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Scubadoc's
Diving
Medicine Online
Comprehensive
information about diving and undersea medicine for the
non-medical diver, the non-diving physician and the specialist. Online Questions, answers
and comment.
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ADHD or ADD
is brain disorder affecting children early in life and continuing on
into adulthood in some adults. The individuals display certain
characteristic behaviors over a period of time, including, inattention,
hyperactivity, and impulsivity.
This
brain disorder, usually recognized early in life, is manifested by an
inability to concentrate or sustain attention. It may or may not be
accompanied by physical hyperactivity. ADD is a significant (but
often over-diagnosed) cause of learning disability. The problem usually
improves with age.
Diving Concerns
---Condition
Related
The following is the latest
requirements for the diagnosis
of ADD (or ADHD):
DSM-IV Criteria for ADHD
The use of DSM-IV criteria to
diagnose ADHD is the current state of the art and allows for greater
uniformity in communication
across such wide sectors as health, mental health, and education.
DSM-IV criteria for ADHD
require the identification of at least 6 out of 9 behaviors to a degree
that is maladaptive and inconsistent with developmental level, in either or both of
the dimensions presented below:
(1) Inattention
Often fails to give close attention
to details or makes careless mistakes in schoolwork, work, or other
activities
Often has difficulty sustaining
attention in 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 (not due to
oppositional behavior or failure to understand instructions)
Often has difficulty organizing tasks
and activities
Often avoids, dislikes, or is
reluctant to engage in tasks that require sustained mental effort (such
as schoolwork or homework)
Often loses things necessary for
tasks or activities (eg, toys, school assignments, pencils, books, or
tools)
Often easily distracted by extraneous
stimuli
Often forgetful in daily activities
(2) Hyperactivity-impulsivity
Often fidgets with hands or feet or
squirms in seat
Often leaves seat in classroom or in
other situations in which remaining seated is expected
Often runs about or climbs
excessively in situations in which it is inappropriate (in adolescents
or adults, may be limited to
subjective feelings of restlessness)
Often has difficulty playing or
engaging in leisure activities quietly
Is often "on the go" or often acts as
if "driven by a motor"
Often talks excessively
Often blurts out answers before
questions have been completed
Often has difficulty awaiting turn
Often interrupts or intrudes on
others (eg, butts into conversations or games
---Treatment Related
As one might expect, there is little
in the literature about diving and psychoactive medications of any
kind. What we have to do is to
extrapolate known dangers to divers in general with the effects and
possible side effects of these
drugs. We published several articles in 'Alert Diver', a publication of
DAN, Divers Alert Network;
Psychological Issues in Diving, DAN's 'Alert Diver', Sept-Dec, 2000) .
This is reproduced in our web page at
http://www.scuba-doc.com/psych.htm . A search of Medline fails to reveal any
material about ADD and diving. Numerous articles are found about the condition and driving - a somewhat
comparable attention related skill - but not at depth/pressure.
Below are listed the label warnings
and listed side effects for clonidine, ritalin and Zoloft, medications often used for this
condition. Please note that all say in one way or another 'This drug may impair the ability to drive or operate
machinery'. Very few drugs have been studied under hyperbaric (increased pressure - for example, when diving)
conditions. One of the effects of increased pressure is "nitrogen
narcosis", an effect similar
to alcohol intoxication that may intensify the psychological side
effects of drugs. Even though the diver may tolerate his medications
without side effects on the surface, there's no way of predicting what
side effects they may have
with increasing depth and time.
Ritalin
(Methylphenidate); Adderal
This drug may impair the ability to
drive or operate machinery. Use care until you become familiar with its
effects. Methylphenidate
should be used with caution in patients with a history of seizures
and/or EEG abnormalities.
There is some evidence that the drug may lower the seizure threshold in
patients with a history of seizures, in those with prior EEG abnormalities in the
absence of seizures, and, very rarely, in those without a history of seizures and no prior evidence of EEG
abnormalities.
Adverse effects that might be
dangerous to diving
CARDIAC ARRHYTHMIAS
FALSE SENSE OF WELL-BEING
IRRITABILITY/NERVOUSNESS
CLONIDINE HCL ORAL
Label Warnings from First DataBank
May cause drowsiness. Alcohol may
intensify this effect. Use care when operating a car or dangerous
machines.
This drug can cause low blood
pressure and cardiac arrhythmias
Adverse
effects that might be dangerous to diving
DIZZINESS
DROWSINESS
FATIGUE OR WEAKNESS
Zoloft
This anti-depressive (Sertraline) has
a low but definite incidence (0.1%) of causing seizures - which would be fatal if occurring underwater.
Adverse effects that might be
dangerous to diving
ANXIETY
DIZZINESS
DROWSINESS
HEADACHE
TIREDNESS/WEAKNESS
TREMORS
Strattera
I am not aware of any studies that show any ill effects of diving while
taking 'Strattera'.
The drug is not similar to other drugs used for ADD and is specifically
not a sympathomimetic medication. [Sympathomimetic drugs increase the
risk of seizures from O2 toxicity.] It has some side effects which
might be inimical to diving but if you take the medication and
don't have these problems - then you probably could dive safely.
Among STRATTERA-treated patients, aggression (0.5%, n=2); irritability
(0.5%, n=2); somnolence (0.5%, n=2); and vomiting (0.5%, n=2) were the
reasons for discontinuation reported by more than 1 patient. These are
not traits that would be good for you or your buddy, whether you are
using EAD or compressed air.
Diving
Risk Assessment
---Risk from the
Condition
Martin Quigley, MD, who is
knowledgeable about diving medicine and is also a diving instructor,
has the following to say: "Most good instructors would have would have
great concerns in certifying as an independent diver an individual who "often...makes careless
mistakes", "often has difficulty in sustaining attention in tasks",
"often does not follow through
on instructions" or "often loses things necessary for tasks". Scuba
diving is very task loading,
and inattention to details (such as tank air remaining and depth/time
limits) can be fatal. There
are certainly risks involved in all activities. But a scuba diver puts
not only himself at risk, but also his buddy and/or and individuals who might
become involved in a rescue effort. Numerous good instructors have made the tough choice to deny scuba
training to teenagers with ADD on medications. It's a tough decision, because these potential students are
usually very bright and enthusiastic. However, I feel that the risks to themselves and others are not worth the
benefits to be obtained from recreational diving. There are many other recreational activities available where
the symptoms of ADD and the medications' side effects would not be potentially life-threatening. "
---Risks from the
Treatment
Although not
proven, nitrox diving might be contraindicated due to risk of seizures
in association with the possible increased risk of oxygen toxicity with
Ritalin and steroids.
Adderall (R) is a combination of
amphetamine and dextroamphetamine, non-catecholamine sympathomimetic agents that stimulate the release of
norepinephrine (NE) and other biologic amines from central adrenergic receptors. Ritalin is a similar drug.
These drugs are known to increase the rate of development of oxygen
poisoning (Clark, Lambertsen),
possibly increasing your risk of a seizure underwater. This would
indicate that you should proceed with caution in the use of nitrox while taking this
medication, particularly if you anticipate multiple depth exposures.
In
addition, they can cause cardiac arrhythmias, a false sense of
well-being and irritability and nervousness - all seemingly adverse to
diving.
Other drugs such as clonidine and sertraline can cause
drowsiness, dizziness, anxiety, headache, fatigue and weakness - all
adverse to diving.
Dive
or not dive
Advice re diving: Case
by case review in treatment responders. Diving with ADD would seem to
be somewhat risky, considering the attention to multiple tasking that
is required in diving. Training
agency standards require medical clearance
and also restrict the maximum depth of dives to 40 feet. Modifiers
would include the types of drugs required; the effects and
responses of each individual to drugs; assessment of the need to dive
and informed evaluation of the risks involved.
DAN
has the following to say about ADD:
Fitness & Diving
At its worst, ADD can be so pronounced as to prevent
a prospective student from learning the simple skills necessary for
safety. This could present a significant hazard in many areas,
including both driving and scuba diving. ADD is usually not that
intense, however. Fitness to dive can best be assessed by looking at
social, school, athletic and job performance. Note that because some
ADD patients take medications, they should consider the potential
impact of medications while diving.
A case by case dive candidate review is necessary to
determine if an individual has the necessary physical or mental
abilities to handle the stresses of underwater activity. Additionally,
scuba diving is a buddy activity that assumes a diver can perform buddy
and self rescue in an emergency situation.
