Pilots With Attention Deficit/Hyperactivity Disorder (ADHD)
By Dr. Chris M. Front and Dr. Randy J. Georgemiller, FAA Office of Aerospace Medicine
Safety experts agree that at least 70% of aviation accidents are attributable to the pilot. NASA scientists report that most accidents result from some failure in the pilot’s cognitive performance, with distractions and errors in aeronautical decision making (ADM) most prominent.
For example, when a pilot decides to launch into marginal VFR conditions, continues as conditions deteriorate, enters IMC, and loses control of the aircraft, the fatal crash may be categorized as a “loss of control” event, but it was rooted in poor ADM. Even experienced pilots with no impairing conditions occasionally make errors in ADM or get distracted. That fact led to the emphasis on CFIs creating realistic distractions in flight to teach effective distraction management, as well as scenario-based training and formal risk assessment tools to improve ADM.
The likelihood of an accident rooted in distraction or poor ADM is heightened when the pilot has a condition that negatively affects such skills. Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder with symptoms of inattention and/or hyperactivity-impulsivity that interfere with functioning or development. ADHD occurs in approximately 5% of children and frequently persists into adulthood, affecting about 2.5% of adults.
Three subtypes of ADHD are based on the symptoms exhibited: a “predominantly inattentive” presentation, a “predominantly hyperactive/impulsive” presentation, and a “combined” presentation. All three include symptoms that pose a hazard to flight safety.
Inattention manifests behaviorally in ADHD as being disorganized, easily distracted, wandering off task, and having difficulty sustaining focus. Hyperactivity refers to excessive motor activity or excessive restlessness, or talkativeness. Impulsivity refers to hasty actions without adequate consideration of possible consequences, despite a high potential for harm.
NTSB investigations of fatal accidents attributed to ADHD have documented that pilots with ADHD: failed to adequately prepare for flight (e.g., did not check the weather), continued flight when it was ill-advised (e.g., due to deteriorating weather), engaged in hazardous actions (e.g., low-level maneuvering to show off), and became distracted and made critical errors (e.g., failed to maintain airspeed, stalled, and spun while circling a friend’s home at low altitude). Due to the risks to flight safety posed by ADHD, regulatory authorities worldwide consider ADHD a disqualifying condition for pilots.
Unfortunately, pilots sometimes fail to disclose ADHD to their Aviation Medical Examiner (AME). The result is that the FAA learns about the condition after a fatal accident when the toxicology results reveal the presence of medication used to treat ADHD. Notably, pharmacological treatments for ADHD are not approved for flying because they can cause harmful effects on perceptual, motor, and cognitive functions and impair the recognition of fatigue. Additionally, their effectiveness is time-limited, a particular concern if a dose is missed or flight time exceeds the therapeutic impact of the drug.
Complicating the picture is the fact that an inaccurate diagnosis of ADHD is not uncommon. Proper diagnosis of ADHD is a complex and time-consuming process. Medical providers, acting under time pressure and attempting to respond to the concerns of patients (or their parents), sometimes prescribe medication to treat ADHD or assign a diagnosis without adequate evidence of the disorder. The result is a subset of the adult population with a documented history of treatment for ADHD — some of whom truly had the condition and others who probably did not.
To determine if the adverse impact of ADHD is present or not, the FAA requires a thorough evaluation by a licensed psychologist. It is most beneficial to see a psychologist familiar with the FAA’s specific protocols and standards. AMEs have access to a list of FAA-eligible providers to assist with referrals. The FAA’s evaluation requirements for a history of ADHD are available in the AME Guide.
Upon review, the FAA will either deny the pilot’s application or grant an unrestricted or Special Issuance (SI) medical certificate. If the pilot receives a time-limited SI, further monitoring and assessment may be required. While time-consuming and costly, based on the safety risks posed by the symptoms of ADHD, the FAA has established this evidence-based risk assessment protocol to safeguard both the pilot and the national airspace system.
Chris M. Front, Psy.D., is an instrument and multi-engine-rated commercial pilot and clinical psychologist in the FAA’s Office of Aerospace Medicine. He is board certified in assessment psychology. Randy J. Georgemiller, Ph.D., is a neuropsychologist in the FAA’s Office of Aerospace Medicine and is board certified in clinical psychology.