Neurodiversity in Sports: Finding Uniqueness in Differences

Dr. Carla Edwards, MD
Sports Psychiatrist

What is neurodiversity?

The term “neurodiversity” describes differences in brain function and behavioural traits that are considered part of normal variation in the context of human neurodevelopment. (1) It encompasses the many ways in which individuals experience and interact with the world, including the ways that they think, learn, and communicate. (2) Neurodiversity is not a medical diagnosis, rather a manner of describing individuals’ differences in brain function and behavioural traits using words other than “normal” and “abnormal.” Neurodiversity-affirming practice takes a strengths-based approach to education, activity, and ability (2). While “person-first” language is commonly felt to be most appropriate by professionals in medicine and science while describing individuals who are neurodiverse (ie. “person with autism”), this is opposed by many individuals in the autism community who advocate that “identity-first” language is least harmful (ie “autistic person”). (3-6) Identity-first language is used for the rest of this article. “Neurotypical” individuals have strengths and challenges that aren’t affected by differences in how their brains work.

Conditions included under the “neurodiverse” umbrella that have been explored in athletes include attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and specific learning disorders (LDs). Neurodiverse individuals can satisfy diagnostic features of one or more of these conditions simultaneously and may experience an array of comorbidities that can complicate diagnosis and management. It is important for sports medicine practitioners to understand the unique features and challenges presented by neurodiversity to optimize function, relationships, performance, and the sport experience for athletes.

It is now widely accepted that athletes are susceptible to the same mental health symptoms and disorders as the general population. It stands to reason that this includes neurodiverse conditions. Understanding the features of these conditions can help with anticipation of potential challenges that may be encountered in the sport setting.

Key features of ADHD, ASD, and LDs are listed below. (7)

1. ADHD

Prevalence: 5-11% (age <18), may be higher in athlete populations (8-10)

3 subtypes:

• Predominantly inattentive presentation: features 6 or more symptoms of inattention for more >6 months, inconsistent with developmental level, and negatively impacting social, academic, or occupational activities
• Predominantly hyperactive/impulsive (H/I) presentation: features 6 or more symptoms of H/I for more >6 months, inconsistent with developmental level, and negatively impacting social, academic, or occupational activities
• Combined presentation: criteria are met for inattentive and H/I subtypes for the previous 6 months

Inattentive symptoms include failure to give close attention to tasks, careless mistakes, difficulty sustaining attention, distractibility, difficulty starting and finishing tasks, challenges with organization, and losing or forgetting things.

H/I symptoms include fidgeting, squirming, difficulty sitting still, difficulty engaging in activities quietly, talking excessively, difficulty waiting for their turn, interrupting or intruding on others, and using other people’s belonging without asking permission.

Several inattentive or H/I symptoms are present in 2 or more settings (ie. home, school, work, social, sports, other activities), and there is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

2. ASD

Prevalence: 0.70-3% (age <18)

Persistent deficits in social communication and social interactions spanning multiple contexts, including:

• Social-emotional reciprocity ranging from abnormal social approach, difficulty initiating social interactions, restricted sharing of interests, emotion or affect, and difficulty engaging in back-and-forth conversations
• Nonverbal communicative behaviors used for social interactions, including abnormalities in eye contact and body language, deficits in understanding and use of gestures, and total lack of facial expressions and nonverbal communication
• Developing, maintaining, and understanding relationships including adaptive behaviour, difficulty engaging in imaginative play or making friends, and absences of interest in peers

Restricted, repetitive patterns of behaviour, interests, or activities, manifested by at least 2 of:

• Stereotyped or repetitive motor movements, use of objects, or speech
• Cognitive rigidity, inflexible adherence to routines, insistence on sameness, ritualized patterns of verbal and nonverbal behavior, difficulties with transitions
• Highly restricted, fixated interests that are abnormal in intensity or focus
• Sensory processing differences (hyper- or hypo-reactivity to sensory aspects of the environment (including pain, temperature, sounds, textures, smells, and visual stimuli)

Levels of severity are defined by the degree of support that is required to address the elements of social communication and restricted, repetitive, behaviours:

• Level 1: Requiring support
• Level 2: Requiring substantial support
• Level 3: Requiring very substantial support

Symptoms may present in the early developmental period but not fully manifest until social demands exceed limited capacities; or may be masked by learned strategies later in life

3. LDs

Prevalence: 3-10% of global population

Difficulties learning and using academic skills as indicated by the presence of the following symptoms (that have persisted for at least 6 months despite targeted interventions)

• Inaccurate or slow and effortful word reading
• Difficulty understanding the meaning of what is read
• Difficulties with spelling
• Difficulties with written expression
• Difficulties mastering number sense, facts, or calculation
• Difficulties with mathematical reasoning, including severe difficulty applying mathematical concepts, facts or procedures to solve quantitative problems

The affected skills are substantially and quantifiably below those expected according to the individual’s chronological age, and cause significant interference with academic or occupational performance, or with activities of daily living.

The learning difficulties begin during school-age years but may not manifest fully until the demands on for the affected skills exceed the individual’s limited capacities.

Accommodations can be helpful to improve function and success. These can be tailored to the specific needs of the individual relative to their symptoms and functional challenges, and should be considered in educational, occupational, and sports environments.

Masking (adoption of neurotypical traits by neurodivergent individuals to adapt to environmental or other challenges) can lead to under-recognition of conditions and misdiagnosis. It is a social compensation that may occur in environments where neurodivergent behaviors are not accepted or understood to avoid stigma or bullying and allow the individual to assimilate. (11-13)

Other types of neurodivergence include dyslexia, dyscalculia, Tourette’s Syndrome(TS)/tic disorders, sensory processing disorder, and various categories of “giftedness.”

Despite the array of challenges that can be experienced by neurodiverse individuals, a brain that works differently can also have many strengths. These strengths can include enhanced memory, higher than average visuospatial skills, and advanced mathematical abilities. An individual with dyslexia may struggle with reading but may have advanced abilities to visualize 3- dimensional pictures. This may lead them to successful roles in graphic design, arts, and engineering, which can also translate to greater ability to “see” and understand visuospatial aspects of certain sports. It is not uncommon for neurodiverse individuals to present with a “mixed picture” of features related to strengths and others that lead to difficulties. This can create a very challenging experience for the individuals involved; and can also impact the sport setting,

Common comorbidities to ADHD, ASD and LDs include anxiety, depression, sensory processing disorder, and obsessive-compulsive disorder (OCD).

Impact on Sports

Many features of elite sports may appeal to the strengths of neurodiverse individuals, including: (8)

• Intense focus
• Structure for training regimens
• High energy expenditure
• Structured play
• Personality and cognitive requirements

Sport may be helpful in exposing neurodiverse individuals to predictable peer socialization situations in sport, which can be protective for those with social-emotional reciprocity differences. (2)

There are additional features of sports that can exacerbate the cognitive, sensory, behavioural, and other needs of neurodiverse individuals. These include noise (ie crowd noise, whistles, cow bells, air horns), last minute schedule changes, complicated play designs or strategies, and new play designs that need to be immediately executed.

Recognizing the ways in which an athlete’s neurodiversity affects them, in terms of sensory experience, interpersonal relationships, cognitive rigidity, difficulties with transition, problems sustaining attention, ability to learn, focus, adaptability to changing conditions, and emotional reactivity should guide the development of a support plan.

One qualitative study explored the experience of neurodiverse athletes in sport. Themes which emerged from that study included athletes feeling lack of belonging, overwhelmed and overloaded, and a need for plans to help the participants navigate the sports environment. (14)

Case 1

14-year-old female Team Canada Field Hockey goalie with diagnoses of ADHD combined presentation, sensory processing disorder, and autism spectrum disorder. She also experiences episodes of intense panic attacks as well as overthinking and chronic general worries. Challenges include difficulty staying engaged in the game when she didn’t get many shots and being easily distracted by the crowd noise and air horns. She also experiences negative thought spirals when scored upon and ruminates about mistakes. If game strategy changed unexpectedly, she experiences panic attacks and shuts down. Her coach is “a yeller”, and this style tended to make her shut down and stop playing.

Case Discussion:

Neurodiverse athletes have different needs in the sport setting. Specific areas of need include:

• Communication: information, directions and feedback should be relayed clearly, using words that can be understood by the individual. Providing this information in written form to serve as reminders may be helpful. Following up to ensure they understand the information would be helpful.
• Attention to the sensory environment: noise-reducing earbuds or ear plugs may be helpful for individuals who have significant sensitivity to sounds. Other individuals may have to wear sunglasses or shaded visors due to light sensitivity.
• Efforts may be required to help the neurodiverse individual feel more comfortable in the social space of the team and sport, particularly if travel is involved. This may include facilitating social relationships and strategically selecting partners and roommates to match individuals with similar or complimentary features.
• If an athlete has aversions to touch (including handshakes and hugs); efforts should be made to find ways for that athlete to comfortable participate in celebrations and support gestures.
• Neurodiverse athletes may experience distress and shut down when surrounded by intense yelling (ie by coaching staff). Coaches should be informed of this challenge, and methods of communication should be adjusted to a mode that is healthier and tolerated.

Approaches to Neurodiverse Athletes

1. Listen: individuals with neurodiversity do not want to be left out. Listen to them, hear them, and collaborate with them for their care.
2. Communicate in ways that can reach them: understand how the individual prefers to receive communication. Some neurodivergent individuals prefer written communication, while others prefer phone calls or face-to-face conversations. Take the time to understand your athlete’s preferences.
3. Recognize and understand uniqueness: everyone is different. The personalities, histories, and preferences of neurodiverse individuals can be very different, even if they have the same conditions.
4. Treat everyone with respect: treat individuals with dignity and ensure their human rights are respected. Accommodations can be constructed to preserve their human dignity.
5. Don’t assume neurodiversity means unintelligent or incapable: while neurodiversity can cause sim individuals to appear or act differently, but this does not directly reflect on their intellectual capabilities and resources.
6. Be aware of team dynamics: additional efforts may be required to facilitate communication and bridge relationships.
7. Be mindful of how you are delivering information: deliver information in small quantities, with frequent check-ins to ensure the correct information is being interpreted and retained. Consider following up with written summaries of the sessions.
8. Avoid comparisons: do not compare neurodiverse and neurotypical people. There may be significant differences in interpretation, perception, communication styles and reactions between different types of athletes.
9. Consider the learning styles of your athletes if you are aware of their differences: Some conditions negatively impact information processing, retention and retrieval. These athletes may benefit from strategies to utilize in their sports with their coaches, including how sport-related strategies are communicated and reinforced.

Take away points:

• Athletes are susceptible for the same mental health symptoms and disorders as the general population, which can include neurodiverse conditions such as ADHD, ASD, and LDs.
• It is important for sports medicine practitioners as well as coaching and team/athlete support staff to have an awareness of the specific needs and strengths of neurodiverse athletes, to reduce triggering situations and establish a healthy environment in which they can navigate effectively.
• Key areas of focus for neurodiverse individuals include cognition, learning, and interacting with their environment.
• Recognition and identification of neurodiverse conditions are made more complex by masking and camouflaging symptoms, behavioural adaptations, and the presence of comorbidities such as anxiety, depression, sensory processing disorder, and OCD.
• Education, understanding, and incorporating sport-related accommodations (including communication, inclusion and planning) are essential in assisting neurodiverse individuals in the sport environment.
• Neurodiverse individuals can have one or more diagnoses and require special considerations in the sport environment; but can still engage in training and competition most of the time.

References:

1             Clouder, Lynn, Mehmet Karakus, Alessia Cinotti, María Virginia Ferreyra, Genoveva Amador Fierros, and Patricia Rojo. 2020. “Neurodiversity in Higher Education: A Narrative Synthesis.” Higher Education80 (4): 757–778. https://doi.org/10.1007/s10734-020-00513-6.

2             Hoare E, Reyes J, Olive L, Willmott C, Steer E, Berk M, et al. Neurodiversity in elite sport: a systematic scoping review. BMJ Open Sport & Exercise Medicine. 2023;9:e001575. https://doi.org/10.1136/bmjsem-2023-001575

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7             American Psychiatric Association. (2022). Neurodevelopmental Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).  https://doi.org/10.1176/appi.books.9780890425787.x01_Neurodevelopmental_Disorders

8             Han DH, McDuff D, Thompson D, et al. Attention-­ deficit/hyperactivity disorder in elite athletes: a narrative review. Br J Sports Med 2019;53:741–5

9             Åkesdotter C, Kenttä G, Eloranta S, et al. The prevalence of mental health problems I n elite athletes. J Sci Med Sport 2020;23:329–35.

10          Ekman E, Hiltunen A, Gustafsson H. Do athletes have more of a cognitive profile with ADHD criteria than non-­ athletes. Sports (Basel) 2021;9:61.

11          Lockwood Estrin G, Milner V, Spain D, et al. Barriers to autism spectrum disorder diagnosis for young women and girls: A systematic review. Rev J Autism Dev Disord 2021;8:454–70.

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13          Cook J, Hull L, Crane L, et al. Camouflaging in autism: A systematic review. Clin Psychol Rev 2021;89:102080.

14          Wood S, Marshall B, Kaiseler M and Wood G. Navigating neurodiversity in elite sport: lived experiences of neurodivergent athletes. Qualitative Research in Sport, Exercise and Health. 2025: 1-15. http://doi.org/10.1080/2159676X.2025.2534896.