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 “adult adhd”

Mental Health of Footballers. Very little is known. This needs to change


As a football fan and psychiatrist I have more than a passing interest in the Aaron Lennon story this week. Sadly newspapers like Sun and Daily Mail dramatised things appallingly . 

The reality in this story is clear . The police have powers under Section 136 of The Mental Health act to take anyone whom they deem in need of psychiatric assessment to a designated place of safety for that assessment . The legal holding lasts for 48 hours during which time it is expected the assesssment is complete. At that point other sections can be applied for with 28 days being common under Section 2 and 6 months for Section 3. Many caveats apply . In general terms Section 2 is likely to be applied if necessary where the patient is unknown previously. At this stage nothing has been reported suggesting that Section 2 has been applied. 

Any football fan will recognise certain personality types on the field with players being often impulsive and prone to anger. I have a personal theory that adult ADHD will be far more prevalent in footballers than the general population . ADHD is also strongly linked to alcohol abuse and depression. In addition one suspects that borderline personality disorder would be more common. The Telegraph reports today that Stan Collymore received that diagnosis.  

Despite the plethora of stories of depression in sportsmen and suicides, there is no precise knowledge of how common mental health disorders are in footballers. No research to my knowledge has systematically evaluated this.  All speculation is thus unproven. 

Screening for these disorders is possible through fairly simple screening tools and should detect those who need further evaluation. For example a simple questionnaire for adult ADHD if it comes out negatively means that those people are around 98% likely not to have ADHD. 

Football clubs do have a duty for mental health care. They are best placed to flag up needs for assessment . What also needs to be understood is that life stresses often tip people over into illness. Not always but often. There are forms of depression that are not obviously linked to a precipitating cause but many forms are. 

Players also would benefit from such assessments. For example impulsivity traits and emotional volatility can be recognised and to some extent the effects ameliorated. Whatever happened in Aaron Lennon’s life to make whatever happened happen, it is unlikely that there was no previous warning.  Someone in the club is likely to have seen or heard something that may have been important. 

Mental illness is common and there should be no stigma about accepting help nor diagnosis. The onus lies within the clubs to do this . Players will also benefit 

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.

 

 

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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A Day in Wimbledon


Just a day out really but things that catch your attention.

  1. Empty trains at midday. Why cannot train companies like Southwest Trains look at operating far more a supply and demand service? It is crazy to have completely empty carriages.
  2. The weather in UK can vary from blazing sunshine to rain in only a few minutes. I Phone weather forecasts sadly are the worst source of information. Just open your eyes and look.
  3. How nice to take time and relax and sit peacefully and drink a coffee watching the world go by. No computer and no work
  4. Very little evidence of adult adhd
Variable UK weather

Variable UK weather

Empty South west Trains service

Empty South west Trains service

Wimbledon Train Station

Wimbledon Train Station

Muffins

Muffins

Rain in wimbledon

Rain in wimbledon

Nonsuch Park Cheam


Nonsuch Park is an under rated park amongst the many in Surrey. Nonsuch school sits in one corner and there are times of the day when maybe the car parks are best avoided. By chance I was there this afternoon as the sun was going down, the rain had stopped but with only the I Phone as a camera. These photos attempt to capture a chill winter late afternoon. A certain amount of adult ADHD was also apparent in those attempting to leave the car park.

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Dubai in the United Arab Emirates


Sometimes travelling for work has its pleasures and this is one such occasion. A routine British Airways flight was turned into a great experience by being upgraded to first class. Nice service and nice staff. Worth paying for? Definitely not. Save your money for your hotel room in Dubai. This hotel The Park Hyatt is superb. every little thing is special. The free coffee machine in the room, the two Danish Pastries left for an early morning arrival, the staff showing me how various things work in the room ( like the coffee machine). The balcony overlooks the marina and at sunset looks gorgeous. Not quite a Cayman Islands sunset but not too shabby either.

The Immigration process was not too bad either. Decent numbers of officials, quick entry and then quick exit from the airport. Terminal 5 please take notice.  Busy enough but not too chaotic, so all in all a great first impression. Some unusual birds pecking away on the lawn next the marina, bizarre colourings, have no idea what they are. Now wishing that I had brought my cameras…….

But work to do, an ADHD talk to write. Marina View from Park Hyatt Dubai Black Image Dubai Marina Marina Sunset Balcony View copy Sunset Balcony View

Heathrow to Slovenia


For some unfathomable reason I have done little travelling this year such that this mornings early morning visitation to Heathrow reminded me what a shocking place it is. Crowded, with people pushing aimlessly, expensive and generally not a good place. However thanks to Lufthansa and Adria Airways I reached Slovenia mid-afternoon and on time.

I was taken to Lake Bled for lunch which is potentially a tourist spot about 45 km from Ljubjana  and had a nice large schnitzel by the lake. The thing that strikes one immediately about Slovenia is that it is calm and the people seem happy. They also seem remarkably young compared with New Malden.

This evening however is work as I set about distilling 110 slides into a sensible 45 minute talk on Adult ADHD for tomorrow.

The river that runs through Ljubjana

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