Lesson 2: Introduction to ADHD

In this lesson we will cover all the key things you need to know about ADHD so you feel better able to recognise the traits in an athlete and understand the specific issues so that as a coach you are able to consider how you might work with ADHD athletes really effectively.

What is ADHD

ADHD is considered to be present when someone has persistent patterns of inattention, hyperactivity or impulsivity (or a combination) which causes significant dysfunction and challenges in their lives. ADHD has previously been characterised by attention deficit.

Increasingly evidence suggests that there may also be a reward and motivation deficit too so maybe it would be better to consider ADHD as a condition that causes some deficits in some cognitive functions.

An even better definition might be ‘a condition that causes some differences in cognitive functions; the ways we monitor and regulate our goal-directed behaviours, can impact our behaviours, emotions, performance, relationships and motivation, allowing us to work things out to rationalise, find solutions, contextualise, problem solve, learn and feel safe.’

Traits and Symptoms of ADHD

12 symptoms you might notice in an athlete or participant with ADHD might be:

• Inattention – difficulties in focusing and getting distracted easily. They might struggle to listen to a coach giving instructions.
• Impulsivity in behaviour and emotions – Quick to anger, easily excitable, get frustrated and find it hard to self soothe. In sport they might lose their temper with coaches or referees.
• Slow information processing speed – the athlete or participant may take longer than others to take in information, interpret the meaning of that information and respond to it. This means they might be slower to start a drill or respond to a mid-training or competition instruction.
• Risk taking – doing activities that have the potential to be dangerous or harmful and not considering the consequences. They might ignore some of the rules in place.
• Difficulties in switching task – any transitions feel hard as the brain pushes back against switching from one activity to another.
• Impaired response inhibition – Unable to hold back from doing inappropriate actions or saying inappropriate things, even when doing so might harm your goals or plans. This might see an athlete or participant tell a referee or umpire what they really think of their decision making!
• Hyperactivity – Unusually or abnormally active. Unable to sit or stand still. You may notice them constantly fiddling, moving about or dancing when you want them to listen.
• Poor working memory – unable to hold information for short periods of time so forget what you are supposed to be focusing on. This might mean they switch off and don’t keep on practicing what they have been asked.
• Planning difficulties – struggling to anticipate and consider the future and see time in a binary way (so there is only now or ‘the future’) making organisation poor and showing up late to practice or meetings.
• Lack of cognitive flexibility – difficulty adapting and changing behaviour to match the situation or environment they are in. They might carry on with a competitive approach when everyone else has switched to being friendly.
• Deficits in motor abilities – delayed motor coordination, sluggish gross motor movements and poor graphomotor (writing) ability.
• A love of novelty – in sport this might look like constantly looking for the ‘next big shiny thing’ and trying new exciting sounding treatments or equipment that they hope could make all the difference. We sometimes call this Magpie Syndrome.

The three types of ADHD

Combined Type: The most common form of ADHD. If someone is given this diagnosis they most likely have problems with sustaining attention, maintaining persistence, resisting distractions, feeling hyperactive, acting impulsively, struggling to find the right actions, words, thoughts and emotions that are appropriate for the situation and find it hard to stay on target towards longer-term goals and wellbeing plans.

Inattentive Type: If someone is diagnosed with the predominantly ‘Inattentive’ type then they will exhibit the symptoms of inattention; having difficulty in focusing, getting easily distracted, forgetting lots of things and being disorganised. This type used to be known as ADD – dropping the H as there is no hyperactivity showing up.

Hyperactive Type: The ‘Hyperactive-Impulsive’ diagnosis will be given to those who need constant movement. If someone receives this type of diagnosis it is likely to be because they constantly fidget and wriggle around, struggle to stay seated or still and move about excessively. It may seem like they talk non-stop, interrupt lots, blurt out answers and struggle with self-control.

A clinical diagnosis requires…

A medical evaluation with information obtained from the patient (child or adult), parents and other family members or partners, teachers, and work colleagues. ADHD traits must be present in more than one setting (usually home, school or work) but if someone has managed to choose a work or sporting environment that is flexible or even suits their ADHD traits, then they may be masking in that environment or the traits may not cause so many frustrations.

In some sports, the requirements to be allowed to use ADHD stimulant medications are higher than they would be for regular diagnosis and may need more information provided. This information is essential because if the athlete wants to take medication and would be competing in their sport they will need a Therapeutic Use Exemption (a certificate that shows the athlete is taking a medication on the WADA Banned list for a legitimate reason) – you can learn more about this in Lesson X on medication later on in the course.

Prevalence levels

Over the last 20 years there has been a big rise in awareness of the condition.

• A 2015 study suggests 11% of children in the US have ADHD, in general the figure is usually thought to be around 5-8% of under 18s.
• In the UK at the moment there over half a million people on the waiting list for an ADHD assessment.

Is ADHD more common in males or females?

More boys than girls are currently diagnosed but this is thought to be because they will often present differently and that teachers (who generally trigger the assessment process) will be looking for it in boys (who more often externalise their behaviours) and not girls (who more often internalise theirs).

The stereotype of an ADHD child (as a highly excitable, distracted boy) overlooks the specific characteristics that so often show up for women and girls such as anxiety and masking. What we see if that many girls with ADHD are able to function well until they hit puberty where the hormonal changes and the additional organisational requirements of school cause them psychological collapse.

Is it just a childhood condition – can you grow out of ADHD?

Between 65% – 85% of those diagnosed as children will still meet the diagnostic criteria when they become teens but some of the traits change, in particular hyperactivity may become less visible. As these teens become adults the diagnosis would still fit but again externally noticeable elements might change as some learn coping mechanisms and tools to handle the factors that are hindering their abilities to function well.

A meta-analysis (a study which pulls together and examines lots of earlier studies) of ADHD studies which followed those diagnosed into adulthood found that 75% of those diagnosed will still continue to have significant ADHD related impairments as an adult.

Higher rates of ADHD in Sport

Studies suggest the elite athlete population may present with ADHD at greater rates than that seen in the general population and, as a result, it is thought in the US that at least 10% of athletes have ADHD. To start to understand this we can investigate the numbers of athletes who are using TUE (Therapeutic Use Exemptions) for ADHD medication. A study at a US university in 2010 found 7.1% of their elite athletes had a relevant TUE. In the 2018 season the USA Major League Baseball (MLB) reported that 8.4% were granted a TUE.  Considering only around 60% of those with ADHD take medication (some don’t like how it feels and others have medical issues which would be exacerbated by a stimulant) and the clinical standards required to get a TUE within the MLB are much higher than the standards required in the community to get a diagnosis, the actual rates in athletes would then be expected to be much higher.

Why higher rates in athletes?

There are three suggestions as to why there might be higher rates of ADHD in elite level sports:

1. Parents of those with hyperactive ADHD may well encourage their children into lots of sports to ‘tire them out’ and use up excess energy. If they find a sport they love then their ability to hyperfocus can mean they have both the energy required and the intense engagement to work hard, dedicate themselves and improve at that sport, getting them to an elite level and able to do well in it. Additionally, the hyperfocus allows athletes to be highly stimulated and still able to ignore other distractions which in some sports can be really beneficial. Alongside the hyperfocus, the ability to react quickly to changing stimuli can be valuable in many sports.

• Some with ADHD will be drawn to activity to gain positive reinforcement through chasing the Dopamine buzz that comes from doing something well and feeling a sense of achievement, as a way to self-medicate.

• Traits from ADHD can sometimes be helpful in sport, making sport an excellent way for neurodivergent athletes to feel good and thrive. They can channel excess energy to emotionally regulate, use their creativity to see opportunities where others wouldn’t and use their hyperfocus to get exceptionally good at new skills. In a neurotypical world, when you sometimes might feel that you don’t fit in, are constantly told you are not living up to your academic or intellectual potential or reprimanded that ‘if you could only focus you might actually learn something,’ life can feel hard – and sport can feel like your safe place and a place where you want to spend more of your time.

Where ADHD can impact in sport

Models for understanding the development of sport performance tend to focus on five factors: physiology, biomechanics, psychology, tactics and overall wellbeing. ADHD can impact on most of these; biomechanics (those with ADHD reportedly have more accidents due to distraction and motor function issues), tactics (especially when impulsivity is involved or instructions have been missed), wellbeing (particularly around emotions and relationships) and psychology (behaviours and motivation) which when not managed well can diminish potential performance.

Specific issue in sport: Relationships

Studies have found that the inattentive, hyperactive, and impulsive behaviours within ADHD can socially disadvantage children and adults as intrusive interpersonal styles break unwritten codes of social life if they disturb others, interrupt conversations or blurt out inappropriate comments. The higher likelihood of Rejection Sensitive Dysphoria (RSD) where neutral comments or actions are interpreted as critical or attacking and can feel physically painful) can also have an impact.

Specific issue in sport: Training behaviours

The symptoms of ADHD might show up in some behaviours that feel hard to handle when you have a large group of people to manage:

• Hyperactivity, impulsivity and risk-taking may make it difficult to sit still or follow rules that are designed for safety or order.
• Risky behaviour might increase Dopamine levels to soothe an athlete’s brain after a day in school or work fighting to focus but will cause friction with others.
• The athlete might also have low tolerance for frustration so instead of being able to sit with discomfort or unpredictability they will have a temper out-burst or mentally beat themselves up.
• Potential to show up late or to be disorganised.
• An athlete having a lack of concentration, poor attention to detail, slower processing speed, forgetfulness, a brain going off on tangents and emotional dysregulation.

In children these elements might mean constantly fidgeting in coaching sessions, disrupting others trying to focus, shouting at a team-mate or running off the sports pitch without reason.

Adults may interrupt team meetings, seem unable to plan or complete projects, ignore team rules (like not partying ahead of matches or talking to the media) and driving recklessly, putting their own health and club reputation at risk. They might seem like they are not thinking about the consequences of their actions (which is true – they are not because they cannot) and this can cause frustration from coaches and peers.

Specific issue in sport: Self-esteem

The behavioural and relationship aspects and their impact on performance ultimately harms an athlete’s confidence. Studies suggest adults with ADHD may not rise to the level within their occupation that their intelligence might suggest they should, have fewer years of schooling, are more likely to be unemployed, earn less and have lower productivity. The impact of these means that the person with ADHD can get labelled as lazy or disinterested which doesn’t just reduce opportunities for them but also exacerbates the likelihood of a mental health problem like anxiety or depression as self-esteem falls and relationships fade. These can lead the athlete to feel shame and powerlessness – often causing a huge amount of stress.

Specific issue in sport: Stress

Stress is essential for athletes to have a handle on as it has such a strong response on our psychology and physiology. Living with unmanaged or poorly managed ADHD can feel incredibly stressful and mirror burnout. Stress management solutions are then essential. There are a number of approaches that can be used; psychotherapy, psychoeducation, neurofeedback, counselling, behavioural management, family support and exercise.

Is ADHD a superpower for athletes?

If it helps an athlete to think of their ADHD as a superpower and a strength then why not. It doesn’t harm them. However, many say that label frustrates them as it hides the fact they need to work extra hard every day to function at the same level as others can without effort.  It doesn’t mean though that you should discount the traits that they might have that really help them.

Strength	Explanation
Instinctiveness	Their brain can see the solutions – they don’t need to waste time working them out   Coaches who work with ADHD say that they are sometimes blown away by the ability of an athlete with ADHD to see the match or competition in a very different way which can lead to a great ability to problem solve. The athlete may not be able to explain how they did it or ‘show their working’ as we would ask when doing a maths problem but often have a unique but effective way to see problems and resolve them.
Rapid reaction times	Their predisposition to distraction means they can react quickly to changing stimuli which can be valuable in many sports.   With quick movement patterns and reactive decision-making due to impulsivity some athletes with ADHD naturally excel in sports like baseball and basketball. Athletes with ADHD are also thought to excel in using visual feedback which can help them improve some of the required motor skill movements. These fast reaction times are often heralded as a benefit in sport; ‘straight off the blocks’ on the track, ‘jumped on the back of a breakaway’ in cycling or a ‘brilliant defensive action’ on the tennis court. However, we don’t always want great reactions – what we want are speedy responses – and there is a difference. Reacting happens in the moment and is often driven by threat or emotion. It happens without thought. Responding is slower, more thoughtful and often based on an assessment of longer-term consequences so will be slightly slower but effective. Some studies have found there is a speed–accuracy trade-off in children with ADHD so that their reaction time might be super-fast but that may be to the detriment of accuracy.
Patterns of play	There is more of a feel for the game or movement pattern and the athlete has developed implicit memory so their body knows what to do. In fact, instructions are unhelpful and distracting.
Hyper focus	If their sport is their passion they’ll fixate on working on improvements and skills.   Hyperfocus is a state of heightened, intense focus (usually when doing something that you intrinsically enjoy) where you might lose track of time, fail to notice what is going on around you, get totally engrossed in a task, so much so you struggle to stop something to move onto another task, and can get ‘stuck’ fixating on small details. It can be considered both a strength and a weakness. Some definitions of ADHD suggest that there is a not an attention deficit, but instead a maldistribution of attention, highlighting that some things can be given a plethora of attention when considered intrinsically rewarding.   Hyperfocus is helpful for giving an athlete the motivation to work incredibly hard on areas they love and enjoy (like participating in sport) but it can also cause issues if they are so focused on one area that they neglect other needs, even elements like self-care and health. Performance wise, it can also mean you ignore the areas you find boring but are essential for long term viability in your sport so you might work really hard on the pitch or court but ignore the strength and conditioning work in the gym that you need to do to stay injury free. The positives come when your hyperfocus means you are unencumbered by distractions from other hobbies and able to give all your attention to daily sports practices. In competition it means you can focus better on the sporting activity itself (once playing) rather than noticing or become overwhelmed by competition type distractions.
Creativity	The novelty seeking within ADHD means an athlete thinks about how to do things differently, less predictably or by taking more risks.
High energy levels	The hyperactivity symptom is thought to show up in around 70% of children’s cases and to reduce within adult ADHD. The hyperactivity will be seen as being unable to sit still, constant fidgeting, excessive physical movement, excessive talking, not being able to take turns or show patience when needed. The hyperactivity is often cited as the reason there are so many athletes with ADHD. Parents wanting to find a way to tire out their hyperactive children put them into sporting classes and the hyperfocus (next) means they work incredibly hard at the sport, eventually for those with talent and the right body type, becoming elite.   At its base level, having high levels of energy, lots of creativity and thinking imaginatively can be really valuable in sport. However, the impact of hyperactivity in sport actually goes far deeper, when we consider the psychological impact of being in an environment where your traits can finally support your success.

The demands of competitive sport (such as structure, routine, dedication, and effort levels) could have a protective role for those with ADHD as it gives a safe energy outlet and fulfils the need for routine, hyperfocus and high energy. When these athletes feel safe in an environment they achieve more – something that, for some, might have been missing in an academic environment.

Where do the difficulties show up?

ADHD is not someone lacking knowledge or skill; but sometimes not being able to connect those to their performance. When they are trying to perform at a high level and have the knowledge and skills to do this but their regulatory functions have not developed enough to make this happen it can be incredibly frustrating. Therefore, if ADHD is fundamentally a difference in the way the brain processes help an athlete to function day to day it is important to understand the main brain processes:

• Executive dysfunction
• Self-regulation
• Emotional dysregulation.

We will explore each of these within the course; specifically modules 5, 6, and 7.

Take aways

• ADHD is considered to be present when someone has persistent patterns of inattention, hyperactivity or impulsivity (or a combination) which causes significant dysfunction and challenges in their lives. There are three types (combined, hyperactive and inattentive) and a number of traits and symptoms that we might see in an athlete which include: Inattention, Impulsivity, Slow information processing speed, Risk taking, Difficulties in switching task, Impaired response inhibition, Hyperactivity, Poor working memory, Planning difficulties, Lack of cognitive flexibility, Deficits in motor abilities and a love of novelty.
• Over the last 20 years there has been a big rise in awareness of the condition. We currently think that around 10% of the population have ADHD with higher levels in sport. More males than females are currently diagnosed but that may well be due to not previously understanding how symptoms show up in females.
• Specific issues can show up around difficult sporting relationships, harder to handle training behaviours, lower self-esteem and increased stress levels.