Almost eight million boys and girls participate in secondary school sports. Given the number of participants, playing sports is relatively safe and beneficial in the development of an individual physically, mentally and socially. However, along with their competitive spirit comes the risk of injury.
The latest research indicates the leading causes of death in high school sports are sudden cardiac arrest, exertional heat stroke, traumatic head injuries and sickle cell complications. Although all athletes are not immune to injury, those stepping onto the playing field with pre-existing conditions may increase their risk for sustaining certain injuries. One such risk is exertional heat stroke (EHS) in those athletes with attention deficit hyperactivity disorder (ADHD).
EHS is non-discriminatory as it can occur with male or female athletes, football or field hockey and freshmen or seniors. A combination of poor environmental conditions creates the perfect storm for EHS. However, for those with ADHD, a warm environment may be the sole variable putting those athletes at risk.
As a result, environmental conditions must be monitored through Wet Bulb Globe Temperature (WBGT) versus the Heat Index. Since the WBGT measures ambient temperature, relative humidity, radiant heat from the sun and wind speed, it is most appropriate to use in athletics.
The Heat Index is a measurement of ambient temperatures and relative humidity while resting in the shade. It is intended to provide outdoor restrictions for the elderly and adolescents during times of elevated temperatures and not relevant in an athletic setting.
Many ADHD athletes are managed with prescription medications that permit the brain to reach a balance by increasing cognitive activity to bring executive functioning up to normal levels, or increasing inhibitory activity to bring impulsivity down to normal levels. Regardless of the approach, certain stimulants are usually the treating physician’s medication of choice. Also, ADHD is a “2 for 1” disorder with 20 to 30 percent of adolescents having comorbid conditions such as depression, bipolar, OCD, ODD, anxiety and/or Tourette syndrome. These disorders are commonly treated with some tricyclic anti-depressants.
Athletic trainers and coaches must remember that secondary school athletes are students first. Any prescribed pharmacological treatments are important for both their classroom and social functioning; however, these medications may also put those athletes at risk for a heat-related illness.
Studies show an increase in core temperature in those individuals taking a stimulant medication. Initially, athletes may not exhibit any obvious signs of fatigue due to the nature of the drug. They will continue participating at a high intensity in the heat, increasing the risk of their core temperature reaching >40 C (>104F) for an extended period of time.
Equally important, athletes treated with anti-depressants may experience dysfunction with the body’s sweating mechanism; therefore, decreasing the body’s ability to effectively cool when exercising. Unfortunately, not until ADHD athletes reach the stage of collapse do coaches become aware of this true emergent situation.
The risk of ADHD athletes falling victim to EHS can be significantly reduced through proper management by the athletic trainer and coaching staff. Prior to the sports season, the school nurse should provide the athletic trainer and the team’s coach with a list of medical considerations of the athletes on that team. Not only does this help identify those athletes with pre-existing conditions related to cardiac, sickle cell, asthma and seizures, but it also informs the staff of those athletes taking medications for ADHD.
In order to maintain confidentiality, it is advisable that the athletic trainer and head coach meet with the ADHD athletes individually and privately in order to discuss the signs and symptoms of heat illness and its management on the playing field. Adequate and unlimited hydration should be readily available. A “cooling station” in a shaded area should be easily accessible. It is recommended the cooling station contain an immersion tub with cool water, coolers of ice and wet towels.
Exertional heat-related deaths in ADHD athletes are 100 percent survivable when the appropriate management and treatment measures are followed. First and foremost, an approachable, non-intimidating atmosphere must be established by the head coach. ADHD athletes should feel comfortable expressing the feeling of any heat-related signs or symptoms when playing in the heat.
Continued surveillance of ADHD athletes by the athletic trainer and coaching staff during practices and games decreases the risk of these athletes suffering from a catastrophic heat-related illness. Let’s face it, when playing sports, we all want to win. But when parents sign the consent to permit their son or daughter to participate in interscholastic athletics, they expect the athletic trainer and the coach to ensure their health and safety is held in the highest regard.
David Csillan, MS, LAT, ATC, is the athletic trainer at Ewing High School in Ewing, New Jersey. He is a member of the New Jersey State Interscholastic Athletic Association Sports Medicine Advisory Committee.