May I Have Your Attention, Please!

Certification with Attention Deficit/Hyperactivity Disorder (ADHD)

By Leo M. Hattrup, M.D.

Source: FAA Safety Briefing, Jan/Feb 2020

Attention deficit/hyperactivity disorder (ADHD, also known as attention deficit disorder (ADD)) is a chronic disorder. Commonly diagnosed in childhood, it can persist into adulthood.

ADHD is also diagnosed in adulthood. An estimated two to four-percent of adults in the United States have ADHD. It is an aeromedical concern due to impairments of attention, hyperactivity and impulsivity, leading to judgment and decision-making problems. Accordingly, the FAA requires a detailed evaluation of an applicant for medical certification. Naturally, this generates many questions.

ADHD manifests itself differently in adults than children. In an adult, inattention, restlessness, and impulsivity are more prominent while hyperactivity recedes. Inattention issues include problems with organization, prioritization, task completion, forgetfulness, and missed deadlines. Maintenance of attention for long periods (e.g., cruise phase of a routine flight) can be difficult for someone with ADHD. Executive function is also impaired, manifesting through problems in working memory (the ability to hold information long enough to solve a problem), task management, and multi-tasking. Over-reaction to frustration is frequently present. Clearly, these deficits can be hazardous in the aviation environment.

Individuals with ADHD are also at risk for other mental health diagnoses, substance abuse, and relationship problems. Traffic violations are more common, raising concerns for risky behavior. A recent review of NTSB data linked nine fatal mishaps to ADHD or ADD.

The cause of ADHD is not clear, but there is a genetic component. Its development is also linked to exposure to cigarette smoke, alcohol and other drugs, and environmental toxins such as lead. Brain injuries are also implicated. The diagnosis of ADHD requires a comprehensive evaluation by a licensed clinician who gathers information from those who know the individual, including family members, co-workers, and teachers. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before age 12. Unfortunately, over-diagnosis is not unusual.

While there is no cure for ADHD, available treatments can reduce symptoms and improve function. Treatments include medication, psychotherapy, education or training, or a combination of these. Medications used for ADHD can have side effects that are not compatible with flight safety; therefore, the FAA cannot authorize their use. The FAA will consider other treatment modalities on a case-by-case basis.

The FAA has recently simplified its protocols for evaluation of the diagnosis of ADHD, either current or historical. Airmen with a history of ADHD/ADD get a screening battery. Also, individuals who have taken stimulant medications for other reasons (e.g., fatigue) must be screened even with-out diagnosis of ADHD/ADD. These medications include amphetamine, methamphetamine, and methylphenidate (not a true stimulant). The FAA no longer requires a full neuropsychological testing battery unless the screening battery is abnormal.

To be considered for a medical certificate, the applicant must be off all medications used to treat ADHD for a minimum of 90 days. Medical records are reviewed and, if possible, observations made by those who know the individual in a variety of environments. School transcripts (on and off medications, if ever taken), performance reports, etc., are also reviewed. The applicant must complete a series of neurocognitive tests, some of which have been normed for the pilot population. These help assess the applicant’s cognitive ability off medications. Fortunately, we are able to qualify many applicants for medical certification. In fact, in many cases, the evaluator determines that the individual actually never had ADHD/ADD.

As always, our goal is to certify as many applicants as we can when safety permits.

Learn More

Airmen can find information describing the steps necessary for certification here: bit.ly/2CZobso

Leo M. Hattrup, M.D., received bachelors’ degree from Wichita State University, a master’s in public health from Harvard University, and a doctorate from Vanderbilt University. He is retired from the U.S. Air Force in which he spent the majority of his career in aerospace medicine. He is board certified in aerospace and occupational medicine. He is a certificated flight instructor and enjoys flying airplanes, helicopters, and gliders.