INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is a relatively common neurobehavioral disorder, affecting up to 11% of the population worldwide.1–5ADHD is more common among men than women6 and is presumed to be more prevalent among athletes.1,2,5 Diagnosis of ADHD remains largely subjective; an evidence-based, standardized diagnostic tool should be used. Management strategies for ADHD are multifaceted, ranging from behavioral therapy to pharmacologic management and physical activity.1–5,7–10 Prescribing physicians should be vigilant for potential unfair performance advantages because of stimulant use, differentiating these from changes in performance because of appropriate treatment of ADHD. It is noteworthy that ADHD treatment may have unique direct and indirect impacts on an athlete's performance. In addition, the risks of unfair performance advantages from using stimulants and their adverse effects, especially regarding heat-related illnesses, must be deliberated.11

The primary purpose of this position statement is to evaluate current evidence on the proper diagnosis and management of ADHD among athletes at different competition levels, providing guidance for sports medicine practitioners that leverages scientific evidence for clinical utility. This study updates and expands on the 2011 American Medical Society for Sports Medicine (AMSSM) position statement.12

METHODOLOGY Writing Team Selection Process

A call for a lead author was sent to all AMSSM members; although AMSSM has an international reach, its activities are focused mainly within the US. The lead author was chosen by the AMSSM Board of Directors, at which time a separate call for coauthors was sent. The AMSSM Board of Directors and the lead author reviewed responses. Coauthors were chosen with the goal of a writing team that represented the diverse membership of AMSSM, including sex, clinical specialty, focus of expertise, geographic region, and race and ethnicity.

American Medical Society for Sports Medicine is a multidisciplinary organization of sports medicine physicians dedicated to education, research, advocacy, and care of athletes of all ages. Most AMSSM members are board-certified primary care physicians with fellowship training in sports medicine who combine their practice of sports medicine with their primary specialty. AMSSM includes members who specialize solely in nonsurgical sports medicine and serve as team physicians at the youth level, secondary schools, National Collegiate Athletic Association (NCAA), National Football League, Major League Baseball, National Basketball Association, Women's National Basketball Association, Major League Soccer, and National Hockey League, and with Olympic and Paralympic teams. By nature of their training and experience, sports medicine physicians are ideally suited to provide comprehensive medical care for athletes, sports teams, or active individuals looking to maintain a healthy lifestyle.

METHODS

Studies were identified by a health sciences librarian by developing and running searches in the following databases: MEDLINE (1946-Present), Embase (1974-Present), Cochrane Central Register of Controlled Trials (1991-Present), and Cochrane Database of Systematic Reviews (2005-Present) via the Ovid interface, and Science Citation Index Expanded (1975-Present) and Emerging Sources Citation Index (2015-Present) via the Web of Science interface. There were no limits to language or publication dates, a strength of this review. Filters to remove editorials, letters, conference posters, and proceedings were included, and filters to remove animal studies, a possible limitation. Search strategies were created using a combination of keywords and standardized index terms. Search terms included standard NLM Medical Subject Headings and Emtree terms, and keywords, such as “attention deficit disorder with hyperactivity,” “ADHD,” “athletes,” “sports,” and concepts for each specific aim. The search strategy for all specific aims was completed between September 20, 2021, and October 18, 2021, resulting in 8142 unique articles. Full search strategies are available on request.

Specific aims of the article were developed through periodic meetings. The writing team was divided into subgroups (Table 1). Consensus on article inclusion and draft content was reached within each subgroup before the full group content meeting. This article is not a primer on ADHD diagnosis and treatment, but rather focuses on issues most pertinent to the competitive athlete with ADHD.

TABLE 1. - Division of Work for Members of the Writing Team by Section Section Author(s) Abstract Pujalte Introduction Khodaee, Pujalte Methodology Brigham,* Clifton* Results/Literature summary  Diagnosis and management of ADHD Pujalte  ADHD mimics: Pattern identification for differentiation Narducci  ADHD and issues related to diversity, equity, and inclusivity Callender, King, Pujalte, Wolf  Pharmacotherapy King, Liebman   Medication adverse effects Liebman, Smith  The role of exercise in the treatment of ADHD Callender, Nuti  Effects of ADHD on sports participation Kane, Liebman, Logan  Effects of ADHD medications on athletic performance Narducci, Smith  The relationship between ADHD and concussions Wolf  Regulatory issues Israel, King References Brigham,* Clifton*

*Acknowledged contributor.

RESULTS/LITERATURE SUMMARY Diagnosis and Management of ADHD

Diagnosing ADHD principally warrants comprehensive input (eg, interviews or assessment tools) from the patient and their parents, caregivers, and teachers. Other conditions that resemble ADHD (eg, depression, anxiety, posttraumatic stress disorder) should be assessed through diagnostic evaluation. Table 2 presents diagnostic criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.13 Neuroimaging and laboratory evaluation are rarely necessary to diagnose ADHD, especially when no other etiologies are being considered.14

TABLE 2. - DSM-V Criteria for the Diagnosis of ADHD Persistent Pattern of Inattention And/Or Hyperactivity-Impulsivity that Interferes with Functioning or Development Inattention Six or more symptoms of inattention in children up to 16 years old, or 5 or more in adolescents aged 17 years or older and adults. Symptoms have been present for at least 6 months and are inappropriate for the person's developmental level:
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
• Often has trouble holding attention to tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (eg, loses focus, is sidetracked)
• Often has trouble organizing tasks and activities
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework)
• Often loses things necessary for tasks and activities (eg, school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, or mobile telephones)
• Is often easily distracted
• Often forgetful in daily activities Hyperactivity-impulsivity Six or more symptoms of hyperactivity-impulsivity in children up to 16 years old, or 5 or more in adolescents aged 17 years or older and adults. Symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level:
• often fidgets with or taps hands or feet, or squirms in seat
• Often leaves a seat in situations where remaining seated is expected
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
• Often unable to play or take part quietly in leisure activities
• Is often “on the go” or acting as if “driven by a motor”
• Often talks excessively
• Often blurts out an answer before a question has been completed
• Often has trouble waiting for their turn
• Often interrupts or intrudes on others (eg, “butts into” conversations or games) The following conditions must also be met: • Several inattentive or hyperactive-impulsive symptoms present before 12 years old
• Several symptoms present in 2 or more settings (eg, at home, school, or work; with friends or relatives; in other activities)
• Clear evidence that symptoms interfere with or reduce the quality of social, school, or work functioning
• Symptoms not better explained by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, or personality disorder)
 • Symptoms do not happen only during the course of schizophrenia or other psychotic disorder

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; DSM-V, diagnostic and statistical manual of mental disorders, Fifth Edition.

A team approach that includes the athlete is preferred.1,3,4 The primary members of this team (ie, health care professionals, athlete, family members) need to participate in discussions about short- and long-term treatment plans along with coping and management strategies. Teachers who work closely with athletes should also be incorporated into the intervention and management team.

Cognitive behavioral therapy and social skills training alone are not sufficient for ADHD management.15 The most effective treatment for ADHD is a multidisciplinary approach that combines pharmacotherapy with cognitive and social therapies. Left untreated, ADHD can negatively impact performance in school, job stability,16 self-esteem,17 relationships, substance use disorder,6 and mood (eg, anxiety).18

Of the various medication options (Table 3), stimulants are considered the first-line treatment with selected nonstimulants prescribed less frequently.19 Family and personal histories of cardiovascular diseases should be examined before prescribing stimulant medications for ADHD.20

TABLE 3. - Commonly Used Medications for ADHD and Known Pharmacology Medication Pharmacology Stimulants  Methylphenidate Increases norepinephrine and dopamine release and prevents reuptake  Dextroamphetamine-amphetamine salts Increases norepinephrine and dopamine release and prevents reuptake  Dextroamphetamine Increases norepinephrine and dopamine release and prevents reuptake  Modafinil Inhibits GABA release, possible α1 agonist Nonstimulants  Atomoxetine Norepinephrine reuptake inhibitor  Bupropion* Norepinephrine and dopamine reuptake inhibitor  Guanfacine Selective α2A agonist Tricyclic antidepressants*  Amitriptyline Norepinephrine and dopamine reuptake inhibitor
Norepinephrine and dopamine reuptake inhibitor
Norepinephrine and dopamine reuptake inhibitor
Norepinephrine and dopamine reuptake inhibitor  Desipramine  Imipramine  Nortriptyline

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; GABA, γ-aminobutyric acid.

*Off-label.

It is essential to educate coaches, families, and other sports personnel working with athletes with ADHD about this disorder. Privacy of the patient should be maintained throughout these interactions. The patient and their parents (if applicable) need to document their approval to involve other individuals. The extent of the team's involvement should be detailed in the medical record by the physician when appropriate.

ADHD Mimics: Pattern Identification for Differentiation

There are various medical conditions that can mimic the signs and symptoms of ADHD. Appropriate diagnosis and treatment of ADHD is paramount, particularly in athletes, because there are potential adverse effects of pharmacologic treatment and restrictions placed by various sports organizations regarding the use of stimulant medications.21

Difficulty concentrating, inattentiveness, and impulsivity can be presenting symptoms of several other psychological conditions, including, but not limited to major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, bipolar disorder, and obsessive-compulsive disorder.22ADHD symptoms are often instigated by external stimuli and are constant, whereas symptoms of mood disorder are more commonly episodic.23 Use of condition-specific screening tools, such as Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale, can help differentiate between ADHD and other psychologic disorders, although the diagnoses are not mutually exclusive (Table 4).

TABLE 4. - Psychological Conditions that May Lead to ADHD-like Symptomatology, and Corresponding Assessments Conditions Assessment Tools Learning disabilities  Intellectual disability Intelligence quotient tests
• Cognitive assessment system
• Kaufman assessment battery for children
• Stanford–Binet intelligence scale
• Wechsler adult/Children intelligence scale  Language communication disorders Sequenced inventory communication development  Autism spectrum disorders Modified checklist for autism in Toddlers (18 and 24 months)
Child development review (18-60 months)
Pervasive developmental disorders screening
Autism screening questionnaire
Eyberg Child behavior inventory  Depression disorder Children
• Children's depression inventory
• Reynolds Child depression scale
Adolescents
• Reynolds adolescent depression scale
• CES-D
• BDI
• PHQ-9
Adults
• CES-D
• BDI
• PHQ-9  Anxiety disorder Generalized anxiety disorder scale
Short health anxiety inventory
Beck anxiety scale Attachment disorders  Oppositional defiant disorder Freely available scales
• National institute for Children's health quality Vanderbilt assessment scale
• Swanson, Nolan and pelham, version IV, teacher and parent rating scale
Fee for use
• Connors 3
• Child behavior checklist  Obsessive compulsive disorder Obsessive-compulsive inventory-revised
Florida obsessive-compulsive inventory
For monitoring
• Yale–Brown obsessive-compulsive scale  PTSD PTSD screening checklist
Startle, physiologic arousal, anger, numb score Personality disorder  Substance abuse CAGEa questions
National institute on alcohol abuse and alcoholism quantity and frequency questionnaire
Drug abuse screening test
United States preventive services task force–recommended screening tools
• AUDIT
• AUDIT-C

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; AUDIT, alcohol use disorders identification test; BDI, beck depression inventory; CES-D, center for epidemiologic studies depression scale; PHQ-9, Patient Health Questionnaire-9; PTSD, posttraumatic stress disorder.

Acronym: Cutting down; Annoyed by criticism, Guilty feeling, Eye-opener.

Behavioral dysfunction and outbursts are common among populations with autism spectrum disorders, oppositional defiant disorder, some personality disorders, substance use or abuse, and ADHD.22,24 Persons with autism spectrum disorders often exhibit an inability to tolerate alterations in their environment, whereas features of impaired behavioral composure are more common in ADHD.25,26

Medical conditions, such as lead poisoning,27,28 malnutrition-related deficiencies,29 cardiovascular pathologies,20,30 sleep disorders,31,32 and endocrine disorders33 can be distinguished from ADHD through history, physical examination, and other distinctive tests (Table 5).

TABLE 5. - Physiological Conditions Mimicking or to Be Considered as Differential Diagnosis for ADHD Conditions Examples Additional Information and Further Testing Neurodevelopmental syndromes Fragile X syndrome, fetal alcohol syndrome Genetic testing Motor coordination disorders Cerebral palsy, muscular dystrophies Genetic testing, muscle biopsy Hearing or visual impairment Congenital versus acquired causes Vestibular/vision testing, audiometry; referral to ophthalmologist, neuro-ophthalmologist, audiologist, or otorhinolaryngologist Central nervous system conditions (infectious, trauma) Encephalitis, meningitis, neurosyphilis, CVA, sickle cell CVA, traumatic brain injury, concussion Brain imaging: MRI, magnetic resonance angiography, functional MRI, quantitative EEG
Cerebrospinal fluid testing Iron deficiency with or without anemia Chronic blood loss, decreased production or dietary intake, chronic kidney disease, malabsorption Complete blood count, iron studies Seizure disorder Epilepsy, absence or myoclonic seizures EEG, referral to neurology Lead poisoning Measure blood levels Endocrine disorders Thyroid disease, hyper/hypothyroidism, thyrotoxicosis, diabetes mellitus, exogenous ingestion of insulin Thyroid studies, hemoglobin A1c, insulin, C-peptide level Cardiac abnormalities Heart failure Electrocardiography, echocardiography, cardiology referral Malnourishment Malabsorptive disorders (celiac disease, inflammatory bowel disease), eating disorders, low energy availability Vitamin deficiency Assess growth parameters
Dual-energy X-ray absorptiometry, eating disorder screening questionnaires, laboratory testing (prealbumin, leptin, erythrocyte sedimentation rate) Sleep disorders Sleep apnea, narcolepsy, restless leg syndrome, parasomnias Polysomnography, ferritin levels

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CVA, cerebrovascular accident; EEG, electroencephalography; MRI, magnetic resonance imaging.

Central nervous system trauma or infection can mimic ADHD. Similar to ADHD, sports-related injuries, such as concussions, can lead to mood disturbances, cognitive dysfunction, reduced attention, and somatic idiosyncrasies.3,34,35 History of multiple head injuries, central nervous system infection, cerebral vascular disease, or brain tumor suggests a diagnosis other than ADHD.36,37

Conditions affecting the vestibular-visual system simulate ADHD symptoms and can be assessed with vestibular, visual, and audiologic testing and referral to suitable specialists (ie, audiologist, ophthalmologist, or otorhinolaryngologist).38,39

It has also been reported that psychosocial factors, such as social media, can lead to impaired attention, memory, information processing, and problem-solving (Table 6).40,41 Effects of stress or considerable fluctuations in the athlete's environment, including school absence, disorientation, and changes in mental health, can mimic ADHD.42 Moreover, the dynamics of caregiver relationships, specifically inadequate or corrective parenting and parental psychopathology, may result in childhood ADHD-like behaviors that can persist into adulthood.43–45

TABLE 6. - Psychosocial/Environmental Scenarios that May Lead to ADHD-like Symptomatology, and Corresponding Testing Condition Examples Additional Methods of Testing Stress or distraction by external stimuli Occurring in multiple environments (eg, school, home, work, social media) • Vanderbilt ADHD diagnostic teacher and parent rating scales, Brown attention-deficit disorder symptom assessment scale, Conners abbreviated symptom questionnaire
• HEADSS psychosocial interview Caregiver dynamics Inadequate or corrective parenting
Parental psychopathology (eg, substance abuse, psychological disorder) • Mental health assessment of caregivers
• Child protective services involvement Child abuse or neglect • Skeletal survey radiography, head imaging
• Abdominal trauma: Liver function tests, lipase/amylase, urinalysis, fecal occult blood test
• Coagulation studies: Complete blood count, platelets, prothrombin time, partial thromboplastin time
• Urine toxicology Adverse childhood experiences

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; HEADSS, home, education/employment, peer group activities, drugs, sexuality, suicide/depression.

Attention-deficit/hyperactivity disorder is a complex issue that may be too challenging for a single health care professional to manage. As ADHD can imitate or coincide with other diagnoses, understanding these parallels and distinguishing them from ADHD will promote appropriate diagnosis and management of athletes with ADHD. We are advocating a team approach that is comprised of clinicians with specific expertise for adequate clinical management (Tables 4–6).

ADHD and Issues Related to Diversity, Equity, and Inclusivity

Globally, ADHD is more prevalent in boys than girls.46 However, diagnosis of ADHD in girls is often delayed. Social norms for behavior among girls may disguise ADHD-related dysfunction and delay observation of ADHD symptoms.

Boys are more likely to be referred for hyperactive symptoms, whereas girls are more likely to be referred for learning problems.47 This might affect the treatment rates for ADHD.48 Because of the frequency of disruptive classroom behavior, boys are often presumed to exhibit gender-correlated behavioral patterns compared with girls. However, girls tend to have their ADHD behaviors overlooked and are diagnosed with generalized anxiety disorder.49 When expulsion and suspension are a school's primary means of handling behavioral problems, boys are more likely to have ADHD behaviors misinterpreted as conduct issues.50 In contrast, although girls receive school suspension less often, this does not mean that girls with ADHD are not impaired and do not need referral for treatment.51

More research is warranted to examine the contributing risk factors for ADHD and the components of socioeconomic status.52 Compliance with medications and other treatments correlate well with the socioeconomic background of the child's family. When receiving behavioral and pharmacologic treatments, children from low socioeconomic backgrounds do not experience substantial improvement and are less likely to adhere to treatment.53 Parental engagement may be the primary determinant, making it even more important that clinicians actively address cultural competencies to aid in communication with families about their child's ADHD treatment.54,55

Children from marginalized communities are less likely to receive an ADHD diagnosis than the most represented groups.56 Black people are about two-thirds less likely to be recognized as having ADHD than White people. In one study, Black children were diagnosed with ADHD less often than White children despite more symptoms of distractibility and hyperactivity.57 Children of marginalized communities diagnosed with ADHD are less likely to use their prescribed medication and have a higher drop-out rate from treatment. There are different hypotheses explaining these disparities: 1) less health care access for those in marginalized communities; 2) poor ability to pay for health care; 3) communication and language barriers; and 4) known ADHD stigma and negative views toward disability.58

Children and adolescents with parents born in traditionally non–English-speaking countries are less likely to be treated with stimulants.59 For immigrant children, ADHD medication is prescribed less frequently, and the children are less likely to take the medication. This increases with the concentration of foreign-born children in the geographic area around the child's home.60

The COVID-19 pandemic has likely led to specific risks for individuals with ADHD, especially those who are vulnerable to distress caused by physical distancing measures. Loss of social structure because of school closures, distance from hobbies and friends, and anxiety related to isolation may cause behavioral disruptions in children and adolescents with ADHD, in addition to worsening their sleep issues. Preexisting disparities because of factors discussed above may have worsened during the COVID-19 pandemic. More research is required to analyze the pandemic's impact in this regard.61

Pharmacotherapy

Each drug has its own special considerations when used by athletes. Table 3 lists medications currently approved by the US Food and Drug Association (FDA) for ADHD. Medications used to treat ADHD are categorized as stimulants or nonstimulants; most published research addresses norepinephrine and dopamine pathways.62,63Stimulants remain first-line medications; nonstimulant medications may be considered when stimulants fail, are poorly tolerated, or are contraindicated.64,65Stimulants for ADHD treatment include methylphenidate, dextroamphetamine-amphetamine salts, modafinil, and dextroamphetamine; most are available in short- and long-acting formulations.66,67 Nonstimulant medications include atomoxetine, tricyclic antidepressants (TCAs), clonidine, guanfacine, and viloxazine.1,12,68,69 Adverse effects of TCAs may make them less tolerable to athletes. Bupropion is prescribed for off-label use and is typically an adjunct to first-line therapy.12,70,71

Medication Adverse Effects

Medication class and mechanism of action often determine the adverse effects observed in athletes treated for ADHD.1 When discussing possible adverse effects, it is important to understand the mechanism of action of each drug class. Common adverse effects of any stimulant include decreased appetite, gastrointestinal upset, sleep disturbances, irritability, headache, elevated heart rate, and increased blood pressure.2,5,11,66,70

Sudden cardiac death in athletes is a concern and has been reported in those using stimulants to manage their ADHD.3,11 It is currently believed that stimulant use does not increase the risk of sudden cardiac death in patients without underlying cardiovascular disease.1,3,11,72 However, dextroamphetamine-amphetamine salts carry a warning for cardiovascular events and sudden death with misuse. Therefore, stimulants should not be prescribed for athletes at risk for cardiovascular disease. Current evidence does not support ordering electrocardiography routinely because of starting stimulant medications in children.73–75 Although stimulant medications may cause elevations in heart rate and blood pressure, there seems to be no increased incidence of sudden cardiac death with the judicious, proper use of stimulant medications for the treatment of ADHD.76,77 Routinely ordering electrocardiography before initiating stimulant medications has not been shown to add benefit in preventing sudden cardiac events78,79 and may result in treatment delay and increased or unnecessary anxiety. Detailed family history and physical examination are therefore crucial before initiation of stimulants, because these will be the main determinants of whether electrocardiography is needed. All children started on stimulant medications for ADHD should be monitored for palpitations, chest pain, high blood pressure, and tachycardia.80,81 Clinicians must also remember that stimulants can theoretically increase the risk of arrhythmias.82

Athletes taking stimulants have an elevated core body temperature with physical activity that can increase the risk of exertional heat illness.83 In athletes whose sports require considerable exertion or occur in hot or humid environments, clinicians must understand this increased risk of heat illness when prescribing stimulants for ADHD. Of note, clinically relevant hyperthermia, rhabdomyolysis, and hypertension after therapeutic use of stimulants for ADHD has not been reported.84–86 Risk for these effects is theoretical and extrapolated from data on use of ephedra as a performance enhancer and improper stimulant use or abuse.86–88 More studies are needed to observe whether proper use of stimulant medications in athletes with ADHD can lead to such adverse effects. Based on current evidence, it is likely that properly dosed stimulants can be safely used without clinically significant risk.89,90 Treatment need not be delayed, because benefits can outweigh the theoretical risks as long as monitoring begins with the initial prescription of the stimulant.

Atomoxetine is one of the most commonly prescribed nonstimulant medications for ADHD.5 Its adverse effects include gastrointestinal disturbance, weight gain, liver toxicity, and hypertensive crisis.1,3,91 Clonidine and guanfacine, both α2 agonists, are also nonstimulant options with common adverse effects of dizziness, sedation, bradycardia, hypotension, and QT prolongation.1,3 TCAs are another off-label option, but the potential adverse effects (eg, weight gain, dry mouth, fatigue, cardiac dysrhythmia) often prevent their use in athletes.3 Of note, suicidal tendency is among the top 20 reported adverse effects of nonstimulant medications.91 Suicidal ideation and mania are serious potential adverse effects of viloxazine; less serious adverse effects include elevated blood pressure and heart rate, headache, and fatigue.92

The Role of Exercise in the Treatment of ADHD

Despite being the most commonly diagnosed pediatric psychiatric disorder,93 the prevalence of ADHD may be disproportionately represented in athletes because of the attention-activating effects of physical activity.3,11,12,14,94–98Athletes, families, and caregivers who are apprehensive about the mainstream treatment with psychostimulant medications may seek exercise as an alternative therapeutic option.3,11,93 Sports participation may help develop physical skills and control in young athletes with ADHD by building motor coordination and static-dynamic balance and improving their psychosocial skills. More research is needed to demonstrate whether the prevalence of ADHD is overrepresented in athletes because of attention-activating effects of physical activity, or because those with ADHD gravitate toward pursuits that require attention activation.

Athletic participation and regular exercise serve as emotional and physical outlets and offer positive reinforcement in a venue where impulsivity can be an advantage.