ADD/ADHD and Diving

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.

AUTHOR

Ernest S. Campbell, M.D., FACS

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