Attention-deficit/hyperactivity disorder (ADHD)

Developed in collaboration with CASA Medical.

Information about the disease at its treatment

Attention Deficit Hyperactivity Disorder (ADHD) is a diagnosis based on the way a person thinks and behaves. It is a neurodevelopmental condition that has features of developmentally inappropriate levels of inattention, impulsivity, and hyperactivity. The diagnosis is made based on a comprehensive and detailed assessment including clinical and neuropsychological assessments along with a person’s developmental, educational and occupational history. Aviation medical certification will rely on these reports combined with aeromedical and operational risk assessment to decide whether there is any impact on aviation safety.

The impact of ADHD can vary from minimal to profound and may vary based on the environment in which the person is living and working. Most people with ADHD are able to function within their social, working and home environment using cognitive and behavioural strategies. Safe aviation operations for certain people with ADHD can be achieved provided the challenges are identified and managed, and people can thrive in the aviation industry when it is inclusive for neurodiversity.

ADHD: Strengths	ADHD: Challenges
Creativity	Difficulty focusing
Energy	Impulsive behaviour
Intuition	Disorganisation
Quick comprehension	Forgetfulness
Positive risk taking	Oversharing
Empathy	Negative risk taking
Ability to hyperfocus	Mood instability

Medication can be helpful for some people with ADHD to function effectively and safely in their aviation roles. When ADHD is well managed with medication, the person has overall better mental and physical health, reduced rates of substance use, lower rates of anxiety and depression. When taken effectively, ADHD medications are beneficial in the following ways:

Domain	Untreated ADHD	Treated ADHD
Attention	Distractible, poor focus	Improved focus, better task completion
Impulsivity	Risky decisions, poor judgement	More deliberate actions, better risk assessment
Organisation	Disorganised, forgetful	Structure routines, improved memory
Safety risk	Elevated	Reduced with effective management

Medications for ADHD and aviation medical certification

CAA NZ Av Med may approve the use of medications to treat ADHD for holders of Class 2 and Class 3 medical certificates in certain circumstances. These decisions are reserved for CAA NZ AvMed (cannot be made by AMEs). Use of ADHD medications is safety-relevant for aviation operations both directly and due to associated medication risks (such as cardiovascular and mental health complications).

If a non-stimulant medication is approved, it must be used continuously to be able perform aviation duties and managed under the supervision of a consultant psychiatrist.

If a stimulant medication is approved, it must be used as directed for aviation duties and managed under the care of a consultant psychiatrist. Specifically, stimulants must be at consistent therapeutic levels while undertaking aviation duties. Refer to the table below for guidance and if any doubt exists, contact CAA NZ for advice.

Drug	Therapeutic window	Duty limit post dose
Methylphenidate Sustained release	1 hr to 6 hours	2 hours to 5 hours
“Ritalin LA”	1 hour to 8 hours	2 hours to 7 hours
“Concerta” oros system	1 hour to 12 hours	2 hours to 11 hours
Lisdexamphetamine	1 hour to 13 hours	2 hours to 12 hours

When planning aviation operations using these therapeutic windows, due consideration should be given to matters such as fatigue management and operational contingency planning (such as delays and diversions). This is important for safety, even where there is no workplace or regulatory requirement.

Pilot and controller information

If pilots or controllers have been diagnosed with ADHD, they must notify CAA NZ and obtain a ME review.
Pilots and controllers must consult with their treating doctor and ME if they experience any problems with their treatment or experience a recurrence of their symptoms.

Do not fly or control aircraft if:

Pilots or controllers have a new diagnosis of ADHD
Treatment (of any kind – medication, psychological or self-management strategies) is started, stopped or changed
There is a diagnosis of another mental health condition or symptoms
You start, stop or change the dose of any mental health medication including ADHD medications (if approved to take)
You miss your usual daily dose of any mental health medication (if approved to take)
You are not in the approved operational window for your ADHD medication (if approved to take)

Aeromedical relevance

Effect of aviation on the condition

Aviation duties and related activities can impact the effectiveness of treatment (medication and non-medication) due to:
- Irregular work and sleep hours, circadian shifts causing issues with medication and dosage intervals
- Social activities may include alcohol consumption
- Reduced opportunities to engage in behavioural strategies for management
- Use of sleep aids such as sleeping tablets
The demands of training and operations may exceed the person’s cognitive reserve and coping abilities.

Effect of the condition on aviation

When ADHD is severe and/or not adequately treated, the following hazards may be present.

Overt incapacitation
- Acute severe mental health event (psychotic episode, suicidality or acute situational stress)
- Cardiovascular events (with stimulant medication)

Impairment
- Inattention: Difficulty sustaining focus, missing details, and being easily distracted can impair situational awareness and decision-making
- Impulsivity: Hasty decisions without considering consequences can lead to risky flight behaviours
- Hyperactivity: Restlessness and difficulty remaining seated or calm may interfere with cockpit discipline and the working environment
- Executive dysfunction: poor organisation, forgetfulness and trouble following procedures can compromise flight safety
- Social and behavioural difficulties: Challenges with interpersonal communication and non-technical skills.
- These issues have all been linked to increased accident risk, with documented cases of pilots failing to prepare adequately, making poor decisions, and becoming distracted during critical phases of flight

Information required for certification

New cases

Confirmation of diagnosis from a consultant psychiatrist that includes:
- Details of a comprehensive clinical assessment of developmental, educational, occupational and social impact of ADHD including direct and collateral history (family, partner, school).
- Results of validated diagnostic assessment tools such as the Adult ADHD Self Rating Scale (ASRS)
- Detailed discussion of any current or historical mental health comorbidities including substance use disorders
- Recommended treatment (and response to treatment if commenced)
  - If medicated, a report of prescription and dispensing including authorisation for prescription – in this case Medical Examiners are not authorised to issue or renew aviation medical certificates for people with ADHD without an application for an Accredited Medical Conclusion (AMC).
  - Any side effects of treatment
- Surveillance and follow-up plan

Neurocognitive assessment which must include the following:
- An Assessment of the diagnostic features of ADHD that are present
- An assessment of current symptoms on standardised scales (e.g. Connors)
- Full cognitive assessment including measures of
  - Current and premorbid intellectual ability (e.g. TOPF, WAIS-5, including all ‘core’ indexes)
  - Vigilance/Sustained Attention (e.g. CPT, psychomotor vigilance)
  - Simple reaction time and variability (e.g. CPT, psychomotor vigilance)
  - Response inhibition (e.g. DKEFS Colour/Word Interference)
  - Set shifting/Mental Flexibility (e.g. DKEFS Trails, WCST)
  - Planning/Problem Solving (e.g. BADS Zoo Map, DKEFS Tower Test)
  - Verbal Fluency (e.g. DKEFS Verbal Fluency)
- Cognitive assessment reports must include, and report, both measures of performance validity and symptom validity, including measures of both positive and negative response biases
- Assess for any co-morbid mental health conditions/substance use

Other collateral information
- Records of education and academic results and assessments (primary, secondary and tertiary/vocational if available, for example, NZQA)
- Record of occupational history including report from current employer if applicable
- Report of aviation performance (CFI or supervisor or CAA operational assessment form)
- Complete GP or other primary health care provider clinical records
- Ministry of Justice report
- Results of a short-notice (within 5 working days) hair test for drugs of abuse

Renewal

Renewal - unmedicated

Report from a consultant psychiatrist, clinical psychologist or General Practitioner
- Updated review of educational, occupational and social impact of ADHD
- Updated results of any assessment tools used (eg ASRS)
- Specific discussion of any substance use and/or mental health comorbidities
- Recommended treatment (and response to treatment if commenced)
  - Confirmation of compliance with appointments, strategies and interventions
  - Confirmation that medications are not clinically indicated and have not been prescribed
- Surveillance and follow-up plan
Report of acceptable aviation performance (CFI or supervisor) (If the applicant has not commenced training they will be required to provide this prior to the first solo flight)
Negative short-notice hair drug test, and satisfactory alcohol risk assessment

Renewal - medicated

This information is provided for clarity. Medical Examiners are not authorised to issue or renew aviation medical certificates for people with ADHD without an application for an Accredited Medical Conclusion (AMC).

Report from a consultant psychiatrist:
- Updated review of educational, occupational and social impact of ADHD
- Updated results of any assessment tools used (eg ARS)
- Specific discussion of any substance use and / or mental health comorbidities
- Recommended treatment (and response to treatment if commenced)
  - Confirmation of compliance with appointments, strategies and interventions
  - Any side effects of treatment
- Surveillance and follow-up plan
Report of aviation performance (CAA operational assessment form)
Results of a short-notice (within 5 working days) hair test for drugs of abuse
Report of prescription eg from GP records

ME aeromedical decision guide

If ALL criteria in the table below are met, the applicant meets the acceptable criteria for certification by the ME. Evidence supporting the ME’s decision (for example reports and results) must be provided to CAA.

ME must confirm	Tick
Diagnosis is confirmed by a psychiatrist as ADHD (at renewal – no change)
GP or psych report confirms no concurrent or previous unacceptable mental health diagnosis
GP or psych report confirms no medications for ADHD for 2 years (must be referred to CAA if medicated within the last 2 years)
GP or psych report confirms no functional impact of symptoms for 2 years (confirmed by reference to GP records)
Negative short-notice hair drug test, and satisfactory alcohol risk assessment
Report of acceptable aviation performance (CFI or supervisor) (If the applicant has not commenced training they will be required to provide this prior to the first solo flight)
Mandatory for initial application: Satisfactory neuropsychology reports (average or above in all domains)
Mandatory for initial application: Satisfactory psychiatry report
Mandatory for initial application: Satisfactory educational achievements (eg NZQA) and stable work history
Mandatory for initial application: No concerns on MOJ check
ME considers safe to certify

ME letters

For initial applications / new diagnosis [DOCX 21 KB]

ADHD medical certificate letter [DOCX 22 KB]

ADHD 020 operational restrictions letter [DOCX 23 KB]