Case text with master prompt edited for antidoping situation.
AI Model: Sonnet 4.5 (Claude) on November 6th, 2025.
Expert: Carina Brunner

Antidoping case study

A 20-year-old floorball player in the L-UPL has recently been diagnosed with ADHD. Her general practitioner referred her to a specialised psychologist for assessment and the general practitioner has now prescribed Concerta®. The next competition is in four weeks. She knows that all the players on her team are part of the TUE pool and that she is required to obtain advance therapeutic use exemptions (TUEs). However, she participated in the U19 World Championships last year and wonders if this will affect her TUE application. After reviewing the application criteria, she also wonders if the reports are sufficient.
How do you address these questions?

Introduction

Among the most challenging scenarios I encounter as a sports physician involves athletes receiving new diagnoses of conditions requiring prohibited medications after achieving elite competitive status. The intersection of recent diagnosis, compressed timelines, and stringent anti-doping requirements creates complex clinical and regulatory challenges demanding careful navigation.
ADHD affects approximately 2.5-4.4% of adults, with many never having received childhood diagnosis. [1] However, adult-onset ADHD diagnoses requiring stimulant medication create heightened anti-doping concern. Methylphenidate (Concerta®) appears on the WADA Prohibited List as prohibited in-competition due to performance-enhancing potential in healthy individuals. [2] The fundamental challenge lies in distinguishing legitimate medical diagnosis from strategic diagnosis-seeking to obtain legal access to performance-enhancing substances.
My role requires balancing multiple responsibilities: ensuring appropriate medical care; protecting clean sport principles; navigating regulatory frameworks when international competition history affects TUE jurisdiction; and providing realistic assessment of TUE approval probability when diagnostic documentation may be insufficient.

Case Reference

Our twenty-year-old L-UPL floorball player presents multiple concerns from an anti-doping perspective: recent diagnosis, adult presentation, assessment by psychologist rather than psychiatrist, general practitioner prescription, and timing relative to elite competition. Her U19 World Championships participation establishes international-level athlete status, fundamentally changing TUE requirements. Her awareness of teammate TUE prevalence raises questions about diagnostic motivation. These complexities require careful exploration while providing realistic assessment of the significant challenges she faces.

Clinical Background

ADHD is characterized by persistent inattention and/or hyperactivity-impulsivity interfering with functioning [3]. DSM-5 requires several symptoms present before age 12, symptoms in multiple settings, clear functional impairment, and exclusion of alternative explanations. [3] This creates particular challenges for adult diagnosis: retrospective recall may be unreliable, adult structure may mask compensated symptoms, and differential diagnosis becomes complex.
The WADA TUE framework requires four criteria: (1) significant health problems without the substance; (2) therapeutic use produces no additional enhancement beyond normal health; (3) no reasonable permitted alternative exists; and (4) necessity not resulting from prior non-therapeutic use. [2] For ADHD, WADA emphasizes diagnostic rigor, comprehensive neuropsychological testing, childhood symptom documentation, and differential diagnosis exclusion. [4]
Critical issues in adult-diagnosed ADHD involve establishing childhood onset. Research demonstrates that adult self-report of childhood symptoms shows limited correspondence with prospective data, raising validity concerns about purely retrospective diagnoses. [5] Differential diagnoses—anxiety disorders, mood disorders, sleep disorders, stress-related conditions, and athletic burnout—must be rigorously excluded. [6]
Gold-standard assessment requires: structured diagnostic interview; neuropsychological testing; childhood documentation review; collateral informant interviews; comprehensive differential diagnosis assessment; and functional impairment documentation across multiple domains. [7] This evaluation requires specialized expertise—typically a psychiatrist or neuropsychologist—and cannot be adequately completed in brief assessment.

Management and Regulatory Reasoning

I begin by establishing critical facts. Her U19 World Championships participation establishes international-level athlete status, requiring advance TUE approval from the International Floorball Federation before competing with methylphenidate. [8] Retroactive provisions available for some national-level athletes do not apply.
With competition in four weeks, approval is highly unlikely. Standard TUE processing requires 21-30 days minimum, and applications with insufficient documentation often extend further. [2] Emergency TUEs apply only to urgent medical conditions or unforeseeable circumstances—her situation likely does not qualify. [8]

I assess documentation adequacy against ISTUE requirements:
Childhood symptom onset: She must demonstrate symptoms present before age 12 through contemporary documentation (report cards, teacher comments) and collateral history. Retrospective self-report alone is insufficient.
Comprehensive assessment: Her psychologist assessment likely does not meet TUE committee standards. Was structured diagnostic interview used? What neuropsychological testing was performed? Were differential diagnoses systematically excluded? General practitioner prescription, while medically reasonable, does not provide specialist confirmation expected by TUE committees.
Functional impairment: If she achieved World Championship participation despite alleged ADHD, committees may question whether symptoms cause significant impairment or whether diagnosis-seeking follows competitive advancement.
Treatment alternatives: Has she tried atomoxetine or bupropion (non-prohibited alternatives)? Were non-pharmacological interventions attempted? Direct stimulant prescription without trying alternatives reduces TUE approval likelihood. [9]

After reviewing requirements, I provide honest assessment: her current documentation is almost certainly insufficient for international-level TUE approval.
I recommend urgent psychiatrist referral for comprehensive evaluation including: structured diagnostic interview; comprehensive neuropsychological testing; collateral history from parents; childhood documentation review; systematic differential diagnosis exclusion; functional impairment assessment; and trial of non-prohibited alternatives if not attempted. This process requires 8-12 weeks minimum. Obtaining TUE approval for competition in four weeks is highly improbable.

She faces difficult choices:
Option A: Defer competition until TUE approved—pursue comprehensive evaluation properly; compete only after approval obtained.
Option B: Compete without medication—discontinue methylphenidate allowing adequate washout (minimum one week); compete without treatment; pursue evaluation for future competitions.
Option C: Attempt emergency TUE application despite low approval probability given documentation insufficiency.
Option D (NEVER RECOMMENDED): Competing with medication without TUE constitutes anti-doping violation risking 2-4 year suspension, disqualification, and reputational damage. [10]
I strongly recommend Option A or B. Despite low probability, I support emergency TUE application attempt if she wishes, preparing her for likely denial.
I coordinate with her general practitioner and psychologist to gather existing documentation and explain TUE requirements. I provide comprehensive anti-doping education covering strict liability, supplement contamination risks (12-58% of supplements contain undeclared prohibited substances), [11] medication checking resources (Global DRO), and violation consequences.

Return to Play and Clearance

Return to play depends on her decision and TUE outcome. If she competes without medication, I provide clearance after confirming adequate washout and educate about managing symptoms without medication: behavioral strategies, performance preparation, stress management, and realistic expectations. If she defers competition, focus shifts to completing comprehensive evaluation thoroughly.
If TUE is eventually approved, ongoing considerations include: validity duration and renewal requirements; dose modification procedures; international competition TUE recognition; doping control procedures; and whereabouts obligations if in Registered Testing Pool.

Prognosis and Athlete Counseling

Prognosis regarding TUE approval is guarded given documentation limitations and adult-diagnosed presentation. However, if comprehensive evaluation supports genuine ADHD with childhood onset, adequate documentation can eventually be assembled, though requiring months rather than weeks.
I encourage approaching diagnosis with complete honesty. The fundamental question is not “how can I get TUE approval?” but “do I genuinely have ADHD, and what treatment is medically appropriate?” If comprehensive evaluation does not support ADHD—perhaps symptoms reflect anxiety, sleep issues, or stress—this serves her wellbeing despite TUE disappointment.
We discuss ethics openly. Athletes with genuine medical conditions have legitimate rights to treatment and TUE approval when criteria are met. The challenge is demonstrating genuine medical necessity convincingly. I explore whether other factors might explain symptoms: stress, burnout, anxiety, sleep problems, or life transitions.
I emphasize evidence-based psychosocial interventions: cognitive-behavioral therapy for adult ADHD, organizational skills training, environmental modifications, and stress management. If TUE approval is delayed or denied, non-prohibited alternatives (atomoxetine, bupropion) represent options, though with reduced efficacy. [9]
I establish long-term follow-up expectations: complete comprehensive psychiatric evaluation; trial non-prohibited alternatives; pursue psychosocial interventions; assemble childhood documentation systematically; submit thorough TUE application when documentation complete; and prepare for possible denial requiring alternative treatment pathways.

Take-Home Messages

• Adult-diagnosed ADHD in elite athletes faces heightened TUE scrutiny requiring exceptionally robust diagnostic documentation—recent diagnosis timing, adult presentation, and psychologist/GP assessment typically do not meet international TUE committee standards without comprehensive psychiatrist evaluation and neuropsychological testing.
• International-level athlete status requires advance TUE approval from International Federation—U19 World Championships participation establishes this classification; competing within four weeks is highly improbable without pre-existing comprehensive documentation; retroactive national-level provisions do not apply.
• Childhood symptom onset before age 12 represents the most challenging documentation requirement—TUE committees require contemporary childhood documentation combined with structured collateral interviews; adult retrospective self-report alone is insufficient given recall bias and performance-enhancement concerns.
• Athletes must choose between competing without medication or deferring competition—competing with methylphenidate without approved TUE constitutes anti-doping violation risking 2-4 year suspension; either discontinue medication with adequate washout or withdraw until proper evaluation and TUE approval completed.
• Diagnostic validity must drive the process rather than TUE acquisition goals—athletes should approach comprehensive evaluation honestly seeking accurate diagnosis for wellbeing; if evaluation does not support ADHD, alternative explanations (anxiety, sleep disorders, stress) should be explored and treated appropriately regardless of anti-doping implications.
• Comprehensive evaluation requires 8-12 weeks minimum including psychiatrist assessment, neuropsychological testing, childhood documentation gathering, differential diagnosis exclusion, non-prohibited medication trials, and functional impairment documentation—attempting emergency TUE with insufficient documentation will likely result in denial; proper evaluation timeline must be accepted for credible application.

Image credits: Gemini, Model: flash 2.5.
https://gemini.google.com/
Prompt: “A 20-year-old female floorball player sits in a quiet consultation room at a sports medicine clinic, dressed in casual team gear. She holds a Concerta® blister pack in one hand and looks thoughtfully toward her open laptop showing the International Floorball Federation TUE Application Portal.
On the desk lie scattered documents: a partially completed “TUE Application” form, neuropsychological test reports, and a handwritten note reading “Competition in 4 weeks.” A stethoscope, a psychiatrist’s referral form, and a sealed “Doping Control” kit emphasize the intersection of medicine and regulation.
In the softly lit background, a transparent overlay shows two contrasting paths: one leading toward an international arena with WADA and IFF banners, the other toward medical charts and diagnostic testing symbols—representing the dual demands of elite competition and clinical validation.
The atmosphere is realistic, slightly dramatic, and introspective—evoking uncertainty, responsibility, and the weight of ethical compliance. The color tone is natural with gentle contrast; depth of field centers focus on the athlete’s expression and the documents.
Style: photorealistic, cinematic lighting, natural textures, subtle storytelling composition, professional sports medicine realism”.

References

1. Fayyad J, Sampson NA, Hwang I, et al. The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. Atten Defic Hyperact Disord. 2017;9(1):47-65.
2. World Anti-Doping Agency. International Standard for Therapeutic Use Exemptions (ISTUE). Montreal: WADA; 2021.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
4. World Anti-Doping Agency. Medical Information to Support the Decisions of TUE Committees: Attention Deficit Hyperactivity Disorder (ADHD). Montreal: WADA; 2019.
5. Mannuzza S, Klein RG, Klein DF, et al. Accuracy of adult recall of childhood attention deficit hyperactivity disorder. Am J Psychiatry. 2002;159(11):1882-1888.
6. Schatz DB, Rostain AL. ADHD with comorbid anxiety: a review of the current literature. J Atten Disord. 2006;10(2):141-149.
7. Asherson P, Buitelaar J, Faraone SV, Rohde LA. Adult attention-deficit hyperactivity disorder: key conceptual issues. Lancet Psychiatry. 2016;3(6):568-578.
8. World Anti-Doping Agency. World Anti-Doping Code 2021. Mon­treal: WADA; 2021.
9. Cunill R, Castells X, Tobias A, Capellà D. Efficacy, safety and variability in pharmacotherapy for adults with attention deficit hyperactivity disorder: a meta-analysis and meta-regression in over 9000 patients. Psychopharmacology. 2016;233(2):187-197.
10. World Anti-Doping Agency. Code Compliance & Results Management. Available at: https://www.wada-ama.org/en/what-we-do/results-management. Accessed November 2025.
11. Martínez-Sanz JM, Sospedra I, Ortiz CM, et al. Intended or unintended doping? A review of the presence of doping substances in dietary supplements used in sports. Nutrients. 2017;9(10):1093.
12. Sibley MH, Mitchell JT, Becker SP. Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies. Lancet Psychiatry. 2016;3(12):1157-1165.
13. Cortese S, Kelly C, Chabernaud C, et al. Toward systems neuroscience of ADHD: a meta-analysis of 55 fMRI studies. Am J Psychiatry. 2012;169(10):1038-1055.
14. Volkow ND, Wang GJ, Kollins SH, et al. Evaluating dopamine reward pathway in ADHD: clinical implications. JAMA. 2009;302(10):1084-1091.
15. Knouse LE, Teller J, Brooks MA. Meta-analysis of cognitive-behavioral treatments for adult ADHD. J Consult Clin Psychol. 2017;85(7):737-750.

Not all references were assigned by AI.

The expert’s review

Carina Brunner, Swiss Sport Integrity

AI was asked to generate answers to a case study with aspects to consider regarding the Therapeutic Use Exemption (TUE) application process. In the following, I will only cover the most relevant points from an anti-doping perspective.
This case study was designed to address two aspects: clarification if the floorball player is a National- or International- Level Athlete (NLA or ILA) and the corresponding responsibilities, as well as the evaluation of appropriateness of the available reports.
Both aspects were identified and addressed by AI. The complexity of the situation is acknowledged, and a structured approach is proposed. In parts, the text is slightly repetitive and lengthy. Nevertheless, it addresses useful additional anti-doping topics such as strict liability and offers valuable thoughts on ethics.

Background information

The AI text provides a lot of background information on ADHD, including diagnosis, and correctly summarises DSM-5. The concept of TUEs is well explained. It is also correctly explained that methylphenidate is prohibited in-competition. AI reasons that its inclusion on the Prohibited List is only due to its potential performance enhancing effect. However, substances must meet at least two of the following three criteria for inclusion in the Prohibited List: potential to improve performance, actual or potential health risk, against the spirit of sport. It would have been desirable for the ‘in-competition’ period also to be specified. According to anti-doping rules ‘in-competition’ is the period commencing at 11:59 pm on the day before a competition, through to the end of this competition and the sample collection process relating to such competition. In addition, it should be emphasised that not only the use but also the detection of methylphenidate and its metabolites are prohibited in-competition.

Solution to the concrete questions

NLA and ILA Definitions – AI evaluation

It is correct that the player is considered ILA due to her participation in the Floorball U19 World Championships. Unfortunately, the only source cited here is the WADA Code, which contains general provisions on ILA and NLA. It therefore remains unclear whether the ILA definition of the International Floorball Federation was correctly applied.
I would have preferred to have more information on NLA and ILA definitions, rather than a generalised reference to ‘elite status’. Each International Sports Federation has its own ILA definition, which is based, for example, on world rankings, license or participation in certain international competitions. Therefore, the ILA definitions vary considerably between federations and must be reviewed for each sport individually. At the same time, each National Anti-Doping Organisation (NADO) defines its NLAs (referred to as TUE pool athletes in Switzerland). Both NLA and ILA require prospective TUEs. The AI generated text incorrectly indicates that some NLAs can submit retroactive TUE applications, which could potentially lead to an anti-doping rule violation by a NLA. Only athletes who are neither ILA nor NLA can apply retroactively.

NLA and ILA Definitions – practical advice

As an incorrect ILA and NLA definition can result in an anti-doping rule violation, you should always double-check these definitions. The ILA definitions can be found on the websites and in the scope of the anti-doping regulations of the International Sports Federations. You can also find an overview with links to the ILA definitions of numerous International Sports Federations on the Swiss Sport Integrity website. In addition, the International Testing Agency provides an overview of the International-Level Athlete definitions for its affiliated sports federations.

Supporting medical documentation – AI evaluation

AI assesses the adequacy of the available reports and the time remaining until the next competition realistically. International Sports Federations and NADOs require documentation of ADHD diagnoses in accordance with DMS-5 or ICD-10 criteria by a relevant specialist. Depending on the previously available documentation and the treating physician it can be necessary to refer an athlete to a specialist, e.g. psychiatrist. Moreover, the International Floorball Federation may ask for a second opinion from a psychiatrist – which would also be required for NLAs in Switzerland.
AI suggests either not taking part in competitions or pausing methylphenidate intake until a TUE has been approved. I consider both sensible options. The generated text mentions a washout period of one week for methylphenidate without citing a source. While it is correct that methylphenidate and its metabolites can be detected for several days after use, Swiss Sport Integrity cannot provide washout periods for methylphenidate and other substances indicated for ADHD, as there are no official recommendations from WADA. As a third option, AI proposes an emergency TUE application. This is a misinterpretation of an emergency situation as defined by WADA’s International Standard for Therapeutic Use Exemptions (ISTUE). Onset of an ADHD therapy would usually not be considered an emergency or urgent treatment. Instead, the application process and start of therapy can be handled as described above and the responsible Anti-Doping-Organization might prioritise the TUE application to provide a response of its TUE committee as soon as possible.

Supporting medical documentation – practical advice

In such situations, you ideally reach out to the Anti-Doping-Organization that evaluates the TUE application to verify the necessary steps to be taken, especially as waiting times for referrals can be long.

Further aspects

It is mentioned several times that the athlete must use therapeutic alternatives. The principle and the cited source (ISTUE) are correct. However, in the case of ADHD, there is no need to test permitted substances such as atomoxetine or bupropion (off-label in Switzerland) before using indicated stimulants. This false statement could lead to an unnecessary delay in effective treatment for the athlete, with negative consequences for her private and professional/educational life. This exception is specific for ADHD therapies. For other indications and therapies requiring a TUE, thorough assessment and documentation of permitted alternatives is required for a TUE application.
AI recognises the ISTUE, in particular article 4.2, as a key article that must be fulfilled for obtaining a TUE, but quotes article 4.2 a) vaguely as ‘significant health problems without the substance’. Whereas article 4.2 a) clearly focuses on correct diagnosis and clinical evidence.
I would like to highlight that AI is considering aspects after the approval of a TUE, where sports physicians can assist their patients in order to avoid administrative errors: validity period, renewal applications and dose adjustments. The mentioned international recognition is not necessary if a TUE is granted by the International Sports Federation. And a TUE from the International Sports Federation is automatically valid at national level. In case of a NADO approving a TUE, the athlete must obtain international recognition from its International Sport Federation when becoming ILA.

Author profile

Carina Brunner
med@sportintegrity.ch

Affiliation: Swiss Sport Integrity
Specialization: Anti-Doping
Year of my pharmacy school graduation: 2014
Sports organizations/federations I work with: All federations affiliated to Swiss Olympic and WADA Code Signatories
Fields/topics I am fond of: Anti-doping education for athletes, physicians, and other athlete support personnel
How I use AI: I don’t use AI very much so far, and only in private contexts.