Arcticterntalk.org

The blog of a travelling psychiatrist and football lover. Who happens to be a halfway decent photographer. Takes a cynical view of the world

Archive for the tag “ADHD”

Therapeutic Use Exemptions (TUE) and Harm. The solution is obvious for Sportsmen and Doctors in Asthma and ADHD


Matt Dickinson , the chief sports writer in The Times, writes an excellent article today 16/9/16 regaring TUEs. Essentially the article reads that more athletes than ever are being granted TUEs and there is a healthy degree of scepticism as to the likelihood that a large proprotion are actually essential. All fair points. However the real debate is why is the medical evidence to support a TUE is not more solid? This is the clear missing factor.

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As a doctor I would be looking at many illness features before offering an opinion or report. Firstly if an athlete is only requesting TUE rarely, why? The types of illness cited mostly here by Matt Dickinson are long term and in general terms stable over a few months, notably asthma and ADHD. It would be a hard hearted person to determine that an asthmatic, and most cases of asthma ( not all though) develop in childhood and early adolescence, cannot compete in sport due to the need for medication. It also needs to be said upfront that asthma does kill people annually and regularly, it can be a very serious illness. Stopping medication is rarely a safe nor sensible thing to do, so to be allowed to continue medication when in competition is essential and medically necessary. And this is the point. Medication usage is generally stable. So TUEs when granted should refect the regular need for a medication over months. Competition is intense sure, but also so is training. Exertion levels are not likely to vary enormously. A TUE should never for example allow a medication to be started just prior to competition. In simple terms, the asthma medication carries on as normal. To be convinced to start a new medication, steroid for example, there needs to be serious evidence of a deterioration in asthma that would not just have occurred overnight. Hence the intermittent usage of Kenalog (triamcinolone) for example could only be entertained on a strictly seasonal basis if hayfever symptoms had been  prominent annually at that time of the year. It requires some explanation why Bradley Wiggins took only 3 injections of Triamcinolone June 2011, June 2012 and April 2013, if these medical facts are indeed correct. They may not be. It would also be interesting to entertain the spcific pollens giving the allergy.

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For ADHD it is much the same. The diagnosis of ADHD is made generally with a history of symptoms that have been present in certain well prescribed patterns for many years. Adults diagnosed with ADHD must have shown evidence of long standing symptoms present since before 12 years old. The need to treat ADHD generally does not differ markedly over a period of time, in that the likelihood that a treatment needs commencing immediatley prior to an event is minimal. Treatment needs tend to be stable. Stopping ADHD treatment is not a good thing either.

Lastly Matt Dickinson points out that ADHD is relatively common in adults, he cites 4-6% of the adult population, which is a little high, maybe 3-4% is probably correct using the updated DSM-5 diagnostic criteria. But his scepticism about Major League Baseball players having ADHD in 10% of cases might be unfounded. ADHD is more common in sportsmen as many of the illness facets tend to be helpful in sport provided they are harnessed appropriately. Thus 10% is not an unreasonable estimate, though no thorough research seems to have been done on this. Creativity, hyperactivity and hyperfocus are features of ADHD and as such gymnasts like Simone Biles as an example may do well despite having ADHD. They too however need treatment. Impulsivity is the one feature of ADHD that does often get sportsmen into trouble. Lastly an interesting recent medical finding is that asthma is far more common in those with ADHD than the general population. The reason is not clear.

00005945So where should the scepticism come in? Firstly any sudden TUE prior to a competition needs a full investigation and critical analysis. Secondly any TUE where there is an unexpected and changed medication need, especially if intermittent, needs again careful analysis. If sportsmen are using TUEs as legal loopholes then it is the duty of doctors to stop this happening, and thats far easier than many imagine.

 

ADHD and Sport.The Russians Hack into medical records. How many athletes have ADHD and should they receive treatments?


So the result of an almighty hack into the medical records of USA competitors in the Rio Olympics tells us not unsurprisingly that  a few use Oxycodone for pain,  a few use steroids or derivates and Simone Biles the world’s leading gymnast uses Methylphenidate ( which sadly most of the world including The Times, think is synonymous with Ritalin , when a little education would tell folks that there are multiple formulations ).  All these drugs were evaluated by independent doctors and judged to be fit for purpose. Nothing here is new.  In fact Olympic-level athletes must submit a therapeutic use exemption (TUE) form to the Therapeutic Use Exemption Committees detailing the symptoms, diagnosis, and testing criteria utilized in forming the diagnosis of ADHD. So spurious diagnoses are unlikely and uncommon. img_1553

ADHD is likely rife in sport and now that adult ADHD is more often recognised and treated prevalence rates will likely increase. Adult ADHD has a prevalence rate of at least 3-4% of the population.  In fact any football fan will complain weekly about “adhd traits” in their team, without recognising what they are referring to. The key ADHD traits in adults relate to impulsivity and inattention. And often occur together in fact.

Many athletes are already recognised as having ADHD. Louis Smith the UK gymnast and Michael Phelps are two current examples. It is well known that some Premiership footballers are undergoing treatment. Some will decline medication ( regardless of any ruling about medicinal use) , preferring the non-drug treatments ( and yes there are quite a few). Some will also choose to only take medication sporadically for their own reasons.

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Should they be allowed to? Categorically yes. The lack of focus that comes with ADHD is not a good feature in sports where focus is critical. Gymnastics being one such example.

So how many athletes have ADHD? Firstly maybe it needs definition of what exactly is an athlete?  Reported figures suggest that around 8-10% of professional sportsmen have ADHD. It is worth also citing that whereas in childhood forms of ADHD the male-female ratio is around 5-1, in adults the ratio becomes almost 1-1. Some of the more inattentive cases of ADHD in females not getting diagnosed as early as the more over hyperactive males.

Some estimates of ADHD prevalence are even higher. Recent statistics put out by Major League Baseball show the incidence of ADHD  is twice as high as in the general adult population, at about 9 percent versus 4.4 percent in the 14-44 age range (National Institute of Mental Health study, 2006. ). Many also remain undiagnosed and some fear to have a diagnosis made, so prevalence estimates could well be as high as 15%.

I can find no clinical research on prevalence rates in these populations however watching any football game there is usually a few players who are more impulsive and have more inattention than others. Impulsivity may lead to yellow and red cards and unwise passing. Most fans can point to a couple of their players that meet these criteria.

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ADHD paradoxically can also potentially be an advantage in athletes where periods of focus for racing or playing are often short, some times less than 10 seconds. In some cases treatment may have negative effects and not the potentially ” improved” effects that some might believe from usage of stimulants or non-stimulant medications.

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Some of these strengths linked to ADHD which, managed properly , can lead to success in multiple areas of life, and  include: an ability to multitask, deal with chaos, creativity, non-linear thinking, an adventurous spirit, resilience, high energy, risk taking, calm under pressure, and the capacity for hyper focus . Talking to many ADHD experts they report that in many adult ADHD cases hyper focus is prevalent and in certain situations ADHD patients can focus better than the general population.

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Should ADHD be treated then in athletes? Generally it should as most athletes have lives outside of their sport and other facets of their lives including relationships may suffer.

ADHD can manifest in many ways, including lack of focus and concentration, oppositional behavior in team sports, argumentative attitude, frustration, poor self-esteem, and mood lability. In addition, anxiety, depression, substance abuse, each of which directly affects team sports and participant interaction. For these reasons, athletes with ADHD often perform better with medical treatment in life and in their sport.

Some disagree with this and a few papers discuss the ethics of using stimulants based on performance enhancement. My view is different. The medication elevates underperformance where this is found, not in all cases,  and brings it to normal levels. Athletes also deserve a life and relationships and employment. Medication has an important role to play.

 

 

Reflections on 24 Hours in Helsinki.


This is not a city that I find easy to enjoy. Maybe this is me and not Helsinki. Walking around the city seems bland in comparison with other Scandinavian and Baltic capitals. A kind of hidden vibrancy is missing, something almost invisible cannot be seen.

00003440There were few smiling faces. Many engaged with their headphones, music and phones and not so much conversation going on even in the cafes.

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The obligatory young persons uniform. Cigarette, headphones and phone. just dont let the world in

The harbour and marina areas looked tired and uninterested in visitors.

00003459 There were indeed many historical looking buildings, some grand and some not. But none enticed anyone inside.

IMG_2804Even the high steps did not seem dangerous or challenging  when walking down them. There were in fact few people around. Maybe at different times in the year the feel of this city will be different but in April this city seemed comatose. The only time it came to life for me was when sitting in a hotel bar and in the next room a private function was taking place , maybe a record launch, with a singer and her singing was amazing. Amazing enough to download Shazam and discover who she was. A rasping voice that oozed feeling. The singer is called Katea. The song was California Baby. IMG_2777

Much of the city centre is a melange of shops and shopping malls. There was little evidence of any pavement cafe society even allowing for the April weather. Few smiling faces. The architecture surely can be described as grand but is it beckoning? Even the trams looked sad as they slowly went their way through the city, with less self-esteem and grandeur than Amsterdam or Manchester trams, that would happily sweep you off your feet.00003429

The only sign of life was inside coffee shops and the one that caught my eye was Strindberg down near the harbour area where enough people were inside to give me a feeling that I was not alone on this earth. The other one that also escapes my criticism is the Neuhaus cafe shop, that sold the delicious chocolates but also functioned as a pleasant street cafe. A cup of tea (3 euros for a teabag, but served in a curiously interesting mug) and some homemade mango cheesecake, though no-one ever states in which home it was made, kept me occupied for the best part of an hour.

IMG_2829 The shop was run by a highly efficient  girl who gave the image of being an academic student ( like a Latin or Greek scholar maybe) who not only ran the shop, sold the chocolates , took and ordered the food, but also made whatever had to be made. Clearly not a British employee.

The boats looked sleepy and disinterested. As though waiting for a different week or month to attract people.00003391.JPG

In huge areas there were so very few people walking around. Part of the harbour area had some tents erected that were mini-restaurants selling mostly Finnish food, such as reindeer hotdogs and other more usual foods. IMG_2806FullSizeRender-1

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Restaurants  in the city centre of course there were many but often impossible to know if they were open or closed.  Food was expensive. In many restaurants, just average ones, the main courses were around 20 euros and with a starter and a drink that made a fairly simple lunch cost over 30 euros. It was easy to find set course lunch menus costing 50 euros or more. Lunch seemed curiously to start around 10.30 am and by 11.30 am ” ladies that lunch” could be seen sipping champagne and having important conversations in some of the more eloquent looking restaurants.

IMG_2784IMG_2782There was little evidence of the wonderful and artistic graffiti that adorns many European cities. In the central part of the city rather curiously the only sign of graffiti was on the door leading to the National Library of Finland. In short the best adjective to sum up 24 hours in Helsinki is Neutral.

IMG_2787IMG_2789As in all cities there were a few characters to be seen, together with some interesting takes on hair styling. The exceptionally tall man in the bowler hat I oddly passed twice in very different parts of the city. People observing us might conclude that we were both spies meeting for our assignments. Considering spies there was no evidence of a queue at the Russian tourist board office.00003414.JPG

A plethora of expensive shops abounded. Tumi, who some might recall I encountered at London City Airport, when finding a small carry on case there that looked good, then finding the cost was £675 ( and yes I checked the decimal point), was present. I saw one professional beggar in the same position on the same street, who started ” work” at around midday, and who incidentally wore better clothes than I own.

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There were sights to see of course, but even these were quiet and few tourists were visible. Maybe I need to go back here on a different day or different season.

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Should All Sportsmen Be Screened for Adult ADHD?


As someone who has watched football and other sports closely for 50 years and often photographed games, it is clear that in many games there is evidence of both hyperactivity, inattention and impulsivity, the diagnostic components of ADHD. Emotional lability is also a major feature of ADHD though is yet to feature in the formal list of diagnostic terms. Adults with ADHD can have all of these or simply one component. The diagnosis will still be ADHD if the many other criteria for this diagnosis are met. And thats the real point. Simple acts of impulsivity or inattention do not determine a diagnosis of ADHD, it is far more complicated than that.  In this modern era though where medical screening is routine and obligatory to detect cardiac problems such as various forms of cardiomyopathies ( which have huge arrhythmogenic potential), should it not be useful at a minimum to screen for ADHD? ADHD can be managed and treated by a variety of techniques and medications. IMG_2210

Each week the news is full of sportsmen who have behaved in a manner that is often described as ” reckless”, but it might equally be regarded as ” impulsive” or ” emotional labile” responses.  Joe Marler the England and Harlequins prop forward, was recently determined to have called Samson Lee a ” gypsy boy” in an international rugby game. On his return from a 2 match suspension he last night April 22nd 2016, is cited for ” kicking an opponent in the head”. Seemingly reading comments attributed to Conor O’Shea ,  the Harlequins director of rugby, Marler needs to “learn to control his emotion”. In the same week James Vardy reacted in an emotional and possibly verbally aggressive way to a referee after being sent off. Football often refers to flashpoint tempers, but of course not all players react this way. There is no way of knowing who has ADHD without formal testing and most players with these facets will not have ADHD.

00002399There are of course well recognised sportsmen who have been successful in their careers and also diagnosed with ADHD, but a key facet is that often this diagnosis has come either after their career or later on in it.   A good example is Cammi Granato. An Olympian athlete and history maker, Cammi Granato  has ADHD. As a member of the U.S. women’s hockey team that won gold  in the 1998 Olympics, she  scored more goals than any other U.S. women’s hockey player. But she told Psychology Today in 2011 that her personal life felt out of control until she was officially diagnosed with ADHD in 2003 and started learning how to take control. This is a single case history or vignette but is unlikely to be unique. The key issue for sportsmen is how to learn how to take control and more importantly prevent issues emerging, such as red cards and maybe as a defender inattentive issues.

Clearly I am hypothesising greatly here but do believe that screening all sportsmen in professional sports would be beneficial both to themselves and their sports. An awareness of the potential outcomes of an impulsive act might just reduce incidence of future ones.

A retired Scottish footballer, Roddy Grant, was diagnosed at age 47 which in this era is far from uncommon.

“Football helped me mask the condition because it would burn up so much energy.

“But I was always high as a kite after games, win, lose or draw. Colleagues in the dressing room would say I was hyper and it was a massive issue for me”

http://www.dailyrecord.co.uk/news/scottish-news/st-johnstone-legend-roddy-grant-2934855#kSW5gWRlpVL4G2Ws.99

Other than effects on the individual there are likely effects on the team. Would a clinical research study for example show that players with ADHD have worse disciplinary records? Would strikers with ADHD be more effective as their impulsivity would be positive and creative? Would defenders with inattentive forms of ADHD concede more goals through errors?

There is though a far bigger picture here, and this was well reported in The Guardian last year.

A few years back, a Premier League club found themselves in a moral dilemma because one of their academy players was creating problems behind the scenes. The boy was talented enough to have a chance of a successful career. But his behaviour was erratic and showed no sign of improvement. It went on long enough for psychiatric reports to be ordered and the prognosis was that he had a disorder – possibly ADHD – that needed medication.

The problem for the club was that some of the drugs were prohibited, meaning that if he took them he could not continue as a footballer and would have to be cut free. That left the club with two choices: go with the medical opinion or try to find another way and, in effect, ignore the professional advice.

So screening is not without its problems, however management of ADHD does not mandate the obligatory usage of medications. Screening can also be a fairly simple task, to screen for the possible presence of ADHD, those with positive screens can then be fully evaluated, a far more complex procedure.

There is certainly a case to consider in modern top level sport that sportsmen should be screened for the presence of all disorders that may affect their careers. Possibly ADHD is one of those.

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Do you want to help Bury animals? RSPCA do.


This just made me laugh. Another graphic designer who may need another job!

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Waffle Jacks Wimbledon


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Reflections on Glasgow


Glasgow is a city that many people like and love. Host to various international events and museums. But I have never really “got” Glasgow. Maybe I have not been shown the cool places? I had an hour to spend this walk and just walked around central Glasgow taking a few photographs and again found the city not exactly full of inspiration. As usual it was raining and there was rubbish everywhere. Streets were littered with huge rubbish bags and general detritus. I need someone to point me in the right direction and show me the real highlights of Glasgow please. Strange images of jellybabies playing bagpipes, various graffiti, grey streets and Irn Bru.

Irn Bru looked too dangerous to try. As for the Blue Police box, is this serious? The planes had propellers, ok, I exagerrate a little, but not so much. Glasgow airport looked quite dead compared with previous visits. Few planes coming and going. A million shops selling “real fish and chips”.

Now to put the other side of the equation. From

http://www.peoplemakeglasgow.com

 

Glasgow has been named as one of the top 20 ‘Best of the World’ destinations for 2016 by influential publication National Geographic Traveler, the city has also been voted the ‘friendliest city in the world’ in a Rough Guides poll and named a must visit destination by leading publications like the New York Times, The Guardian and Wanderlust! Earning its reputation as one of the world’s greatest cities, you can expect a very warm welcome and when you add world-class architecture, a vibrant nightlife, breathtaking scenery and outstanding shopping, you’ll never want to leave!

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Photoshop Images by Eve Van B


Whereas Vincent Van B is rightly recognised as one of the foremost upcoming British artists, Eve Van B can be recognised for creative elusive and ephemeral images. Please enjoy and share these.

Lucy splat with texture2pLucy splat with texturegBlue paint splash fireRose splat lucy

Should Football Managers Harangue Officials on the pitch? Tommy Williams and Kingstonian


As a football fan I see plenty of occasions each game where the officials get it wrong and sometimes badly so. Having said that players and managers also are culpable of making errors plenty of times in any given game. I do however take a view that officials should be allowed to do their jobs with the expectation that they will not be perfect and certainly should be protected from on-pitch haranguing and demonstrations of anger on the pitch itself. At the recent Met Police v Kingstonian game at half time, immediately before which Met Police had scored direct from a corner, the officials were approached by the Kingstonian manager Tommy Williams clearly angry at some percieved error of judgement, and in a finger waving manner. We all in non-league should have respect for the officials and I personally cannot condone this behaviour. I am sure there are other views out there and it would be interesting to hear them.

Angry Tommy Williams Kingstonian manager confronts the officials at half time. Why is this acceptable?

Angry Tommy Williams Kingstonian manager confronts the officials at half time. Why is this acceptable?

Ricky Sappleton


Ricky Sappleton is a Jamaican born forward playing in 2015-16 for Kingstonian. having joined last summer from Billericay. Having started of with QPR he made one first team appearance for Leicester City before moving to non league . A giant of a forward with strength as a clear attribute he is not slow either and a few action shots from the Met Police 2 Kingstonian game show this nicely.

Ricky Sappleton

Ricky Sappleton

Ricky Sappleton

Ricky Sappleton

Ricky Sappleton

Ricky Sappleton

Ricky Sappleton

Ricky Sappleton

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