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Aeromedical

The Conundrum of ADHD in Pilots (and Pilot Applicants)

Gradually – almost imperceptibly – a problem is growing, and becoming apparent to me among young, new pilot applicants. A significant (and increasing) number are presenting with the diagnosis of Attention Deficit Hyperactivity Disorder and on stimulant medication. So – let’s have a look at this entity which is increasingly a part of my practice.

A basic review of ADHD is provided here: https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

Quoting some salient points from this review:

People with symptoms of inattention may often:

  • Overlook or miss details, make careless mistakes in schoolwork, at work, or during other activities
  • Have problems sustaining attention in tasks or play, including conversations, lectures, or lengthy reading
  • Not seem to listen when spoken to directly
  • Not follow through on instructions and fail to finish schoolwork, chores, or duties in the workplace or start tasks but quickly lose focus and get easily sidetracked
  • Have problems organizing tasks and activities, such as what to do in sequence, keeping materials and belongings in order, having messy work and poor time management, and failing to meet deadlines
  • Avoid or dislike tasks that require sustained mental effort, such as schoolwork or homework, or for teens and older adults, preparing reports, completing forms or reviewing lengthy papers
  • Lose things necessary for tasks or activities, such as school supplies, pencils, books, tools, wallets, keys, paperwork, eyeglasses, and cell phones
  • Be easily distracted by unrelated thoughts or stimuli
  • Be forgetful in daily activities, such as chores, errands, returning calls, and keeping appointments

People with symptoms of hyperactivity-impulsivity may often:

  • Fidget and squirm in their seats
  • Leave their seats in situations when staying seated is expected, such as in the classroom or in the office
  • Run or dash around or climb in situations where it is inappropriate or, in teens and adults, often feel restless
  • Be unable to play or engage in hobbies quietly
  • Be constantly in motion or “on the go,” or act as if “driven by a motor”
  • Talk nonstop
  • Blurt out an answer before a question has been completed, finish other people’s sentences, or speak without waiting for a turn in conversation
  • Have trouble waiting his or her turn
  • Interrupt or intrude on others, for example in conversations, games, or activities”

The Aeromedical challenge this diagnosis presents is immediately apparent. While “overlooking or missing details” may be an annoyance on the ground – in the air it can be fatal. In fact, reading down the foregoing lists, it is a fairly comprehensive primer of every undesirable characteristic one would not want in a pilot. Obviously, we don’t want to licence anyone who has a high likelihood of killing themselves in an airplane – suggesting those exhibiting such characteristics should be excluded from flight – and flight training- for their own good, as well as that of their future passengers.

And yet – there is a problem here. Read the “characteristics” again. Sound like virtually every youngster you’ve ever known at one time or another in their life? Exactly. What at first glance seems like a well described clinical entity, can, on critical second thought, be characterized as representative of a great number of children/adolescents. In social psychology this is called the “PT Barnum Effect” (as in “there’s a sucker born every minute”) https://www.psychologytoday.com/blog/sideways-view/201411/weve-got-something-everyone-the-barnum-effect . If one makes a psychological analysis sufficiently vague and all-encompassing, such that it applies to virtually every human being – one will be thought of as insightful and accurate. This is the principle by which fortune tellers operate. Here is my own example: “You have overcome some troubling struggles in life – particularly with respect to relationships and sex - sometimes wondering if you were the only one facing these. Through some work, and tough times, you have come through fairly well, and increased your understanding of both yourself and others.” Yeah – so has everybody. The behavioural lists for ADHD above encompass all of us at one time or another.

So the key question is diagnosis. From the same document (emphasis added by me):

“Diagnosis of ADHD requires a comprehensive evaluation by a licensed clinician, such as a pediatrician, psychologist, or psychiatrist with expertise in ADHD. For a person to receive a diagnosis of ADHD, the symptoms of inattention and/or hyperactivity-impulsivity must be chronic or long-lasting, impair the person’s functioning, and cause the person to fall behind normal development for his or her age. The doctor will also ensure that any ADHD symptoms are not due to another medical or psychiatric condition. Most children with ADHD receive a diagnosis during the elementary school years. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present prior to age 12.

ADHD symptoms can change over time as a person ages. In young children with ADHD, hyperactivity-impulsivity is the most predominant symptom. As a child reaches elementary school, the symptom of inattention may become more prominent and cause the child to struggle academically. In adolescence, hyperactivity seems to lessen and may show more often as feelings of restlessness or fidgeting, but inattention and impulsivity may remain. Many adolescents with ADHD also struggle with relationships and antisocial behaviors. Inattention, restlessness, and impulsivity tend to persist into adulthood.”

And yet the vast majority of ADHD patients I see have been “diagnosed” by teachers – who noted poor classroom behaviour and/or academic performance – and suggested being seen by a clinician often recommended by the school – who tends to diagnose this entity in most of the patients they see – a form of self-fulfilling prophesy. In short order the child is placed on stimulants – typically Dexedrine or its cousins – a class of drugs having powerful psychoactive effects. There ensue these powerful effects – which parents take to indicate the drug is “working” and the diagnosis was correct. Likewise these drugs have significant withdrawal effects – further proof of efficacy, as in “he does so much worse when he’s off his medication”. Rather than – he’s in drug withdrawal and feeling terrible.

Now before I get criticized for slamming teachers, or intimating that ADHD is a bogus diagnosis – let me hasten to assure that such is not my intent. Clearly, there appear to be a small, clinically distinct group of kids who meet diagnostic criteria, do much better with appropriate therapy (which doesn’t always involve drugs), and have been identified by skilful and insightful teachers – which brought them to be assessed by careful and thoroughly trained clinicians. My thesis is that such kids are in a minority of the increasing numbers of ADHD pilot applicants I am seeing. I believe significant over diagnosis is occurring. This issue is perceptively discussed here: http://www.huffingtonpost.com/allen-frances/dsm5-diagnoses-in-kids-sh_b_12732918.html
and here: https://www.psychologytoday.com/blog/dsm5-in-distress/201006/psychiatric-fads-and-overdiagnosis

And in point of fact – the fact that this is occurring is good news for the young would-be pilots I see. They can and do fly safely – in many cases because I suspect they do not have a clinically significant illness.

So how does Transport Canada view ADHD? Firstly – medication is out. Stimulants have significant undesirable side effects – as well as the challenge of what would happen if a pilot is trapped somewhere by operational factors and goes into drug withdrawal. If medication must be used during scholastic studies – it must be withdrawn before flight training. Secondly – flight training is, in itself, extremely demanding – and serves as an excellent test of whether the symptoms actually interfere with functioning. A truly ADHD person, with moderate to severe disease – will not pass flight training. At time of licensing Transport Canada will usually ask for diagnostic details – typically a detailed report from the diagnosing clinician, and assurances that medication has been stopped. Provided all this is satisfactory – a medical certificate can be issued. So if you (or a parent reading this) are concerned about your ADHD diagnosis, thinking it prevents a flying career – such is not necessarily the case. What do I suggest? Firstly – since medication is not acceptable in flying – try a medication reduction and withdrawal under your doctor’s supervision (never on your own). How did you do once the withdrawal symptoms stopped? Secondly – off medication – take a couple of hours of flight instruction. Ask for the instructor’s honest feedback. How do they think you performed? If you are on par with others, the instructor and you feel good about it – let’s go and get you flying!