ADHD and Autistic Spectrum Disorder/Condition (ASD/ASC)

It is understood that the term neurodiversity covers a wide range of disorders, disabilities and conditions. The umbrella term can also be neurodevelopmental disorder, learning/developmental disorder or developmental disability.

This guidance is only concerned with ADHD and ASD.

It is understood that different labels may be used including autism and autistic spectrum condition (ASC). DSM5 and ICD11 both refer to ASD and ADHD (listed in ICD 11 under “neurodevelopmental disorder).

Those with ASD or ADHD who are new to diving will require a report from their treating physician and dive instructor (see below). Those who are established divers may only need evidence from their diving club that they have no functional issues diving and the medical sign off is more likely to be valid for more than one year or possibly indefinitely (see below). Those who require medication may have a depth restriction (see below). Due to lack of space on the UKDMC/BSAC form the relevant question has been added to the same line as the psychological questions but this does not mean to indicate these conditions are thought to be psychological. It is planned to try to edit this.

Stand alone dyspraxia and dyslexia need not be declared. However, dyspraxia can include delays and/or impairments in motor co-ordination, movement, balance, learning, organisation and planning. It is possible such impairments may impact the person’s ability to perform some aspects of scuba diving in an accurate and timely manner. However, there is little research evidence and the necessity for input from a Medical Referee may be considered on a case by case basis, if the instructor has concerns.

Each case should be assessed on its own merits with regard to the degree of disability and the potential impact on diver safety and ability to care for one’s buddy. The degree of disability can be highly variable between individuals (1). However, individuals maybe more adept than average in some tasks.

There is little research in this area. ADHD is associated with increased risk of accidents and workplace injuries although a retrospective study of navy divers did not provide statistical evidence that the risk of adverse underwater events is significantly increased in those with ADHD, further sufficiently powered studies being required (2). In another paper the same authors noted ADHD may be over-represented in commercial divers in South Africa and may not necessarily be a contraindication to commercial diving, although the numbers were small and cases were self reported (3). Other papers from abroad have warned re diving with ADHD in children and adolescents (4, 5 and 6).

Screening and advice

For those new to diving a report would be required from the treating physician indicating any adverse effects on day to day living that may also impact on safety critical tasks. It would be useful if the treating physician could address the following questions. A positive response to questions 1 to 5 is required for safe diving. A positive response to questions 6-13 or indication of sedation in response to question 14 is likely to be a contra-indication to diving, although in some cases adjustments/restrictions may be appropriate.

  1. Does the individual have the capacity to understand, concentrate and attend adequately to relevant information/stimuli in the environment and social context?
  2. Does the individual have the ability to follow instructions?
  3. Does the individual have the ability to cope with stress?
  4. Does the individual have reasonable time management skills?
  5. Does the individual have the capacity to consent?
  6. Does the individual have any problems with memory?
  7. Does the individual have a diagnosis of learning disability?
  8. Does the individual have a diagnosis that includes significant speech or language impairment?
  9. Does the individual have co-occurrence of ASD (autism spectrum disorder/condition) and ADHD?
  10. Does the individual have any other psychiatric diagnoses (including mental health & personality disorders)?
  11. Does the individual have support or adaptations in employment or education?
  12. Does the individual have a recorded history of impulsivity?
  13. Does the individual have a recorded history of substance misuse (including alcohol)?
  14. What medication, if any, is required and is it sedating in the individual?

Those newly diagnosed or relatively immature may have more difficulty in meeting these standards. Diving Medical Referees may need to liaise with a specialist more experienced in neurodiversity and diving in addition to the receiving the required report.

Co-occurrence of ASD/C and ADHD, other psychiatric problems or learning disability have been noted to be likely to be incompatible with independent diving (7). Diving is not advised in the event of poorly controlled ADHD symptoms. Even if medication controls ADHD satisfactorily, diving is not advised if symptoms return as the medication wears off between doses (a phenomenon known as rebound, which sometimes presents with more severe symptoms than usual), unless the periods of good control can be predicted with certainty and diving is only undertaken within those periods. The effect of time zone changes must, therefore, be considered very carefully when travelling prior to diving.

Only a single psychotropic medicine is allowed as more than one psychotropic medicine will increase the risk of potentially dangerous side effects whilst diving and susceptibility to narcosis. The individual should be complaint with medication and therapy (8).

If the consultant’s / GP’s report is favorable, there is no clear contraindication to diving, the candidate’s medication (if any) is stable and they are not suffering any side effects that could interfere with diving or have potential side effects that may be exacerbated by exposure to increased pressure such as sedation, narcosis or arrhythmias, then for new divers the Diving Medical Referee can consider certifying for supervised pool based training only initially.

On completion of this training, a report is required from their instructor / trainer to inform the Medical Referee of the diver’s ability to concentrate, learn and implement their learning by undertaking safe diving without a lack of awareness or ease of distraction underwater. An instructor should be asked to comment on whether the student is meeting the standards of the course (as set out by the training agency), whether the student is correctly following the instructions during the training sessions and whether the student is responding correctly to assigned problems/scenarios during the pool training.

If this report is favourable then an open water medical certificate can be considered. Further progress through diver training may need to be undertaken with more support than average to ensure safe diving practice, including assessing ability to cope with stress and to behave in such a way as to not compromise the safety of other divers. However, as the diver becomes more experienced and there is more evidence of there being no issues in some cases the diver may not needed repeated assessments by a Medical Referee and page 3 be marked as fit to dive indefinitely unless there is a change in the applicant’s medical condition or medication/treatment (the form provides for this on page 3). Hence annual medicals are unlikely to be needed as some divers fear.

Adjustments or restrictions may be required such as no “no clear surface” diving, no decompression diving or only to dive with more than one experienced buddy depending on the individual circumstances. A depth limit of 20 metres may be advised depending on medication taken to minimise the risk of DCI and the slight theoretical risk that some drugs might increase narcosis. A further report may be required from the diving instructor again depending on the individual case.

It must be understood by applicants that not all Medical Referees will have expertise in dealing with younger age groups or individuals with ADHD or autism spectrum disorder/condition and may feel they would be practising outside their area of expertise such that they would be unable to undertake the assessment in some cases.

References:

  1. Diana Kloss, Neurodiversity at Work: an exploration of the relevant law, Occupational Health at Work 2023 June/July; 20(1): 34-37.
  2. C.H. Van Wijk and W.A. J. Meintjes, Associations between adverse underwater events and ADHD diagnosis amongst military divers, Journal of Attention Disorders 2019: 1-3.
  3. C.H. Van Wijk and W.A. J. Meintjes, Adult ADHD prevalence among commercial divers in South Africa, Diving and Hyperbaric Medicine 2020 June; 50(2): 164-7.
  4. R. Civeti et al, Scuba diving in children: physiology, risks and recommendations, Aneles de Pediatria 2015; 83(6) 410-416.
  5. Bernd E Winkler et al, Should children dive with scuba, Acta Paediatrica 2012 May;101(5):472-8.
  6. Bernd E Winkler et al, Accidents and incidents during scuba diving events in children, Deutsche Zeitschrift fur Sportmedizin; 62 (2): 42-46.
  7. Learning disability is likely to be incompatible with independent diving (UHMS Medical Guidance, V1.0, 2020).
  8. AL Querido and RA van Hulst, Diving and attention deficit hyperactivity disorder, Diving and Hyperbaric Medicine 2019 Mar; 49(1): 41–47.

Reviewed July 2023