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Psychiatric - ADHD

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - My 8 year old son did his Bubblemaker a year ago and ever since then has wanted to do his Junior Open Water course. The snag is that he's just been diagnosed with Attention Deficit Disorder (ADD) with hyperactivity. He's started a course of stimulant medication and one of our ideas was to get him back into diving. Would this be OK?

A - Hmmm, I think not. This is a condition where the answer is a fairly clear-cut “no”. If you think about the criteria that are used to diagnose ADD, you may see why. “Often makes careless mistakes”, “often has trouble keeping attention on tasks”, “easily distracted”, “often does not follow instructions”, “often loses things”… imagine anyone with symptoms like this underwater and I’d be very concerned that they’d never surface again. I’d also be loathe to sanction someone exhibiting these features as a reliable buddy. Bizarrely and rather counter-intuitively, stimulant medications in hyperactive children actually work to calm them down, but they could quite easily cause even more unpredictable behaviours in the deep. So it’s emphatically unsafe to dive in this situation I’m afraid.

Q - Dear Doctor, I am a BSAC sports diver and have been diving for just over 9 years to various depths (up to 52m). In February 2007 I had a hernia operation. My doctor has now pronounced me fit but as advised me to take things easy with anything physical, especially to start with. In 2003 I was rediagnosed (I was originally diagnosed as a child) with Attention Deficit Hyperactivity Disorder (ADHD). Since then I have been taking the following medication daily:

*Two Methylphenidate Hydrochloride 20mg capsules. About 2 hours apart.
*One Methylphenidate Hydrochloride 10mg tablet as required. I usually take 3/4 of a tablet late afternoon or evening.

Since being diagnosed and taking this medication things have improved a great deal for me. My short term memory is far better and I am able to concentrate and focus far more effectively. I have also continued to dive (although not very much) and have dived several times having taken my medication (up to 25 metres) with no ill effects. I have asked my Doctors at the Learning Assessment Centre if it is ok to dive. One of them has said he will ask the tablet makers. He is still awaiting a reply. Now that I have been passed as fit after my hernia is it safe to continue to dive? Many thanks for your time.

A - A classic case of a hidden dilemma nearly slipping under the radar. Hernias we dealt with a couple of issues ago, and the bottom line is that once they are fixed and fully healed there is no problem with diving. The thing that is a worry here though is diving with a diagnosis of ADHD. Unfortunately this particular illness has had an extremely bad press over the years. Although mostly thought of as a recent medicalisation of tartrazine-crazed kids, descriptions of ADHD-like symptoms go back to Ancient Greek times – in one individual, Hippocrates noted "quickened responses to sensory experience, but also less tenaciousness because the soul moves on quickly to the next impression". His explanation for this was "overbalance of fire over water”. Dearie me. Things have moved on considerably since, and the illness now has a well-defined set of criteria which must be fulfilled for the diagnosis to be made. Some of these involve inattention and, well, hyperactivity and this obviously makes diving with the condition a risk – the last thing you want is your buddy drifting off into a world of their own, or fidgeting hysterically throughout the dive briefing. The effects of pressure and nitrogen on the medication itself is another factor that is very difficult to generalise about; a lot of these medicines will never have been exposed to such conditions and thus evidence is lacking as to their potential side effects. So at the very least you would need to be thoroughly assessed by your local dive doctor before continuing to dive.

Q - My son is 16 years old and has been taking Ritalin for 8 years. He is perfectly well physically, although following a recent growth spurt is a little on the skinny side. He is a Royal Marine Cadet and takes part in all physical training activities without problems. He currently takes 72mg per day of Methylphenidate, branded as Concerta, which helps him focus and concentrate at school (he is an A grade student). But on seeing the PADI medical questionnaire his Doctor has flown into a tizzy, saying she is not qualified to complete a diving medical and he would have to have a full physical check at probable cost of at least £200.

I would be grateful if you could give me some more concise advice.

A - And concise I shall be. Sadly he is not going to be allowed to dive.

Right next question…

OK then I shall elucidate a tad more.

The problem with ADHD, and even a well controlled condition is that the poor kid, who has it, is prone to bouts of well, attention deficit. That’s OK in a maths lesson now and again and even if you are Rio Ferdinand at the back for England, but not with diving. Yes he could pass the Open Water course with flying colours, and I bet know more about air tables than the Instructor, but diving is more than that. There is a whole world of hurt down there in the deep. Kit can fail, buddies can fail, and the sheer unexpected can happen as well.

A situation where cool calm logical thinking is needed. You may not believe that looking at some of the divers munching bacon sarnies on the quays, or in the pubs of Portland on a Saturday night. But they are a good crowd of folk who do well in times of hazards. So can an ADHD sufferer be 100% certain to be able to correct their buoyancy, save a buddy, and launch an SMB all at the same time. As we cannot guarantee they can, then they aren’t allowed to dive.

This is not withstanding the lack of evidence of the effects of Ritalin/ other amphetamines underwater, that has yet to be studied.

So concisely- No. But there’s always kite surfing for the Sea Scout in him. That’s pretty cool, if CSI Miami is anything to believe.

Q - I am taking my son (16) on his first try dive within the next few weeks and I wanted to ask your advice. He takes Ritalin 10mg and Pimozide (for mild tourettes - pacing) and I was wondering if this was safe to dive with.

My son doesn't actually need to take the medication whilst diving but I thought it might be wise as his concentration levels will be affected without it. I can stop the pimozide for the dive day, but thought the Ritalin would be wise whilst going through safety briefs etc.

Please advise, I would hate for him to miss out. Sorry, the medication is for ADHD (attention deficit activity disorder).

A - I've gotta be Doctor Gloomy here and break the bad news. I think diving on a medication like Ritalin is totally unsafe. It's basically an amphetamine, speed if you like. It will increase heart rate, cause dry mouth, whack up the metabolic rate etc. Also there is no research as to the drugs affects at depth, the worst place to find your son getting overly fidgety and not remembering his training. And, as you say if he is off it then he lacks concentration, then watch the dive brief. They can be boring enough as it is without certain divers fidgeting and forgetting the information. I suggest have a good close look at his diet. Went out with a lady once who had an ADHD child, and it seemed to me that all the junk foods, like coke and crisps made him worse. I have a theory that this modern disease phenomenon could be rooted in other causes. So forget taking him into the deep for now. Snorkeling should be OK though.

(other dive medical questions)


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