Sports and Attention Deficit Disorder

 Jennifer Morris MD MBA

American Board of Psychiatry and Neurology

American Board of Preventative Medicine-Addiction

American Board of Obesity Medicine

 ISSP--Certificate of Additional Training in Sports Medicine

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(Simone Biles, Gymnastics)

Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition involving difficulties sustaining or adjusting attention, increased distractibility, high energy levels and challenges managing impulses. 

ADD/ADHD (used interchangeably in this post) affects 11.3 percent of US children, including 15% of boys and 8% of girls. Black children and White children are more often diagnosed with ADD (12% each.) (1) It is suspected that the rates of ADHD are higher in the athlete population than in the general population, though this is controversial  (2, 3).  Making the diagnosis can be challenging, especially in athletics, due to the limited presence of mental health providers in sports, other conditions that resemble ADD, and the stigma of discussing mental health (2.) 

(Zach Wilson, Football)

Sports participation can be uniquely beneficial for children with ADD, as sports offer an outlet for high energy. Athletic participation impacts motivation, stimulation and reward, structure, routine and social interaction. Physical activity increases norepinephrine and dopamine (two neurochemicals adversely impacted by ADD), reduces stress, decreases negative affect, reduces behavioral problems, improves impulse control, and improves inattentiveness, (3, 4). Organized athletic participation  adds supervision and guidance; sustained involvement in structured physical activity benefits motor, cognitive, social, and behavioral functioning. By virtue of the above, sport involvement can have a positive impact on school performance (3). 

(Michael Phelps, Swimming)

Additionally, ADD can be beneficial in some aspects of sports. Specifically, beneficial traits include:

• high energy
• hyper-focusing (an under-described trait of many individuals with ADD)
• creativity
• intuitiveness
• resourcefulness
• tenacity
• hardworking-ness
• a never-say-die approach
• warm-heartedness
• a trusting-forgiving attitude
• sensitivity
• the ability to take risks
• flexibility
• good sense of humor

 These all may aid in the handling the required training load (3,4). 

Unfortunately, ADD may also cause some challenges in athletic endeavors. Signs and symptoms a kid might be struggling with ADD in sports include:

• often late or needs help managing their time. needs frequent task reminders as well as day-to-day schedule
• short attention span-frequent errors in play. spacing out during conversations (or even games) and not paying attention
• difficulty waiting their turn during drills, leading to more frequent instruction or conflict with peers/staff
• may be more likely to lose temper or have quick emotional reactions that can lead to more frequent conflict with coaches or referees
• struggles to receive directions, leading to reminders from coaches. athlete may also interrupt coaches when receiving instructions (2)

(Kevin Garnett, Basketball)

There is much debate on what may possibly be the best sports choices for children with ADD (though athletes can succeed in any sport and there is no data to support one sport is better than others for kids with ADD. Some considerations include: 

1) Swimming--Helps to give ADHD children structure, guidance, routine

2) Martial Arts--Teaches respect, discipline

3) Tennis--Provides individualistic competition

4) Gymnastics--Increases focus, overall awareness

5) Wrestling--Discipline, positive emotion channeling

6) Soccer--Camaraderie, outlet for energy

7) Horseback Riding--mirror the horse's behavior changes

8) Track and Cross Country--Discipline, Routine, Pacing, Energy outlet

9) Archery--Discipline, Routine, Intense focus

10) Baseball--Patience, Sportsmanship, Situational Awareness

11) Basketball--Energy outlet, Situational Awareness, Working efficiently as a team

12) Hockey--Continuous activity outlet

(adapted from: 5, 6)

Ultimately, athletes can succeed in any sport; there is no data to support one sport choice is better than others for kids with ADD. Note that, as motivation is often a core symptom of ADD, and ADD tends to cause more problems in situations where kids find an activity boring or too difficult, the best sports are the ones they enjoy and for which they have a bit of natural talent (7.)

(Molly Seidel, Long Distance Running)

risks: can inc risk of injury, higher levels of aggression and emotional reactivity. 

First line treatment of ADD/ADHD is typically a stimulant medicine, including variations of methylphenidate (Ritalin and its various release formats) and amphetamine salts (including Adderall and its various release formats.)  General challenges with stimulant medicine include the controlled nature of stimulant medicine (with concomitant addiction potential) and cardiovascular side effects including fast heart rate and increased blood pressure. Though the cardiovascular side effects are usually mild and minimal, they can be exacerbated in and by participation in athletic endeavors that also elevated blood pressure and pulse. In addition, other challenges are timing of doses and medication wearing off before competitive play. This is especially true for long-day tournament or competition formats.

Medication timing, such as holding stimulant until after morning cardiovascular training sessions (if necessary) and additional dosing (eg a booster immediate release if the extended release medicine wears off before the end of a long tournament day) may solve some of these concerns.

Nonstimulant medicine is also an option for ADD treatment, and may be appropriate in select situations. Nonstimulant medicine confers the advantage of 24 hour coverage, but in some circumstances may not be as potent as stimulant medicine. 

In addition to medicine strategies, therapy techniques such as cognitive behavioral therapy (CBT) and ADD coaching (for individuals as well as their support systems) are helpful to navigate ADD. 

(Andre Torres, Baseball)

Stimulant medicines are on the World Anti-Doping Agency (WADA) Prohibited List. As inappropriate usage of stimulant medicines can confer an unfair competitive advantage, caution is appropriate. Therapeutic utilization exemptions are conferred in many circumstances if medication is needed to treat a diagnosed condition. The evaluation and diagnosis of ADD/ADHD must be made by a pediatrician, psychiatrist, or other physician who specializes in the treatment of ADD/ ADHD, in accordance with the DSM-5 criteria for ADHD. Additionally, the medical documentation must demonstrate the prohibited medicine is necesary because there are no other reasonable treatment alternatives, and the treatment will only return the athlete to a normal, baseline level of health. 

(Nicola Adams, Boxing)

1. CDC.gov/adhd/data/index.html.  Accessed 7/28/24. 

2. Choulet, Brook. 5 Signs an Athlete May Have ADHD and How to Treat It. https://www.psychologytoday.com/us/blog/sports-and-performance-psychiatry/202311/5-signs-an-athlete-may-have-adhd-and-how-to-treat-it. Posted Nov 21, 2023. Accessed 7/28/24. 

3. Ekman, Elizabeth. Arto Hiltunen, Henrik Gustafsson. Do Athletes Have More of a Cognitive Profile with ADHD Criteria than Non-Athletes. Sports 2021 May, 9(5):61. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8151350/   Published online 2021 May 11. 

Accessed 7/28/24. 

4. Moran A., Toner J., Campbell M. Attention and Concentration. In: Mugford A., Cremades J., editors. Sport, Exercise, and Performance Psychology.  Routledge; London, UK: New York, NY, USA: 2018. pp233-250. 

5. ADDitude Editors. Karate or Kickball? Fencing or Football? The Best Sports for Kids with ADHD. https://www.additudemag.com/slideshows/best-sports-for-kids-with-adhd/ Posted 7/22/22.Accessed 7/28/24. 

6. Henry Ford Health Staff. What Are the Best Sports for Kids with ADHD.  https://www.henryford.com/blog/2017/07/best-sports-kids-adhd. Posted 10 July, 2017. Accessed 7/28/24. 

7. 700 Children's--a blog by pediatric experts. ADHD and Sports: What Parents Need to Know.  https://www.nationwidechildrens.org/family-resources-education/700childrens/2019/08/adhd-and-sports. posted Aug 7, 2019 accessed 7/28/24. 

8. What Do Athletes with ADHD Need to Know about TUEs? https://www.usada.org/spirit-of-sport/education/athletes-adhd-know-abut-tues/. Accessed 7/28/24.