Sight Search

Attention-Deficit/Hyperactivity Disorder and Diving

CREDITS: Text Jim Chimiak, M.D. | Photo: Stephen Frink

Attention-deficit/hyperactivity disorder (ADHD), formerly known as attention-deficit disorder (ADD), is a neuro-behavioral disorder that can involve difficulty paying attention, impulsiveness and restlessness. These symptoms may interfere with learning and daily functioning, and in divers and prospective divers they raise important questions about fitness to dive. The symptoms are related to an alteration in brain development starting in childhood, and the disorder may persist in adulthood.

The Centers for Disease Control and Prevention (CDC) reports that up to 11 percent of children have ADHD, while the National Institutes of Mental Health (NIMH) indicates that 4.1 percent of adults have it. It seems to occur more frequently in boys than girls. The symptoms are not the same in everybody, and in mild cases the individual may have problems only when engaging in certain tasks. For example, an adult may do very well throughout life until a new computer system with a very strict workflow is installed at his or her workplace. Alternatively, a child with ADHD who is placed in an academic setting without much structure might begin to have problems.

People with ADHD are at increased risk of being involved in motor vehicle accidents and sustaining injuries that lead to emergency room visits. Other conditions commonly associated with ADHD, particularly untreated ADHD, are depression, anxiety, cigarette smoking and substance abuse.

ADHD is treated with cognitive behavioural therapy and medications including stimulants and antidepressants. None of the medications used to treat ADHD have been tested for possible interactions with diving. To better understand how ADHD might affect safe diving, we ask the experts.
What are the classic symptoms of ADHD?
Steven Altchuler, M.D., Ph.D.: The symptoms vary; among the most common are inattention, hyperactivity and impulsivity. People with ADHD might make careless mistakes, not pay attention to details, not finish tasks, be forgetful or have difficulty managing tasks that must be done in a specific order. They might fidget, interrupt others or have difficulty waiting their turn.
The symptoms of ADHD change over time. As people grow up, symptoms may become less severe or even disappear. Someone who had ADHD as a child may do perfectly well as an adult.

How is ADHD diagnosed?
Timothy Wilens, M.D.: ADHD is a clinical diagnosis predicated upon careful review of the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), with the individual and, if the patient is a child, the family. While neuro-psychological testing may be helpful to examine co-occurring cognitive or psychiatric problems, it is not necessary to diagnose ADHD. The diagnosis requires that the individual have a sufficient number of symptoms from each symptom cluster listed in the DSM-5; this establishes context for the functional impairment and demonstrates that it is attributable to ADHD rather than another disorder.

How is ADHD treated?
Altchuler: The most common treatment is the use of stimulant medications such as methylphenidate (Ritalin). Students can benefit from measures to minimise distractability in the classroom and opportunities to move around. They may also do well with additional time to complete standardised tests such as college entrance exams. Other medications, including the antidepressant bupropion (Wellbutrin), are used to treat adults.

Wilens: In addition to prescribing medication, which is considered the first line of treatment, the doctor might also consider the individual’s academic or occupational setting and interpersonal or family issues. Appropriate accommodations in various settings (e.g., school, work) may be necessary. Psychotherapies directed at the person with ADHD and/or the family can be very useful for addressing core and associated symptoms.

What additional risks might a scuba diver with untreated ADHD be taking on?
Altchuler: Divers with ADHD might have difficulty concentrating or paying attention or might be easily distracted, particularly if they are multitasking. For example, observing a beautiful coral reef, maintaining buoyancy control, monitoring gas supply, fulfilling a decompression obligation, controlling depth or ascent rate and paying attention to a dive buddy’s location might prove overwhelming. Diving in an overhead environment where strict attention to detail is a life-or-death matter may be challenging.

Wilens: The many tasks involved in a successful diving venture may challenge individuals with ADHD, particularly if they are untreated. Difficulties with associated neuro-cognitive functions such as working memory (remembering and managing short-term issues) and executive functioning (e.g., organisation) may also adversely affect diving.

What are the risks for divers with ADHD who are successfully treated with medication?
Altchuler: Little is known about the effects of stimulant medications such as methylphenidate at depth. Theoretically, stimulants and bupropion might increase the risk of oxygen toxicity. Practical concerns may exist if somebody who is taking methylphenidate or another medicine for ADHD surfaces and is acting unusual. This might prompt the question of whether the changes are related to the medicine or are indications of decompression illness.

Wilens: There are numerous studies and reviews of studies of the use of ADHD medications by people of various ages. Surprisingly few of these studies consider this use in athletic contexts, and none to my knowledge focused on diving. Our laboratory at Massachusetts General Hospital has completed studies of high-dose amphetamine administration in adults with ADHD who were comprehensively tested at baseline and again six months later using multi-modal cardiovascular imaging and graded-exercise testing. We failed to find concerning adverse cardiovascular outcomes but did note non-clinically significant slower heart-rate recovery after exercise, which means longer recovery times following peak exercise performance. In standard atmospheric testing we did not find varying rates of oxygenation or cardiac output or any evidence of arhythmias. Of interest, after thorough diagnostics many professional athletes are treated for ADHD and demonstrate improved overall outcomes and excellent toleration of the medications.

Can people with ADHD dive if they stop taking their medication?
Altchuler: Certainly, if a diver no longer requires medication, then he or she should stop taking it. We are concerned about whether the diver can pay adequate attention to detail and the dive plan to be able to dive safely. Frequently, school-age children and teenagers are given “vacations” from their ADHD medications during the summer. When people need medication to function well in school, where paying attention to detail can affect their grades, we are even more concerned about them paying attention while scuba diving, where attention to detail can become a life-or-death matter.

So whether someone with ADHD can scuba dive really depends on whether the person in fact has ADHD and what treatment is needed. If the person needs stimulant medication to function normally, we have concerns about how the medicine would affect him or her when scuba diving. The U.S. Navy medically disqualifies from diving a person with active ADHD, but “a history of ADHD greater than 1 year prior to military service is not disqualifying.” Use of the medicines that treat ADHD is similarly disqualifying.

Wilens: While we do not have adequate data on the effects of stimulants or non-stimulants in diving conditions, we are accumulating data on the positive effects of treatment on other complex activities such as driving. These data show improvements in all aspects of driving behaviour in simulators. There are also large epidemiological studies that demonstrate a lower overall risk for motor vehicle accidents with treatment. If we were to extrapolate from other complex behaviours that are aberrant in ADHD, I would recommend treatment over no treatment.

What should be done when a prospective diver reports a history of ADHD?
Altchuler: The first thing to do is find out if the person is taking medicine or undergoing some other treatment for ADHD. If the prospective diver is a teenager, do not ask the parents, ask the youth directly. In too many cases teenagers start taking a medication, take it for several months, notice no difference and stop taking it.

People not undergoing treatment need an operational diving examination. We do one for all divers who are new to us. We observe their functioning starting in easy diving environments and progress to more challenging environments to determine if they can dive successfully. It’s critical to observe divers as they progress to more challenging environments. As the number and complexity of tasks divers must do increases, so does the likelihood that ADHD will cause problems. Things an experienced diver might find routine can be overwhelming to a new diver, particularly one with ADHD. Even dives in calm conditions involve management of many tasks, and additional challenges such as choppy seas, low visibility and cold water might make the situation overwhelming.

A challenge diving physicians face is that many recreational diver health forms ask only, “Are you currently taking prescription medications?” A teenager or young adult learning to dive during the summer and taking a “medication vacation” can truthfully answer “no.” Health forms typically do not ask specifically about ADHD but rather list “behavioural health, mental or psychological problems.” While we in the medical field may consider ADHD to fall in this category, the diver or the diver’s parent may think of ADHD as only a school problem and again truthfully answer “no.”

The next challenge is that the diver’s primary physician who completes the form may lack knowledge about dive medicine and the potential for enhanced side effects in high-partial-pressure oxygen environments. The primary doctor may also lack knowledge about the multiple tasks a scuba diver must perform to be able to dive safely.

Divemasters and instructors cannot be expected to be medical experts. They should, however, be observant. Simple questions such as, “Did you take any prescription medicines in the past year, and did your doctor know about them when he completed this form?” may provide useful information.

Wilens: To Dr. Altchuler’s comprehensive response I would add only the recommendation to determine if the individual has been swimming, freediving or scuba diving in the past, whether the person took medications while doing so and how his or her experience was with or without them, noting in particular any adverse effects. These data may help guide the conversation.

Any further comments?
Altchuler: If a person comes to us and says he has ADHD, we should ask if he needs treatment for it in any part of his life to be able to function well. If he needs medications, it is probably best that he not scuba dive. On the other hand, if he functions very well without medications, he is at higher risk for having difficulty while diving but may well be able to do so. Some divers with ADHD might benefit from limiting themselves to clear, calm, warm water and not going beyond 60 feet.

Wilens: ADHD itself should not automatically exclude anyone from diving. Untreated or under-treated ADHD is what places an individual at the greatest risk of difficulties while executing complex actions. The available medications seem to be effective and well tolerated in athletes, and the limited data pertaining to the use of stimulants by adults undergoing multi-modal cardiovascular assessments do not indicate difficulties during peak performance. I recommend that divers with ADHD get treatment, that individuals who are medicated for ADHD dive carefully and that doctors of divers with ADHD monitor the effects of the divers’ medications on their overall performance.


Aqua Pool Noodle ExercisesUnderwater Photographer and DAN Member Madelein Wolfaardt10 Simple Things You Can Do to Improve Your Underwater PhotographyCOVID-19 and Diving: March 2021 UpdateDiver Return After COVID-19 Infection (DRACO): A Longitudinal AssessmentGuidelines for Lifelong Medical Fitness to DiveExperienceFitness Myth or Fitness Fact?The Safety of Sports for Athletes With Implantable Cardioverter-DefibrillatorsCardiovascular Fitness and DivingHypertensionPatent Foramen Ovale (PFO)Headaches and DivingMiddle-Ear Barotrauma (MEBT)O’Neill Grading SystemMask Squeeze (Facial Barotrauma)Sinus BarotraumaInner-Ear Barotrauma (IEBT)Middle-Ear EqualisationAlternobaric VertigoDecompression IllnessOn-Site Neurological ExaminationTreating Decompression Sickness (The Bends)Top 5 Factors That Increase Your Risk of the BendsHow to Avoid Rapid Ascents and Arterial Gas EmbolismUnintended Rapid Ascent Due to Uncontrolled InflationUnexpected Weight LossFlying After DivingWisdom Tooth Extraction and DivingYour Lungs and DivingScuba Diving and DiabetesDiving after COVID-19: What We Know TodaySwimmer’s Ear (Otitis Externa)Motion SicknessFitness for DivingDiving After Bariatric SurgeryWhen to Consult a Health-Care Provider Before Engaging in Physical ActivitiesFinding Your FitnessHealth Concerns for Divers Over 50Risk Factors For Heart DiseaseJuggling Physical Exercise and DivingSeasickness Prevention and TreatmentMember to Member: Guidelines for SeniorsHigh-Pressure OphthalmologyOver-the-Counter Medications
immersion and bubble formation Accidents Acid reflux Acute ailments After anaesthesia Air Quality Air exchange centre Air hose failure Air supply Airway control Air Alert Diver Magazine Alternative gas mix Altitude changes Altitude sickness Aluminium Oxide Ama divers Amino acids Anaerobic Metabolism Animal life Annual renewal Apnea Apnoea Aquatic life Archaeology Arterial gas embolism Arthroscopic surgery Aspirin Aurel hygiene BCD BHP BLS BWARF Back adjustment Back pain Back treatment Backextensors Badages Bag valve mask Bahamas Balancing Bandaids Barbell back squat Barometric pressure Barotrauma Basic Life Support Batteries Bench press Benign prostate hyperplasia Benzophenones Beth Neale Biophysics Black Blood flow Blood thinners Blue Wilderness Blurred vision Boat safety Boesmansgat Bone fractures Bouyancy compensators Boyle's Law Boyle\'s Law Bradycardia Brain Breast Cancer Breath Hold Diving Breath holding Breath hold Breath-hold Breathing Gas Breathing gas contamination Breathing Breathold diving Broken bones Bruising Bubbleformation Buddy Exercise Buddy checks Buoyancy Burnshield CGASA CMAS CO2 COVID-19 Updates COVID-19 COVID CPR Cabin pressure Caissons diseas Camera settings Cameras Cancer Remission Cancer treatments Cancer Cannabis and diving Cannabis Cape Town Dive Festival Cape Town Dive Sites Cape Town CapeTown Carbon Monoxide Carbon dioxide Cardio health Cardiological Cardiomyopathy Chamber Safety Chamber science Charging batteries Charles' Law Charles\' Law Charles\\\' Law Charles\\\\\\\' Law Charles\\\\\\\\\\\\\\\' Law Charlie Warland Chemotherapy Chest compressions Children diving Chiropractic Chlorophll Christina Mittermeier Citizen Conservation Cleaning products Coastalexcursion Cold Water Cold care ColdWater Cold Commercial diving Commercial schools Composition Compressed Air Compressed gas Consercation Conservation Photographer Conservation photography Conservation Contact lenses Contaminants Contaminated air Coral Conservation Coral Reefs Coral bleaching CoralGroupers Corals Core strength Corona virus Coro Courtactions Cristina Mittermeier Crohns disease Crowns Crystal build up Crystallizing hoses Cutaneous decompression Cylinder Ruptures Cylinder handwheel Cylinder valves DAN Courses DAN Profile DAN Researchers DAN medics DAN members DAN report DCI DCS Decompressions sickness DCS theories DCS DEMP DM training DNA DReams Dalton's Law Dalton\'s Law Dalton\\\'s Law Dalton\\\\\\\'s Law Dalton\\\\\\\\\\\\\\\'s Law Danel Wenzel Dauin island Dean's Blue Hole Dean\'s Blue Hole Deco dives Decompression Illness Decompression Sickness Decompression Stress Decompression illsnes Decompression treatment Decompression Decorator crabs Deep diving Deep water exploration Deepest SCUBA Dive Delayed Offgassing Dental Dever Health Diaphragms Diopter Diseases Disinfection Dive Chamber Dive Computer Dive Destinations Dive H Dive Industry Dive Instruction Dive Instructor Dive Medical Form Dive Medical Dive Practices Dive Pros Dive Research Dive South Africa Dive Training Dive Travel Dive accidents Dive buddies Dive computers Dive courses Dive excursions Dive exercise Dive fitness Dive gear Dive heallth Dive health Dive medicals Dive medicines Dive medicine Dive operators Dive planning Dive safety 101 Dive safety Dive safe Dive staff DiveLIVE Diveleader training Diveleaders Diver Health Diver Profile Diver infliencers Diver on surface Divers Alert Diving Divas Diving Kids Diving Trauma Diving career Diving emergencies Diving emergency management Diving fit Diving guidelines Diving injuries Diving suspended Diving Dizziness Dolphins Domestic Donation Dowels Dr Rob Schneider Drift diving Drysuit diving Drysuit valves Drysuits Dyperbaric medicines EAPs EAP Ear pressure Ear wax Ears injuries Eco friendly Education Electronic Emergency action planning Emergency decompression Emergency plans Emergency underwater Oxygen Recompression Emergency Enviromental Protection Environmental factors Environmental impact Environmental managment Equalisation Equipment care Equipment failure Equipment inspection Evacuations Evacuation Evaluations Even Breath Exercise Exhaustion Extended divetime Extinguisher Extreme treatments Eye injuries FAQ Factor V Leiden Failures FalseBay Diving Fatigue Faulty equipment Female divers Fetus development Fillings Fire Coral Fire Safety Firefighting First Aid Equipment First Aid Kit First Aid Training First Aid kits Fish Identification Fish Life Fish Fit to dive Fitness Training Fitness to dive Fitness Flying Focus lights Fractures Francois Burman Fredive Free Student cover Free diving Free flow Freedive INstructor Freedive Training Freediver Freediving Instructors Freediving performance Freediving Gas Density Gas consumption Gas laws Gas mixes GasPerformance Gases Gass bubbles Gastoeusophagus Gastric bypass Gastroenterologist Gear Servicing Germs Gordon Hiles Great White Sharks Gutt irritations HCV HELP HIRA HMLI HMS Britanica Haemorhoid treatment Hazard Description Hazardous Marine life Hazardous marinelife Health practitioner Heart Attack Heart Health Heart Rate monitor Heart fitness Heart rates Heart rate Heart Heat stress Helium Hepatitis C Hepatitus B High Pressure vessels High temperatures Hip strength Hip surgery Hippocampus History Hot Humans Hydrate Hydration Hydrogen Hydroids Hydrostatic pressure Hygiene Hyperbaric Chamber Hyperbaric research Hyperbarics Hypothermia Hypoxia IdentiFin Imaging Immersion Immine systems In Water Recompression Indemnity form Indian Ocean Indonesia Inert gas Infections Infra red Imaging Injections Instinct Instruction Instructors Insurance Integrated Physiology International travel International Interval training Irritation Isotta housing Joint pain Junior Open Water Diver KZN South Coast Karen van den Oever Kate Jonker Kidneys Kids scubadiver Komati Springs KwaZulu Natal Labour laws Laryngospasm Lauren Arthur Learning to dive Legal Network Legal advice Legislation Lenses Leukemis Liability Risks Liability releases Liability Life expectancy Lifestyle Lightroom editing Live aboard diving Liver Toxicity Liver diseas Liz Louw Low blood pressure Low pressure deterioration Low volume masks Lung Irritation Lung function Lung injuries Lung squeeze Lung surgery Lung MOD Macro photography Maintenance Malaria Mammalian Dive Response Mammalian effect Marine Biology Marine Scientists Marine conservation Marine parks Marinelife Masks Master scuba diver Maximum operating depth Medical Q Medical emergencies Medical questionaire Medical statement Medicalresearch Medication Mehgan Heaney-Grier Mermaid Danii Mesophotic Middle ear pressure Mike Bartick Military front press Mixed Gas Mono Fins Mooring lines More pressure Motion sickness Mozambique Muscle pain Mycobacterium marinum National Geographic Nausea Nautilus Neck pain Neuro assessments Neurological assessments Nitrogen Narcosis Nitrogen build up Nitrox No-decompression Non-nano zinc oxide Non-rebreather Mask Nonrebreather masks Normal Air Nosebleeds Nuno Gomes O2 providers O2 servicing OOxygen maintenance Ocean Research Ocean pollution Oil contamination Open water divers Optical focus Orbital implants Oronasal mask Osteonecrosis Out and about Out of air Outreach Oxygen Administration Oxygen Cylinder Oxygen Units Oxygen deficit Oxygen deicit Oxygen dificiency Oxygen ears Oxygen equipment Oxygen masks Oxygen supplies Oxygen supply Oxygen systems Oxygen therapy Oxygen P J Prinsloo PADI Freedivers PFI PJP Tech Parentalsupervision Part 3 Partner Training Perspective Philippine Islands Philippines Phillipines Photographers Photography tips Photography Physioball Physiology Physiotherapy Pills Pistons Planning Plastic Pneumonia Pneumothorax Poison Pollution Pool Diving Pool workout Post-dive Pre-dive Predive check Pregnancy Pregnant divers Preparation Prepared diver Press Release Preventions Professional rights Provider course Psycological Pulmanologist Pulmonary Bleb Pulmonary Edema Pulse Punture wounds Pure Apnea Purge RAID South Africa RCAP REEF Radio communications Range of motion Rashes Rebreather diving Rechargeable batteries. Recompression chamber Recompression treatment Recompression Recycle Reef Conservation Reef safe Reef surveyors Refractive correction Regulator failure Regulators Regulator Remote areas Renewable Report incidents Rescue Divers Rescue Procedure Rescue breathing Rescue breaths Rescue training Rescue Resume diving Return To Diving Return to diving Risk Assessments Risk assesments Risk assessment Risk elements Risk management SABS 019 SafariLive Safety Stop Safety SaherSafe Barrier Salty Wanderer Sanitising Sara Andreotti Saturation Diving Save our seas Science Scombroid Poisoning Scuba Air Quality Scuba Injury Scuba Instructor Scuba children Scuba dive Scuba health Scubalearners Scubalife Sea Horses Sealife Sea Shark Protection Shark Research Shark conservation Shark diving Sharks Shoulder strength Sideplank Signs and Symptoms Sit-ups Skin Bends Skin outbreak Skin rash Snorkeling Snorkels Social Distancing Sodwana Bay Solomon Islands South Africa Spinal bends Spinal cord DCS Spinal pain Splits Squeezes Stability exercise Standars Stay Fit Stents Step ups Stephen Frink Stepping up Strobe Lighting Stroke Submerged Sudafed Sulawesi Sun protection Sunscreen Supplemental oxygen Surface supplied Air Surfaced Surgeries Surgery Suspension training TRavel safety Tabata protocol Talya Davidoff Tattoes Technical Diving The Bends The truth Thermal Notions Tides Tips and trick Tooth squeeze Transplants Travel smarter Travel tips Travel Tropical Coastal Management Tunnelling Tweezers Ultrsound Umkomaas Unconsciousness Underground work Underwaater Photos Underwater hockey Underwater photographer Underwater photography Underwater pho University of Stellenbosch Urinary retention. Vaccines Vagus nerve Valsalva manoeuvers Valve stem seals Vape Vaping Vasopressors Vasvagal Syncope Venting Verna van Schak Virus infections Volatile fuels Washout treatments Wastewater Watchman device Water Resistance Water Weakness Weigang Xu Weights West Papua Western Cape Diving Wet diving bell Wetsuit fitting Wetsuits White balance Wide angles Wildlife Winter Wits Underwater Club Woman in diving Womans health Woman Women In Diving SA Women and Diving Women in diving Womens health Work of Breathing Workout World Records Wound dressings Wreck divers Wreck dive Wreckdiving Wrecks Yoga Youth diver Zandile Ndholvu Zoology abrasion acoustic neuroma excision adverse seas air-cushioned alert diver altitude anemia antibiotics anticoagulants antiseptics bandages barodontalgia bent-over barbell rows bioassays body art breathing air calories burn carbon dioxide toxicity cardiovascular cerebrospinal fluid checklist chemo port children child clearances closed circuit scuba corrective lenses currents cuts dead lift decompression algorithms decongestants decongestion dehydration dive injuries dive medicing dive ready child dive reflex dive tribe diver in distress diver rescue diver training dive diving attraction doctors domestic travel dri-suits drowning dry mucous membranes dry suits dry e-cigarettes ear spaces elearning electrolyte imbalance electroytes emergency action plans emergency assessment emergency training environmentally friendly equalising equalizing exposure injuries eyes fEMAL DIVERS fire rescue fitnes flexible tubing frediving freedivers gas bubble gas poisoning gastric acid gene expression health heartburn histidine hospital humidity immersion and bubble formation immersion pulmonary edema (IPE jaundice join DAN knee longevity lower stress malaise marielife marine pathogens medical issues medical procedures medical risk assesment medications mental challenge mental preparedness micro-organisims micro minor illness mucous membranes nasal steroids nasal near drowning nematocysts neurological newdivers nitrogen bubbles off-gassed operating theatre operations orthopeadic outgas pain perforation phillippines physical challenges pinched nerves plasters polyester-TPU polyether-TPU post dive posture prescription mask preserve prevention psychoactive pulmunary barotrauma rebreather mask rebreathers retinal detachment risk areas safety stops saturation scissors scuba equipment scuba single use sinus infections smoking snorkeling. spearfishing sterilising stings strength sub-aquatic sunscreen lotion swimmers ears tattoo care tecnical diver thermal protection tissue damage toxicity training trimix unified standards upwelling vision impaired warmers water quality zinc oxide