1. ghs.org ADHD and the Concussed Athlete S. David Blake, MD Fellow Department of Developmental-Behavioral Pediatrics Children’s Hospital Greenville Hospital System

2. ghs.org ADHD and the Concussed Athlete Quick review of ADHD ADHD and concussion Special considerations for treatment concussed athletes with ADHD

3. ghs.org 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

4. ghs.org Attention Deficit Hyperactivity Disorder

5. ghs.org 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)

6. ghs.org 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

7. ghs.org Significance of ADHD in the Concussed Athlete Symptoms of Concussion Fatigue Symptoms DrowsinessFatigue Increased sleepDazed FogginessFeeling slowed down Cognitive Symptoms ConcentrationDifficulty Remembering ConfusedAnswering More Slowly Affective Symptoms SadnessNervousness More EmotionalNoise sensitivity Irritability Sleep Problems Difficulty sleeping Physical Symptoms HeadacheNausea Balance problemsDizziness Light sensitivityVisual Problems Clumsiness Amnesia Anterograde Retrograde

8. ghs.org 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

9. ghs.org ADHD and Management of Concussion Pre-participation assessment –Pre-participation history and physical –Concussive history –Baseline Neuropsychological Testing –Baseline Symptoms

10. ghs.org 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

11. ghs.org 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

12. ghs.org 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)

13. ghs.org 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

14. ghs.org ADHD and Management of Concussion Evaluation in [ER or] physician’s office –Team approach is ideal –Medical evaluation –Neuropsychological testing

15. ghs.org 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.”

16. ghs.org 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

17. ghs.org ADHD and Management of Concussion Management of post-concussive symptoms

18. ghs.org Management of Post-Concussive Symptoms Individualized Treatment Program to Address: –Cognitive Symptoms –Physical Symptoms –Sleep Problems –Fatigue Symptoms –Affective Symptoms

19. ghs.org 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

20. ghs.org Greenville Hospital System’s “Expert” Dr. James Beard

21. ghs.org 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.

22. ghs.org 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