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Adam E. Perrin, MD; Vijay M. Jotwani, MD Addressing the unique issues Department of Family Medicine, University of Connecticut School of of student athletes with ADHD Medicine, Farmington (Dr. Perrin); Methodist Hospital Center for Sports The impact of ADHD depends on an individual’s Medicine, Houston, Texas symptoms and chosen sport, which, along with specific (Dr. Jotwani) aperrin@stfranciscare. medication recommendations and cautions, help direct org treatment choices. The authors reported no potential conflict of interest relevant to this article.

he symptoms typical of attention-deficit/hyperactiv- Practice ity disorder (ADHD)—inability to focus concentration recommendations and maintain attention span, and associated hyper- › T Schedule twice-monthly activity—impair normal daily functioning and cause distress visits when prescribing a for affected individuals.1 For the student athlete with ADHD, psychostimulant to assess sports are a natural outlet, fulfilling the need to be active. In the symptom control, review case of a developing child with ADHD, involvement in sports adverse effects, and record often is a haven from negative feedback that can occur in the blood pressure, pulse, height, and weight in determining classroom and an environment in which to experience success. the optimal dose. C Symptoms of ADHD also may offer an advantage in sports. Impulsivity, or the ability to act without reflection, en- › Keep in mind that using ables quick decision-making and the spontaneity required of a a psychostimulant can put quarterback or point guard.2 Well-known athletes with ADHD endurance athletes at risk for heat-related injury. C have said that while tasks requiring long stretches of concen- tration are difficult, aspects of their sport involving instanta- › Advise college-bound neous reactions help them to succeed. Evidence also shows athletes that the NCAA a statistically significant decrease in markers of anxiety and requires a therapeutic use exemption for those who take depression among ADHD subjects with higher levels of sports 3 psychostimulant participation. medications. C Given the positive experience sports can provide, children and adolescents with ADHD are likely to continue participat- Strength of recommendation (SOR) ing and be as large a segment of youth athletes as they are of the A Good-quality patient-oriented 2,4 evidence general population. Primary care providers often treat student B Inconsistent or limited-quality athletes, and in this article we discuss the need for accurate di- patient-oriented evidence agnosis through comprehensive clinical evaluation, proper use C Consensus, usual practice, opinion, disease-oriented of psychostimulant medication and other available treatments, evidence, case series and special concerns for athletes who have ADHD.

Diagnosis: The need for awareness and accurate evaluation The worldwide prevalence of ADHD is 5 5.3%. In the United States, it is 8.7% among adolescents and 4.4% among adults.6,7 continued

jfponline.com Vol 63, No 5 | MAY 2014 | The Journal of Family Practice E1 TABLE 1 Differential diagnosis for inattention and hyperactivity1,3,4,6

Psychiatric conditions Systemic medical conditions Environmental factors Neurologic conditions Major depression Hyperthyroidism Abuse or neglect Hearing deficits Generalized anxiety disorder Lead or other toxicities Disruptive environment Petit mal and partial complex seizures Obsessive-compulsive disorder Hepatic disease Giftedness or cultural factors Post-concussion syndrome Substance abuse Sleep apnea Learning disability

Conduct disorders Tourette syndrome

Personality disorders Pervasive developmental disorders (eg, autism)

One study of NFL athletes found that 14 of the student athlete with a legitimate need for 159 players studied had either ADHD or a treatment from one who is fine and merely learning disability for a combined prevalence looking for a performance enhancer.9 More- of 8.8%.8 ADHD is diagnosed 3 times more over, having a comprehensive assessment often in males than females9; however, stud- with diagnostic confirmation already in place ies have shown no gender effect on ADHD, when an individual enters college greatly fa- and referral patterns contribute to the higher cilitates completion of National Collegiate prevalence pattern for males.10 Athletic Association (NCAA) medical exemp- ADHD usually is diagnosed in child- tion documentation. hood, but increasingly, it is not established z Essential diagnostic steps. The until adolescence or adulthood.2,9 Although core clinical evaluation should cover the there is no age limit for the diagnosis, the following: Diagnostic and Statistical Manual of Mental • Ensure that DSM-5 criteria are met. Disorders (DSM-5) calls for the presence of • Obtain objective reports to confirm some symptoms before age 12, and symp- the presence of symptoms in multiple toms must cause impairment of function- settings. Commonly applied symptom ing in multiple settings.1 While hyperactivity assessment scales include the Brown, symptoms may decrease over time, a signifi- Vanderbilt, and Connors question- cant number of children and adolescents will naires administered to parents, teach- experience inattention symptoms into adult- ers, and adolescent patients mature hood.11 In fact, the disorder may not become enough to complete a self-evaluation. evident until college entry, when academic • Determine whether comorbid condi- demands overwhelm an individual’s usual tions are present. coping strategies.2 • Rule out medical conditions that can z Multiple reasons for an accurate di- mimic ADHD (eg, lead toxicity or thy- agnosis. Initiate evaluation for ADHD for roid disorder). any child 4 to 18 years of age who exhibits symptoms of inattention, hyperactivity, or No neurocognitive or laboratory test for impulsivity to such a degree that it causes ADHD has sufficient sensitivity and speci- distress or impairment at home, at school, or ficity to qualify as a standard diagnostic on the sports field.12 Making an accurate di- test.2,13 In the future, advanced neuroimaging agnosis of ADHD is vital in student athletes may provide a means of diagnosing ADHD. given that treatment, or lack thereof, may put Functional magnetic resonance imaging has their health at risk and adversely impact their shown characteristic patterns of reduced ac- academic and athletic performances. Diag- tivation in the basal ganglia, frontal lobe, and nostic accuracy also aids in distinguishing parietal lobes in patients with ADHD.14

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z The differential diagnosis for symp- that has shown benefit is behavior therapy, toms of inattention and hyperactivity is which includes a broad set of specific inter- large (TABLE 1).1,3,4,6 Once underlying medical ventions that modify physical and social en- conditions have been ruled out, screen the vironments to change behavior.19 Behavioral patient for mental disorders, including de- training, which primary care providers can pression and mood disorders, anxiety, and introduce to parents, teachers, and coaches, conduct disorders, before concluding that involves the simple principles of reinforcing symptoms are likely due to ADHD. When desired behavior through reward and ignor- compared with mood disorders, a patient ing undesired behavior to reduce or elimi- with ADHD will have a persistent course of nate it. Consistent application of rewards or symptoms rather than periods of recurring unresponsiveness helps patients increase and remitting symptoms.2 ADHD is a chron- attention to instructions, comply with rules, ic condition that raises special health care improve productivity, and decrease disrup- concerns for children and adolescents.12 As tive behavior.20 many as two-thirds of children with ADHD The athlete with ADHD will benefit from have at least one coexisting neuropsychi- a structured environment and, depending on atric condition, and symptoms may over- age and level of maturity, can be educated lap, making for a significant diagnostic and by coaches on self-management strategies management challenge.9 Difficult cases may such as time management, effective planning necessitate consulting a specialist (psychia- and organization, and avoidance of distrac- Accurate trist, neurologist, or neuropsychologist) for tions.20 may help relieve subjective diagnosis is guidance. Additionally, in ADHD youth the symptoms of ADHD and comorbid mood needed to overall risk of developing a substance use disorders, but evidence is insufficient to de- distinguish a disorder is twice that of children who do not termine its direct impact on ADHD. legitimate need have ADHD.2,15 for treatment Pharmacologic treatment from an Of the many available medications used to unwarranted Treatment: More than medication treat ADHD (TABLE 2),9,12,16,18,20,21 psychostim- request for Effective treatment for ADHD improves qual- ulants are most effective for reducing core a stimulant. ity of life, decreases the rate of substance symptoms of the disorder.22 It is estimated abuse, reduces errors when driving vehicles, that 56% of patients with ADHD receive drug and decreases the prevalence of comorbid therapy, and most of these drugs are psycho- psychological disorders.16,17 Pharmacologic stimulants.16 These agents increase dopa- and nonpharmacologic options are avail- mine and norepinephrine concentrations in able. With athletes, it’s important to be aware the brainstem, midbrain, and frontal cortex, of and consider alternatives to medication, which likely is responsible for increasing at- particularly given the rules restricting the use tention span and concentration.23 As judged of stimulant medication by the NCAA, In- by increased attention or decreased hyper- ternational Olympic Committee (IOC), and activity in a recent cohort-based study, the the World Anti-Doping Agency (WADA). The positive response rate to psychostimulants IOC and WADA prohibit any use of stimulant was 73.1%.24 medications, and the NCAA requires a thera- Atomoxetine, a selective norepinephrine peutic-use exemption (TUE) for athletes who reuptake inhibitor, is the primary US Food take psychostimulant medications (detailed and Drug Administration (FDA)-approved at right).3,16 nonstimulant medication for the treatment of ADHD. In double-blind randomized tri- Nonpharmacologic treatment als, atomoxetine was roughly equivalent to Published guidelines on managing ADHD psychostimulants in reducing target symp- show greater agreement on pharmacologic toms.21,25 Typically more expensive than psy- treatment than on psychosocial interven- chostimulants, atomoxetine is an acceptable tions, based on strength of evidence.18 One alternative and the more appropriate agent evidence-based psychosocial intervention for the ADHD patient with a history of illicit

jfponline.com Vol 63, No 5 | MAY 2014 | The Journal of Family Practice E3 substance abuse or the athlete whose sport compliance, ensure dosing consistency, and bans the use of stimulant medications. reduce abuse potential. If the desired outcome z Medication adverse effects. Adverse is not being achieved at the highest feasible effects common to psychostimulants are gen- dose, an alternative psychostimulant may be erally mild and include decreased appetite tried. If a desired response is still not achieved, and sleep disturbances. Less common are ner- reevaluate the diagnosis or consider the pos- vousness, irritability, headache, and increased sibility of comorbid conditions or that the pa- heart rate and blood pressure (BP).22 Overdose tient has stopped taking the medication. can result in drug-induced psychosis or cardi- z During the maintenance stage, it is ac arrest.26 Most of these effects are reversible prudent to have monthly contact with the or preventable through dose reduction, in- student athlete before writing refill prescrip- creasing the dosing interval, or changing time tion for a Schedule II medication. of dosing during the day. Linear growth rate z Determining when to terminate deceleration in both height and weight may treatment is a highly individualized decision occur in children and adolescents, but this ef- that entails ongoing analysis of risks vs ben- fect is thought to be small and reversible upon efit.9,12,16,26,29 A student athlete’s diagnosis of discontinuation of medication.27,28 ADHD might have been based on a positive re- Contraindications to using psychostim- sponse to medication in lieu of a comprehen- ulant medications include symptomatic car- sive evaluation, which is regrettable. Response Atomoxetine diovascular disease, structural heart disease, to medication cannot be used to confirm or carries a uncontrolled hypertension, hyperthyroidism, refute a diagnosis of ADHD because psycho- black-box glaucoma, stimulant hypersensitivity, psy- stimulant medication will improve behavior in warning chosis, and a history of drug dependence.29 conditions other than ADHD, including learn- regarding Psychostimulants are Schedule II drugs, ing disability and depression.22 suicidality in which means they pose a high potential for z Misuse of psychostimulants among children and abuse and risk for development of physical athletes. Some athletes will use a psycho- adolescents dependence. The nonstimulant medications stimulant primarily as an appetite suppres- during the first listed in TABLE 2 are not Schedule II drugs sant for weight control. However, perceived month of and, though not as efficacious, generally are ergogenic effects are what make psychostim- treatment. safer and lack the adverse effects typically ulants especially problematic,16 and are the seen with psychostimulants. Atomoxetine, main reason they are banned from competi- however, carries a black-box warning regard- tive sports. Potential performance enhance- ing the risk of suicidality in children and ado- ments include improved concentration and lescents during the first month of treatment, attention to tasks, increased aggression, de- and patients should be counseled according- creased pain perception, and euphoria. ly. Long-term effects of ADHD medications, A 2006 NCAA study of substance abuse either adverse or positive, remain unknown; habits of college student athletes (reflect- few studies have been done over a period lon- ing 2005-2006 data) demonstrated the fol- ger than 24 months.25 lowing findings concerning ergogenic use of psychostimulants:30 Medication management • Psychostimulant use has continually Psychostimulant therapy for ADHD has increased since 1997 among all stu- 3 essential stages: initiation/titration, main- dent athletes. tenance, and termination. • Psychostimulant use has increased z With initiation and titration, de- across all divisions, with highest use in termining the optimal dose requires twice Division III. monthly follow-up visits. With each visit, as- • Psychostimulant use increased in all sess symptom control, review adverse effects, men’s sports except basketball, foot- and record BP, pulse, height, and weight. The ball, and swimming. optimal dose is one at which target outcomes • Psychostimulant use increased in all are achieved with minimal adverse effects. women’s sports except tennis, gym- Long-acting agents are preferred to enhance nastics, soccer, and volleyball. continued

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TABLE 2 Medications prescribed for ADHD9,12,16,18,20,21

Medication groups Brand names Duration Comments and agents of action Psychostimulants Methylphenidate Short-acting Adverse effects include decreased appetite, Ritalin/Methylin 3-5 h sleep disturbances, nervousness, irritability, headache, and increased blood pressure and heart rate. Contraindications include symptomatic or structural heart disease, uncontrolled hypertension, hyperthyroidism, glaucoma, stimulant hypersensitivity, psychosis, and his- tory of drug dependence. Intermediate-acting Ritalin SR/Metadate ER/Methylin ER 4-8 h Focalin (dexmethylphenidate) 5-6 h Long-acting Concerta/Ritalin LA/Metadate CD 8-10 h Focalin XR (dexmethylphenidate) 10-12 h Daytrana Patch Up to 12 h Intermediate-acting See above. and 6-8 h (“amphetamine salts”) Long-acting Adderall XR 8-10 h Dextroamphetamine Short-acting See above. Dexedrine/Dextrostat 4-6 h Intermediate-acting Dexedrine Spansule 6-8 h Lisdexamfetamine Vyvanse 8-12 h See above. Modafinil Provigil 10-12 h Classified as “wakefulness promoter/cognitive enhancer.” Indicated for fatigue due to sleep Armodafinil Nuvigil 12-15 h apnea/MS, narcolepsy. Not approved for pediatric patients due to risk of Stevens- Johnson syndrome. Nonstimulants Atomoxetine Strattera Up to 24 h Selective norepinephrine reuptake inhibitor. Contains black-box warning. (See text.) Antidepressants Dopamine and norepinephrine reuptake Bupropion Wellbutrin inhibitor. Typically used as adjunct ADHD treatment. Improves attention dysfunction. Imipramine Tofranil Due to side effect profile, not usually Nortriptyline Pamelor recommended for competitive athletes. Amitriptyline Elavil/Endep Desipramine Norpramin Alpha-2 adrenergic agonists Clonidine Catapres/Kapvay Rarely used. Guanfacine Intuniv/Tenex FDA-approved for patients 6-17 years of age.

ADHD, attention-deficit/hyperactivity disorder; FDA, US Food and Drug Administration; MS, multiple sclerosis.

jfponline.com Vol 63, No 5 | MAY 2014 | The Journal of Family Practice E5 • Respondents who used stimulants said provide their institution with a copy of the they did so to get more energy or to comprehensive assessment, including his- treat ADHD. tory of treatment. If such documents are not • Respondents who didn’t use stimulants available, then a comprehensive assessment, said they were concerned about the ef- must be performed to establish the diagnosis. fect on health, side effects, and going At minimum, documentation must in- against personal beliefs.30 (The latter clude a description of the evaluation process issue regarding why student athletes and assessment tool(s) used; a statement of do or do not use specific substances the diagnosis; a history of ADHD treatment, is a focus of the 2012-2013 NCAA Na- both previous and ongoing; a statement that tional Study of Substance Use Habits a nonbanned alternative ADHD medication of College Student-Athletes, currently has been considered, if a psychostimulant is underway.) currently prescribed; and a statement reflect- ing evidence of ongoing follow-up/medica- z The rise in the nonprescription use of tion monitoring. Adderall among National Football League If a psychostimulant medication is pre- (NFL) players has become a hot topic. Regard- scribed, NCAA regulations require that a ed by the league as a game-day performance TUE be included in the documentation. The enhancer, it has been banned since 2006. NCAA asks only that the prescribing physi- There is no Muddying the waters on the true prevalence cian consider nonstimulants first; they do compelling of Adderall use is the NFL’s policy of silence not require an initial trial of a nonstimulant evidence to on identifying the specific performance-en- medication.2,9,16 Per NCAA regulation the stu- show that hancing drug that triggered suspension. Only dent athlete must undergo, at minimum, an children with the player, if he so chooses, can disclose the annual clinical evaluation by the team phy- ADHD treated substance in question. It has become con- sician. The NCAA Committee on Safeguards with psycho- venient for players to name Adderall as the and Medical Aspects of Sports has issued a stimulants are culprit, as it lacks the stigma attached to ana- new mandatory reporting form that contains at higher risk of bolic steroids and human growth hormone. criteria, including any known history of sub- sudden cardiac Whether the drug is being used for ergogenic stance abuse, to help differentiate legitimate death. purposes or as an easy alibi, or both, remains use worthy of medical exemption from use unclear.31 that is abusive.32 The student athlete participating in events sanctioned by WADA or IOC must be Competition restrictions and aware that use of psychostimulant medica- therapeutic-use exemption tion is prohibited in competition. The only At the college level and beyond, psychostim- FDA-approved ADHD medication allowed ulant use is highly regulated in competitive for use in competition by all governing bod- sports. Primary care providers can be sup- ies is atomoxetine. Encourage student ath- portive by being mindful of existing restric- letes to check governing organization Web tions when making treatment decisions, and sites to review current restrictions on use of by keeping detailed documentation as stipu- psychostimulants in competition. Psycho- lated in NCAA policy that became effective stimulants are banned in all professional on August 1, 2009.30 sports, though many allow a TUE (except the The policy requires student athletes with National Hockey League). The process of ob- ADHD who take psychostimulant medica- taining a TUE is rigorous, and Major League tion to provide “evidence that the student Baseball requires a second opinion.2,9,16,33 athlete has undergone clinical assessment to diagnose the disorder, is being monitored routinely with use of psychostimulant medi- Specific health concerns for cation and has a current prescription on file.” student athletes treated for ADHD If the diagnosis of ADHD was made in child- Sudden cardiac death (SCD) is rare among hood, policy requires the student athlete to athletes and most often associated with con-

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genital abnormalities affecting heart struc- ture and electrical conduction.16 Although Anticipating and addressing there have been reports of cardiac arrhyth- the misuse of psychostimulants mias related to the use of psychostimulants, no compelling clinical evidence has demon- Psychostimulant medication, with its direct actions and adverse strated a higher incidence of SCD in pediatric effects, has great potential for misuse, and the past 10 years have seen a surge in nonprescription stimulant use among adolescents ADHD patients treated with psychostimu- and young adults.26 The reason most commonly given for using a 34 lants compared with the general population. stimulant is to enhance academic performance through improved The American Academy of Pediatrics, in alertness and sharpened focus. a policy statement subsequently endorsed by the American Medical Society for Sports Adderall is the psychostimulant most in demand as a “study drug.” Medicine, does not support the routine use of Among college students, evidence suggests the individual most likely electrocardiograms before initiating psycho- to misuse Adderall is white, male, affiliated with a formal frater- stimulant therapy.16,34 nity, and more likely to use other illicit substances.26 Adding to the In light of the cardiovascular side effects perpetuation of this phenomenon is that it is relatively stigma-free: of psychostimulants, it remains prudent to Public opinion does not consistently condemn the use of Adderall for obtain a thorough cardiovascular history academic means, effectively legitimizing nonprescription use. before starting medication. If no preexisting Very few universities have an academic policy associating nonpre- cardiac disease is identified, psychostimu- scription use of psychostimulants with cheating. The result is an lants can be safely prescribed for the ADHD unprecedented demand for psychostimulant medications,TK 37 which 34 athlete without worry about the risk of SCD. are increasingly obtained through diversion by profiteering peers or from clinicians under false pretenses.26 Psychostimulants can confer risk of heat injury To help curb the problem of misuse, consider stigmatizing such Endurance ADHD athletes on psychostimu- behavior and that, in addition to significant health risks as- lants may be at increased risk of heat in- sociated with inappropriate use, the vast majority of evidence shows jury when exercising in warm conditions. no cognitive enhancement with stimulants when compared with Evidence suggests that psychostimulants placebo in healthy individuals. Given that psychostimulant misuse is more common with an immediate-release formulation, one means can increase core temperature while also of prevention is to restrict legitimate prescriptions to long-acting masking signs and symptoms of fatigue, al- formulation as much as possible.38-40 lowing for a longer duration of exercise and delayed time to exhaustion in the presence of elevated core temperature and heart rate.35 impairing symptoms, presence of comorbidi- In one placebo-controlled trial of exer- ties, and prior response to medication. cise under warm conditions, core tempera- How the psychostimulant is taken also ture measurements in athletes taking 20 mg can vary depending on an athlete’s prefer- of methylphenidate often exceeded 104˚F, ence and the nature of the sport. For example, and the athletes experienced no change in some athletes will take the medication only their perception of effort or thermal stress.36 for academic purposes (studying, testing). These factors raise concerns for increased Other athletes feel their sport performance risk of heat-related injury in the ADHD ath- improves while on psychostimulants (eg, a lete taking psychostimulant medication. baseball catcher who requires game-long Close monitoring is required. concentration), while yet others prefer not to take it during an event so they can remain un- focused, move randomly, and maintain spon- Your role as the primary care taneity (as with a basketball point guard). provider If psychostimulants are to be used while An optimal treatment plan for the ADHD ath- playing, it is wise not to initiate therapy dur- lete, especially one using a psychostimulant ing a high-stress event, such as a champi- medication, should always be individualized. onship game. In addition, it is important to Many factors come into play: the nature of know when to withhold medication, as in the

jfponline.com Vol 63, No 5 | MAY 2014 | The Journal of Family Practice E7 case of an endurance athlete competing in ers—to sustain a collaborative approach hot weather. to care. Be attentive to signs of inappropriate use of psychostimulant medication (See “Antici- Coordinating all aspects of care pating and addressing the misuse of psycho- In providing the best care for the ADHD stimulants” on page E726,37-40). However, fear athlete, the primary care physician must of potential misuse is not justification for possess comprehensive knowledge of withholding medication, especially when a evidence-based best practices. Educate your- clear indication is evident. Failure to recog- self about all available therapies, including nize ADHD as a legitimate problem puts both behavioral management and use of psycho- academic and social hurdles in the path of stimulants. And become familiar with avail- the student athlete. Evidence shows that ad- able resources and with the referral network equately treating ADHD with indicated phar- (eg, neuropsychologist). macotherapy actually reduces subsequent Acknowledgement of NCAA regula- substance abuse.41 Finally, education of every tions/restrictions is vital to making treatment ADHD athlete on existing restrictions/regu- decisions. In light of the many regulations lations/requirements as posed by govern- (both governmental and within the com- ing bodies (NCAA, US Anti-Doping Agency, petitive sporting world), consider the use WADA, and IOC) is imperative. JFP Do not withhold of nonbanned medications and behavioral medication therapies whenever possible. Throughout the Correspondence Adam E. Perrin, MD, Family Medicine Center at Asylum Hill, for fear of treatment process, involve all stakeholders— University of Connecticut School of Medicine, 99 Woodland potential misuse, parents, athletic trainers, coaches, teach- Street, Hartford, CT 06105-1207; [email protected] but be attentive to signs of inappropriate References use. 1. American Psychiatric Association. Diagnostic and Statistical 13. Boonstra AM, Osterlaan J, Sergeant JA, et al. Executive func- Manual of Mental Disorders. 5th ed. Washington, DC: American tioning in adult ADHD: a meta-analytic review. Psychol Med. Psychiatric Association Press; 2013. 2005;35:1097-1108. 2. Parr JW. Attention-deficit hyperactivity disorder and the athlete: 14. Silk T, Vance A, Rinehart N, et al. Fronto-parietal activation in new advances and understanding. Clin Sports Med. 2011;30: attention-deficit/hyperactivity disorder, combined type: func- 591-610. tional magnetic resonance imaging study. Br J Psychiatry. 3. Kiluk BD, Weden S, Culotta VP. Sport participation and anxiety in 2005;187:282-283. children with ADHD. J Atten Disord. 2009;12:499-506. 15. Biederman J, Wilens TE, Mick E, et al. Does attention-deficit hy- peractivity disorder impact the developmental course of drug 4. Broshek DK, Freeman JR. Psychiatric and neuropsychological is- and alcohol abuse and dependence? Biol Psychiatry. 1998;44: sues in sports medicine. Clin Sports Med. 2005;24:663-679,x. 269-273. 5. Polanczyk G, de Lima MS, Horta BL, et al. The worldwide preva- 16. Putukian M, Kreher JB, Coppel DB, et al. Attention deficit hy- lence of ADHD: a systematic review and metaregression analysis. peractivity disorder and the athlete: an American Medical So- Am J Psychiatry. 2006;164:942-948. ciety for Sports Medicine position statement. Clin J Sport Med. 6. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of 2011;21:392-401. mental disorders in US adolescents: results from the National 17. 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Searight HR, Burke JM, Rottneck F. Adult ADHD: evaluation and 563-577. treatment in family medicine. Am Fam Physician. 2000;62:2077- 9. Kutcher JS. Treatment of attention-deficit hyperactivity disorder 2086,2091-2092. in athletes. Curr Sports Med Reports. 2011;10:32-36. 21. Krull KR. Attention-deficit hyperactivity disorder in children and 10 Biederman J, Kwon A, Aleardi M, et al. Absence of gender effects adolescents: Treatment with medications. Available at: http:// on attention deficit hyperactivity disorder: findings in nonre- www.uptodate.com/contents/attention-deficit-hyperactivity- ferred subjects. Am J Psychiatry. 2005;162:1083-1089. disorder-in-children-and-adolescents-treatment-with-medica- 11. Wilens TE, Faraone SV, Biederman J. Attention-deficit/hyperac- tions. Accessed March 17, 2014. tivity disorder in adults. JAMA. 2004;292:619-623. 22. Conant-Norville DO, Tofler IR. Attention deficit/hyperactiv- 12. 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