Attention-deficit/hyperactivity disorder (ADHD) is a common developmental disorder which can cause issues in multiple settings, including the football field. This FastFact highlights a narrative review, published in the BJSM, which provides an overview of the available literature relating to the diagnosis, prevalence, effect on performance and management of ADHD in elite sport and provides useful clinical recommendations1.
There are very few studies regarding the prevalence of ADHD in elite athletes. It has been suggested that ADHD may be more common in elite athletes, as children with ADHD may be drawn to sport due to the positive reinforcing and ‘attentional activating’ effects of physical activity. Based on the available evidence, and the data from non-athletic cohorts, it appears that the incidence among football players may be as high as 5-10%. This would mean that on average at least one player in an average squad would have this condition.
ADHD may have both performance limiting and performance enhancing effects. The symptoms of ‘lack of focus and concentration’, oppositional behaviour, argumentative attitude, frustration, lowered self-esteem and labile mood found in ADHD may impair athletic performance. In addition there is also a relatively high incidence of associated mood disorders which may also hinder performance. In contrast some of the symptoms associated with ADHD may enhance athletic performance. Performance in sports, like football, that involve quick movements and reactive decision-making may be enhanced. The ability to ‘hyperfocus’ (highly focus) on enjoyable activities without being distracted by regular life activities may also improve performance by ‘blocking out’ distractions during practice and competition.
The key considerations when managing a player with ADHD are to reduce symptoms and improve function, manage any comorbid conditions and to ensure the safety and tolerability of any medication that is used. In general terms the treatments used to manage ADHD can be divided into two domains: psychosocial interventions (which include psycho-therapy) and medications. The authors of this review recommend that psychosocial interventions should be the foundation of management of ADHD and that medication is adjunct to this. Stimulants (methylphenidate and amphetamine compounds) are generally considered to be the primary pharmacologic treatments for ADHD. A key consideration when treating athletes with these medications is that a therapeutic use exemption (TUE) is generally needed prior to starting treatment. Where possible long-acting formulations should be considered first as they are more convenient and less likely to be misused. Non-stimulant medication also has a role – but may not be tolerated by athletes due to side-effects. In all cases a multidisciplinary team approach to treatment is recommended.
A final consideration is that playing football (and physical activity in general) may in itself be a good treatment and improve the symptoms associated with ADHD. Sports participation can act as an outlet for intense emotions and stress, and therefore may help reduce ADHD symptoms. Current data suggests that children with ADHD who participated in three or more sports activities were reported to have fewer anxiety and depressive symptoms (compared with those who participated fewer sports activities).
1Hyun Han D, McDuff D, Thompson D et al. Attention-deficit/hyperactivity disorder in elite athletes: a narrative review. Br J Sports Med 2019;53:741–745. doi:10.1136/bjsports-2019-100713