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ADHD and the Concussed Athlete

S. David Blake, MDFellow

Department of Developmental-Behavioral PediatricsChildren’s Hospital

Greenville Hospital System

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ADHD and the Concussed Athlete

• Quick review of ADHD

• ADHD and concussion

• Special considerations for treatment concussed athletes with ADHD

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Attention Deficit Hyperactivity Disorder

• A neurodevelopmental disorder characterized by the core symptoms of hyperactivity, impulsivity, and/or inattention

• Three types– Predominantly inattentive type– Predominantly hyperactive/impulsive type– Combined type

• 3-10 percent of children and teenagers• Male to female ratio of 3:1• Related to impairments in Executive Functioning

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Attention Deficit Hyperactivity Disorder

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Treatment of ADHD

• Behavioral Interventions• Medications

– Stimulants• Methylphenidate: Concerta, Metadate, Ritalin, Daytrana, Focalin• Amphetamine: Adderall, Vyvanse, Dexedrine

– Non-stimulants• Atomexetine (Strattera)• Alpha-2 adrenergic receptor agonists: guanfacine (Tenex, Intuniv),

clonidine (Kapvay)

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Significance of ADHD in the Concussed Athlete

• Children and teens with ADHD are at higher risk for injuries (including concussion) than children and teens without ADHD

• ADHD is one of several conditions that predispose concussed athletes to a prolonged recovery

• Many post-concussive symptoms are similar to the impairments in Executive Functioning associated with ADHD

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Significance of ADHD in the Concussed Athlete

Symptoms of ConcussionFatigue Symptoms

Drowsiness FatigueIncreased sleep DazedFogginess Feeling slowed down

Cognitive SymptomsConcentration Difficulty RememberingConfused Answering More Slowly

Affective SymptomsSadness NervousnessMore Emotional Noise sensitivityIrritability

Sleep ProblemsDifficulty sleeping

Physical SymptomsHeadache NauseaBalance problems DizzinessLight sensitivity Visual ProblemsClumsiness

AmnesiaAnterogradeRetrograde

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Management of Concussion

• Pre-participation assessment

• On-field or sideline evaluation

• Evaluation in ER or physician’s office

• Management of post-concussive symptoms

• Graduated return to play protocol

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ADHD and Management of Concussion

• Pre-participation assessment– Pre-participation history and physical– Concussive history– Baseline Neuropsychological Testing– Baseline Symptoms

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Baseline Neuropsycholigical Testing

• Baseline testing allows for comparison of the post-concussed athlete’s performance to his pre-injury performance rather than to normative data

• This is particularly important for the athlete with ADHD– Normative data generation often excludes individuals

with neurodevelopmental differences such as ADHD– Depending on the test, individuals with ADHD may

perform differently than individuals without ADHD

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ADHD and Neuropsych Testing

Computerized Neuropsychological Screening of Adolescents with ADHD

Grant Iverson PhD and Carrie Strangway BA

Presented at the National Association of School Psychologists

Dallas, Texas, April 1, 2004

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ADHD and Neuropsych Testing

• Study compared the performance of 38 adolescents with self-reported ADHD and 38 healthy students on ImPACT, a computerized neuropsychological screening battery

• The students were matched for age, education, gender, and history of head injury

• ImPACT generates composite scores for five areas: Verbal Memory, Visual Memory, Processing Speed, Reaction Time, and Impulse Control

• Adolescents with self-reported ADHD performed more poorly on the Visual Memory Composite (p<.006), the Processing Speed Composite (p<.004) and the Impulse Control Composite (p<.001)

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ADHD and Neuropsych Testing

A 2008 study by the same group compared 41 student athletes with academic problems (either in special education or had repeated a grade) with 41 randomly selected controls.

Results revealed significantly worse scores for students with academic problems on Verbal Memory and Processing Speed composites.

The students with academic problems also reported more symptomatology on the Post-Concussion Scale

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ADHD and Management of Concussion

• Evaluation in [ER or] physician’s office– Team approach is ideal– Medical evaluation– Neuropsychological testing

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Neuropsych Testing and the Concussed Adolescent Athlete

• From the Zurich Consensus Statement: “If cognitive testing is performed [in the child and

adolescent athlete] then it must be developmentally sensitive until late teen years due to the ongoing cognitive maturation that occurs during this period which, in turn, makes the utility of comparison to either the person’s own baseline performance or to population norms limited. In this age group it is more important to consider the use of trained neuropsy-chologists to interpret assessment data, particularly in children with learning disorders and/or ADHD who may need more sophisticated assessment.”

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Post-Concussion Neuropsych Testing

• Within 24-48 hours after the concussion

• Administered by an individual trained in administering the instrument being used

• Consultation with a neuropsychologist for interpretation of results

• Periodic testing until performance returns to baseline

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ADHD and Management of Concussion

• Management of post-concussive symptoms

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Management of Post-Concussive Symptoms

• Individualized Treatment Program to Address:– Cognitive Symptoms– Physical Symptoms– Sleep Problems– Fatigue Symptoms– Affective Symptoms

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Concussion and ADHD Medications

• Some Controversy No good evidence• Stimulants and Strattera associated with slight

rise in blood pressure and heart rate– In treatment of concussion, trying to keep athlete at

rest trying to AVOID raising blood pressure and heart rate

– Increased risk of cerebral vascular accident in the area of injury?

• Alpha-2 adrenergic receptor agonists associated with decreased blood pressure and heart rate

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Greenville Hospital System’s “Expert”

Dr. James Beard

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Concussion and ADHD Medications

Dr. Beard: Stop a stimulant or Strattera until headache and neurological symptoms resolve and neuropsychological testing approaching baseline. Continue alpha-2 adrenergic agonists.

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Summary Points

• ADHD is a common diagnosis in children and adolescents

• Athletes with ADHD may be more susceptible to suffering a concussive injury and may have protracted recovery time with concussion

• Baseline Neuropsychological testing is important for all athletes but particularly important for athletes with ADHD

• There is no consensus recommendation on when a concussed athlete with ADHD should restart medications