requires consistent monitoring by a practitioner, who will work closely with the individual with ADHD.


Medication can help with different symptoms including: improved attention and focus, and helping to control impulsive behaviour. However, side effects can include:

  • Reduced appetite (can result in weight loss)

  • Sleeping difficulties / insomnia

  • Stomach aches

  • Mood swings

  • Headaches

  • Dizziness

This table shows some of the medications taken for ADHD, and additional side effects. See references below for additional information.


These are not the only side effects and if you or an athlete have any concerns you should seek professional medical advice.

Type of medication

Different forms and brand names

Additional side effects that may be experienced

Methylphenidate (stimulant)

Immediate release/action: Ritalin


Sustained release/action: Ritalin SR


Extended release/action: Concerta / Ritalin LA

Increased blood pressure & heart rate

Lisdexamfetamine (stimulant)

Elvanse


Vyvanse

Nausea and vomiting


Aggression

Atomoxetine (non-stimulant)

Strattera

Increased blood pressure & heart rate


Nausea and vomiting


Serious side effects: suicidal thoughts & liver damage

Guanfacine (non-stimulant)

Intuniv


Tenex

Tiredness or fatigue


Dry mouth

There are many different medications that athletes with ADHD may be taking, and medication can change over time. Also, not all athletes with ADHD will take medication. It is important for coaches and others in the sporting support network to keep talking to their athletes about what medications they’re taking to understand how it might be affecting them physically as well as psychologically/emotionally. This will allow athletes with ADHD to be best supported.


One important consideration as a coach is to understand that different stimulant medications last different amounts of time. Depending on if a stimulant is immediate, short or long-acting they can last anywhere between 3-16 hours. Coaches should be aware of this, particularly at evening training sessions where medication may be wearing off. It is then even more important to implement the strategies discussed in blog post 2.


Those in the sporting support network of an ADHD athlete do not require full understanding of ADHD medication. However, an awareness of what an athlete may be experiencing is important, so that they can be best supported.



ADHD medication as a prohibited substance


Elite athletes must be aware that some ADHD medications are prohibited in sport, and require a therapeutic use exemption (TUE) because they are suggested to benefit performance through improved attention and concentration. The stimulants: methylphenidate and amphetamine derivatives including lisdexamfetamine are currently prohibited by the World Antidoping Agency (WADA). For guidance refer to this website: https://www.globaldro.com/Home.


Those in the sporting support network should assist the athlete in applying for a TUE if necessary, and also be aware of any negativity or stigma that the athlete may experience surrounding their use of ADHD medication in sport.


Stigma surrounding the use of ADHD medication


There are cases of stimulant medications being used by athletes without ADHD as a form of “brain doping” to improve performance. This is because stimulants increase focus, concentration and reaction time.


For athletes with ADHD “brain doping” can contribute to stigma surrounding the use of this medication for their condition. For example, Russian hackers revealed Simon Biles’ ADHD medication records which showed that she took the stimulant medication Ritalin (see: BBC article). Following this, there was discussion since this medication is banned in Japan, but athletes were exempt and allowed to take it during Tokyo Olympics 2020 (see: article).


The use of ADHD medication as a performance enhancing substance in athletes without ADHD, and the events associated with Simone Biles add to the stigma and misunderstanding around athletes with ADHD taking stimulant medication. This is on top of the stigma that already exists surrounding ADHD medication in the general population with ADHD. This includes misconceptions associated with addiction, dependency on medication and making individuals feel different.



Additional needs of ADHD athletes


Mental health issues


Individuals with ADHD are at a greater risk of mental health difficulties and illness including: anxiety, depression, sleep disorders, OCD and eating disorders. They also face a greater risk of substance abuse and addiction including drugs and alcohol. In sport, this could also manifest as excessive exercise or an exercise addiction.


Risks of mental health issues can be heightened by issues previously discussed in blog post 1, and stigma surrounding the condition including the use of medication.


It is essential for coaches, and others in the sporting support network to be aware of changes in behaviour and mood in athletes with ADHD because of their increased risk of mental health issues. Therefore, actions and interventions to support athlete wellbeing should take a proactive approach.




Conclusion and further resources


ADHD medication can impact an athlete physically, emotionally and psychologically. This can affect the mental health and performance of athletes with ADHD. These are key considerations for a coach (and others in the sporting support network) to understand to support the athlete to reach their performance goals and ensure optimal wellbeing.


There are many different types of ADHD medication with the two main categories being stimulants and non-stimulants. Many ADHD medications come with unpleasant side effects including dizziness, reduced appetite, mood swings, and sleeping difficulties.


To ensure that athletes with ADHD are best supported, it is important that coaches offer an open environment to communicate with the athlete about how it might be affecting them physically and mentally. Stimulant medications require a therapeutic use exemption and so athletes with ADHD should be supported to apply for this, if it is needed.


On top of the misconceptions and misunderstandings surrounding ADHD that were discussed in blog 1, there are also misunderstandings surrounding the use of stimulant medication in sport. Stimulant medications are being used by athletes without ADHD as a form of “brain doping” to improve performance. However, this creates a stigma around medication use in athletes with ADHD, as shown by the recent articles on Simone Biles.


Individuals with ADHD are already at a greater risk of mental health issues. Stigma and misunderstandings surrounding the condition can exacerbate this risk. Therefore, it is key for coaches, and others in the sporting support network to be aware of changes in behaviour and mood in athletes with ADHD, so that interventions to support athlete wellbeing can happen early on.


If you found this helpful, please be sure to share with coaches, athletes and other athlete support staff. If you want to find out more, check out the resources below which were used to inform this blog post. Feel free to get in touch with Kirsty via Twitter (@kirstykrb) if you have any questions or would like to discuss it further.




Bio: This post was written by Kirsty Brown, an MSc by Research student in the School of Sport, Exercise and Rehabilitation Sciences at the University of Birmingham. Her research interests include mental health stigma, student athlete mental health, and mental health help-seeking in athletes.



Here are some resources used in this blog post if you want to read more:


BBC News. (2016, September 14). Simone Biles “not ashamed” and “not afraid” as Russian hackers reveal ADHD treatment - BBC News. https://www.bbc.co.uk/news/newsbeat-37361676


British National Formulary. (2021). Guanfacine. NICE. https://bnf.nice.org.uk/drug/guanfacine.html


Cash, M. (2021, July 30). Simone Biles’ ADHD meds banned in Japan, but Tokyo 2020 exemption allowed them. Insider. https://www.insider.com/simone-biles-adhd-meds-banned-japan-impacting-performance-2021-7


Crawford, A. (2016, September 21). Bravo, Simone Biles, for taking a stand against ADHD stigma. ESPN. https://www.espn.com/espnw/voices/story/_/id/17602540/bravo-simone-biles-taking-stand-adhd-stigma


McGrath, M. (2014, January 15). Study shows “brain doping” is common in amateur sport - BBC News. BBC News. https://www.bbc.co.uk/news/science-environment-25727050


NHS. (2018). Treatment: Attention deficit hyperactivity disorder (ADHD). https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/treatment/


Partridge, B. (2013, April 24). Athletes need performance-enhancing drugs to treat illness. The Conversation. https://theconversation.com/athletes-need-performance-enhancing-drugs-to-treat-illness-13718


Rodden, J. (2021, August 19). Short-acting stimulants vs. long-acting stimulants: Comparing ADHD medications and durations. ADDITUDE: Inside the ADHD Mind. https://www.additudemag.com/short-acting-stimulants-long-acting-stimulants/


Stewart, M., & Dajani, S. (n.d.). Lisdexamfetamine for ADHD. 2019. Retrieved October 25, 2021, from https://patient.info/medicine/lisdexamfetamine-for-adhd-elvanse


Totally ADD. (n.d.). ADHD and addictive behaviour. Retrieved October 25, 2021, from https://totallyadd.com/adhd-video/addictive-behavior/


USADA. (2018, July 2). What do Athletes with ADHD need to know about TUEs. https://www.usada.org/spirit-of-sport/education/athletes-adhd-know-about-tues/


World Anti-Doping Agency (WADA). (2017). TUE physician guidelines: Attention deficient hyperactivity disorder (ADHD) in children and adults. https://www.wada-ama.org/sites/default/files/resources/files/tuec_adhd_version6.0.pdf


Journal Articles:


Berger, N. A., Müller, A., Brähler, E., Philipsen, A., & de Zwaan, M. (2014). Association of symptoms of attention-deficit/hyperactivity disorder with symptoms of excessive exercising in an adult general population sample. BMC Psychiatry, 14(1), 1–9. https://doi.org/10.1186/S12888-014-0250-7


Dietz, P., Ulrich, R., Dalaker, R., et al. (2013) Associations between physical and cognitive doping – A cross-sectional study in 2.997 triathletes. PLOS ONE, 8 (11): e78702. doi:10.1371/JOURNAL.PONE.0078702.


GGA, P., JR, M., MJ, T., WC, T., & M, C. (2019). Considerations in the care of athletes with attention deficit hyperactivity disorder. Clinical Journal of Sports Medicine, 29(3), 245–256. https://doi.org/10.1097/JSM.0000000000000508


Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of adults with attention-deficit/hyperactivity disorder. Neuropsychiatric Disease and Treatment, 4(2), 389. https://doi.org/10.2147/NDT.S6985


Majori, S., Gazzani, D., Pilati, S., et al. (2017) Brain doping: stimulants use and misuse among a sample of Italian college students. Journal of Preventive Medicine and Hygiene, 58 (2): E130–E140. doi:10.15167/2421-4248/jpmh2017.58.2.630.


Mueller, A. K., Fuermaier, A. B. M., Koerts, J., & Tucha, L. (2012). Stigma in attention deficit hyperactivity disorder. Attention Deficit and Hyperactivity Disorders, 4(3), 101. https://doi.org/10.1007/S12402-012-0085-3



Images:

1) Reshot by @msyrko

2) Reshot by @pamelasphotopoetry

3) Reshot by @charlinjanene

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