By Christopher J. Richmond, Ph.D., LP, LMFT
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurobiological disorders of childhood and often continues through adolescence and adulthood. In the past, some individuals and groups believed that young adults would simply “outgrow” ADHD. However, we’ve learned that some young adults develop strategies to mitigate ADHD symptoms, but many find that these symptoms persist into adulthood.Population surveys reported by the American Psychiatric Association indicate ADHD occurs in approximately 5 percent of children and 2.5 percent of adults.
Many people assume that student-athletes are emotionally healthy in the same ways that they are assumed to be physically healthy. However, just as student-athletes may suffer with physical illnesses and injuries, they are also vulnerable to mental health disorders, including ADHD.
The three core symptoms of ADHD are:
Each core symptom includes several additional symptoms. ADHD symptoms are often noticed by student-athletes in situations such as listening to a lecture in class, completing homework assignments, talking with friends or listening to a coach’s instructions.
The core ADHD symptoms of inattention, hyperactivity and impulsivity, as outlined in the new Diagnostic and Statistical Manual of Mental Disorders, (5th ed.; DSM-5; American Psychiatric Association, 2013) are listed in the table below. In order to be diagnosed with ADHD for either the Inattention or the Hyperactivity/Impulsivity symptom set an individual (17 years of age or older) must have at least five of the nine symptoms listed below for at least six months. And they must have been severe enough to interfere with the patient’s quality of life (See Table 1). For the student-athlete this means that ADHD symptoms are usually present on a daily or weekly basis both within the academic setting and in the athletic, social, job or home setting. To confirm a diagnosis of ADHD, there must also be evidence that there were ADHD symptoms prior to age 12. Table 2 lists the three ADHD presentations.
At Ferris State University, student-athletes are primarily referred for an ADHD assessment by a certified athletic trainer. Athletic trainers may refer a student whom they suspect has ADHD because of difficulties in the classroom, on the field or both. Athletic trainers also refer students that have been previously diagnosed and are currently taking a stimulant medication, but lack proper documentation of an ADHD diagnosis. This scenario is common at Ferris State. Often, a student-athletes is diagnosed by a family doctor or primary care physician without a comprehensive assessment, and that physician will make a diagnosis of ADHD based upon the results of just one rating scale assessment or a short diagnostic-focused conversation with the patient.
After the referral has been made for the ADHD assessment, the student-athlete is evaluated at the Ferris State Health Center to assess current symptoms. The Health Center physicians utilize an ADHD screening assessment to determine the presence and severity of symptoms. The physicians then use the data from this assessment to determine whether or not a student should be evaluated further. In this case, the health center physician will refer the student-athlete to the counseling center for a comprehensive assessment. Following the completion of this assessment, which typically spans the course of four to five sessions, the report is released (with the client’s permission) to the health center and the athletics department.
The ADHD assessment protocol employed at the Ferris State Counseling Center follows a multi-method approach, which includes assessment procedures such as interviews, rating scales, psychological tests and a review of past academic records. A multi-method approach to the assessment of ADHD is important because there is no single procedure that addresses all of the criteria for ADHD. ADHD interviews typically fall within one of three areas: (1)structured; (2)semi-structured; or (3) unstructured. The Ferris State Counseling Center protocol utilizes a semi-structured assessment during the first session, which is adapted from the standard intake interview. The protocol employs a structured interview at the second session that more closely examines each symptom of ADHD. This structured interview is geared specifically to the adult population and assesses symptoms that were present during childhood and adulthood.
The ADHD rating scales generally fall within either a broad-band or narrow-band category. The broad-band rating scales assess a wide range of behaviors that typically include psychological symptoms beyond those specific to ADHD such as depression and anxiety, which are often associated with ADHD symptoms. The narrow-band rating scales more exclusively assess ADHD symptoms. Some ADHD rating scales include both a self-report and observer-report version. It is advantageous to collect important ancillary data from close family members or friends.
The psychological tests are typically measures of sustained attention. The continuous performance test is one of the most common diagnostic tests used in the assessment of ADHD. Most are computer-based assessments of attention. For example, the student-athlete may be asked to press the space bar every time the letter A appears on the monitor. These continuous performance tests detect brief lapses of attention through omission errors (lack of attention) and commission errors (impulsive response).
The last assessment area pertains to the review of academic records. This review typically consists of an evaluation of elementary and middle school report cards. The new diagnostic criteria indicate that there must be evidence of ADHD symptoms prior to age 12. Most report cards assess classroom behavior and study habits, which typically include areas closely related to ADHD symptoms. For example, “listens attentively” and “follows directions” are common assessment areas specific to study habits. Teacher comments in the narrative form may also indicate problems related to ADHD.
Due to the complexity of a comprehensive ADHD assessment, they should be completed by a professional—namely, a psychologist, psychiatrist or medical doctor with experience in this area. It is the experience of this author (as the psychologist providing the assessment), that having a close working relationship with the athletic trainers and physicians on campus facilitates an effective and efficient protocol in managing student-athletes with suspected ADHD.
ADHD treatment is often multi-disciplinary in nature, and may include any combination of cognitive-behavioral strategies, goal-oriented strategies, nutritional guidance, psychotherapy and medication management. Stimulant medications are the mainstay of pharmacologic treatment of ADHD (commonly prescribed ADHD stimulant medications are listed in Table 3).
Stimulant medications are NCAA banned substances, and their use requires the institution to maintain documentation on file and submit a medical exception request, using the NCAA medical exception ADHD reporting form, in the event of a positive drug test. The documentation must include a written report of the evaluation conducted to support the diagnosis of ADHD, and medical treatment notes from the prescribing physician. Sometimes, anti-depressant and other medications are used in ADHD treatment, and these drugs are not prohibited. If the health center physician recommends a stimulant medication based upon the outcome of the report, he or she must complete the NCAA medical exception ADHD reporting form, which can be found here.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.