Evaluation of Epidemiological Problem

Attention-Deficit disorder is an epidemiology problem that targets different kinds of people in society. According to various articles and publications, ADHD is caused by malfunctioning of the brain processes that deal with the transfer of information. Many people suffer ADHD without their knowledge considering that the disease does not trigger any form of pain. During flights, a majority of airline passengers would expect the attention of their pilots to be focused on critical data, including altitude and airspeed. However, inattention is a common cause of airline crashes. As a result, it would be sensible for the Federal Aviation Administration (FAA) to ensure that pilots are assisted in keeping their attention; rather, it has enforced regulations which have the opposite impact. 

Pilots with ADHD, a neurological illness linked with impulsivity, hyperactivity, and severe inattention that interferes with people’s ability to function in social settings, at work or in school, may potentially lose their certificates if they open up regarding their medical condition. To worsen the situation, they would be faced with the same result if they take medication as drug testing will probably show that they use medication, thereby creating a dangerous incentive for them to hide their status and continue to fly without seeking treatment (Ahmed & Aslani, 2013) . Reasonably, the FAA does want distracted pilots since the lives of passengers are in their hands. The tedious and rigorous process of medication the pilots are subjected to interferes with their ability to obtain medication and, therefore, obtain or retain a job, thereby negatively impacting both the pilot and third parties. 

Background 

Over the last few years, scientific research has shown a considerable genetic predisposition for ADHD. More than 70% of children with this condition will potentially have the illness as teenagers, and between 40 and 60% will proceed to have it in their adulthood. Even though genetic literature has not established a particular gene for the condition, there could potentially be numerous genes that contribute to the vulnerability to develop ADHD. Twin studies, for instance, have demonstrated a considerable heritability for this disorder (76%) ( NHS, 2017 ). Moreover, the siblings and parents of those with the illness have been indicated to show an ADHD diagnostic likelihood ranging from 4 to 5 times greater than the rest of the population, and compared with girls, boys show higher vulnerability ( NHS, 2017) . 

These data may suggest that ADHD can be diagnosed easily, and therefore, easily treated. However, the criteria and methods for this disorder’s diagnosis are still questionable. Driving the standards currently are collateral histories and clinical interviews from teachers and parents. Sometimes, objective assessments, including neuropsychological assessments and continuous performance are used in evaluating children’s sustainability to attention and the location of the deficits. As reported by Konopka (2014 ), different factors, including family collaboration, medication, low blood glucose, lack of sleep, concurrent anxiety, and motivation, play a part to sustain attention. Physicians consider and assess three main symptoms categories to diagnose ADHD, including impulsivity, hyperactivity, and inattention. Every group describe specific symptoms, for instance, impulsivity entails interrupting, inability to wait for one's turn, answering without thinking, excessive talking, and so on. Hyperactivity can be defined as motoric hyperactivity (excessive moving, climbing, and running), inability to sit still, and fidgety. Lastly, inattention might incorporate failure to complete tasks, organize, and maintain efforts, as well as distractibility and forgetfulness. 

Analysis 

Both ICD 10 and DSM V give guidelines for the symptoms’ duration and frequency under these diagnostic categories and have a common view on the required number of symptoms prior to one receiving ADHD diagnosis. Conversely, untrained individuals may define and score these symptoms ( Curatolo, D'Agati, & Moavero, 2010) . To this end, such unidimensional data may be questioned for validity and reliability. 

Pre-, peri-, and postnatal environmental factors also have a critical role in ADHD pathogenesis. Linked with prenatal factors are maternal lifestyle during pregnancy, including alcohol exposure that has been shown to induce structural anomalies within the cerebellum . Such children might become impulsive, disruptive, hyperactive, and are at a higher risk of mental diseases (Sellers, 2013) . Maternal smoking results in over 2.5-fold increased ADHD risk, and a dose-response connection between hyperactivity and prenatal smoking has been found and is explained in terms of an effect on nicotinic receptors responsible for modulating dopaminergic activity, which has been claimed to play a role in ADHD pathophysiology ( Curatolo et al., 2010) . 

Also implicated are peri-natal factors, with two-fold ADHD rise in an increased birth and pregnancy complications rate and very-low-birthweight children in children's mothers with ADHD ( Kliegel, McDaniel, & Einstein, 2008) . A role for dietary deficiency and malnutrition in ADHD has been suggested among postnatal factors. An imbalanced fatty acid intake has been proposed to perhaps have a part in ADHD development. Nonetheless, additional evidence is necessary to determine a role ( Kliegel et al., 2008 ). In certain situations, iron deficiency has been reported. Also, having significant effects during the postnatal period is an early deprivation of social environment. 

On the contrary, increasing amount of research demonstrates the involvement of frontostriatal network , which includes the caudate nucleus and putamen , the dorsal anterior cingulate cortex, and the lateral prefrontal cortex as potential contributors to ADHD pathophysiology ( Kliegel et al., 2008 ). Volume reductions have been found in the cerebellum, the corpus callosum, the dorsal anterior cingulate cortex, the basal ganglia (striatum), the prefrontal cortex, and total cerebral volume among ADHD patients. A study on ADHD to determine developmental trajectories found a delay in cortical maturation and showed that various clinical outcomes might be linked to various adolescent developmental trajectories and beyond (Curatolo et al., 2010). In cortical development studies among young people with ADHD, a remarkable brain maturation delay was observed. The grey matter was 36 months later compared with the comparison healthy group (NHS, 2017). Prefrontal region, which is essential in controlling cognitive processes like motor planning and attention, registered the most prominent delay. Compensatory networks, namely cerebellum, insula, and basal ganglia have been reported to have relatively lower cognitive load tasks among patients with ADHD. 

Neuroimaging literature has further indicated decreased cortical thickness (CC), midsagittal corpus callosum , and volumes of white matter among ADHD individuals compared to control groups ( Konopka, 2014) . Although a substantially smaller CC was among the most replicated alterations, reports concerning the implicated callosal segments are conflicting ( Konopka, 2014) . Latest magnetic resonance imaging structural research has demonstrated the presence of white matter alterations in adults, adolescents, and children with ADHD ( Konopka, 2014) . Silk et al. (2008) revealed white matter abnormalities in 15 young boys with ADHD in many different areas underlying the inferior temporal cortex, inferior frontal, occipital-parietal, and inferior parietal. Tractography techniques reported these regions are part of white matter pathways linking parieto-occipital and prefrontal with the cerebellum and striatum. Anomalous white matter development in ADHD within cortical areas was also demonstrated as they had initially exhibited to be hypoactive or dysfunctional in functional MRI research participants with ADHD. 

Diffusion tensor imaging (DTI) investigations have shown changes in development in cortical white matter pathways in regions surrounding cerebellum and basal ganglia and prefrontal pathways in those with ADHD, reflecting reducing axons myelination. Researchers believe that these changes lead to decreased neuronal communication speed (Vohs & Baumeister, 2016). In addition, neural networks that serve the corticocerebellar and corticostriatal circuits could potentially represent ADHD putative biomarkers. Using DTI could be pertinent for therapeutic and diagnostic purposes in this disorder (Vohs & Baumeister, 2016). 

Alongside providing new data in mapping the brain systems affected by ADHD and in mapping the results with clinical symptoms, the literature on functional neuroimaging enables the understanding of the treatment response mechanisms (Vohs & Baumeister, 2016). Methylphenidate hydrochloride, as illustrated by positron emission topography literature, obstructs dopamine active transporters (DAT) and that the blockade level, DA release rate, and extracellular dopamine (DA) are directly proportional. This process is linked to an improved external stimulus perception as salient in patients with this disorder. 

Intervention/Prevention 

ADHD has been cited to play a significant role in the aviation industry, particularly on pilots in their ability to obtain medical certification. The FAA has especially reported safety concerns for airmen using ADHD medications, and those diagnosed with ADHD or taking this disorder’s medication are expected to ground themselves voluntarily. Additionally, the FAA often drug test pilots for amphetamines although they are required to disclose medications they take and medical conditions, meaning they should not take ADHD medications. 

Most medications and their underlying conditions, even though the agency is yet to establish a list of restricted or approved medications formally, might be disqualified through the Federal Aviation Regulations (FARs) ( Part 67). Indeed, the regulations disqualify pilots with mental conditions or those under medication based on medical judgement (which must be appropriate and qualified) and case history associated with the involved medication/mental condition ( Sellers, 2013) . According to these regulations, such conditions might prevent pilots from safely carrying out their roles. 

The laws permit the Examiner to consider two examination process components when deciding to issue medical certificates, including pilots’ health history background provided in medical application forms and a physical examination like a standard, yearly physical examination ( Laukkala et al., 2017 ). Whereas ADHD is not among the 15 mental conditions that can lead to disqualification, the Examiner is required to have the pilots’ applications to the agency to reach a final decision in case the pilots uncover their ADHD condition. Naturally, the certification process is bureaucratic making deferred applications not to initially get the FAA response after a long period ( Laukkala et al., 2017 ). Besides, medications which affect the central nervous system are primarily not allowed by the agency. Thus, ADHD medication is not permitted and pilots who admit to using such medication will be denied the application. The table below gives estimated data of groups with ADHD 

Criteria	With ADHD ( %)	Without ADHD
4-year degree	15	48
Graduate degree	0.6	5.4
Fired From a job	61	43
Been laid off	33	13
Quit a job	53	36
Unemployed at not in school by age 32	16.6	2.4

Table1.1 Job prospects and education 

In aviation, pilots who reveal they have ADHD have to stop using medications and be subjected to neuropsychological evaluation after at least three months off the medication to ascertain they do not show any symptoms related to the disorder before being issued with certificates ( Federal Aviation Administration, 2018) . The process is very costly, and pilots are personally responsible. To add to this, the “special issuance authorizations” are limited to one year and may be withdrawn any time in case the condition changes ‘adversely’ ( Federal Aviation Administration, 2018) . The potential perceived incapacitation risk from the disorder and type of medical condition determine this time restriction. To renew their certificates, pilots might undergo additional costly and time-consuming testing at the end of this time. The certificate’s operational privileges, including carrying passengers for hire only in the company of a competent two-pilot crew, may still be in existence even after surpassing these steps. Overall, pilots who display serious ADHD symptoms and need medication or those who decide to self-report may lose their license. 

Airliners must ground themselves if case disqualifying issues come up once the agency offers a medical certificate. Under FAR 61.53, medically certified pilots are not to act as command pilots when they know or have reason to be aware of the medical conditions which would prevent them from meeting the medical certificate requirements ( Sellers, 2013) . Similarly, professional airmen having only sport pilot certificates awarded by an American driver’s license have to ground themselves if they should know or know of medical conditions which would not allow them to operate the aircraft safely. As if this is not enough, FAR limitations on all classes outline that while using any drugs that impact the individual’s faculties in a manner that contradicts safety, a pilot might not be able to act as a civil aircraft crewmember. 

The process described above leads to a system, where the FAA and the Examiner periodically certify all pilots. However, they are also expected to certify themselves often during their medical certificate lives ( Laukkala et al., 2017) . In this system, the first step is to assess whether medical conditions would result in one being disqualified for a certificate, as it typically employs the same procedures used by the FAA and the Examiner in determining whether to provide a medical certificate from the outset. As such, pilots would be expected to ground themselves in case, between certifications, a diagnosis of ADHD was found. The next step is to establish whether any medications utilized in treating the disorder would disqualify an individual. Therefore, pilots would ground themselves if they started taking medications to have their ADHD condition treated. 

Another key area that present significant challenges for a pilot to obtain a medical certificate and obtain/retain a job is associated with FAA drug testing. While federal regulations expect airmen intending to be medically certified to reveal the use of both prescription and non-prescription medications, the aviation medical investigation excludes a drug test (Laukkala et al., 2017). Nevertheless, this omission should not be taken to imply that any less-than-scrupulous pilot under medication who does not ground themselves or uncover this information will go unpunished. In general, the agency emphasizes drug test for air and commercial transport pilots for five substances, including amphetamines. Therefore, they would probably be detected if they take any medication utilized for ADHD treatment (Sellers, 2013). The different kinds of drug testing performed on airmen at different stages include pre-employment; post-accident; random, annual testing for more than 50% of safety-sensitive staff; testing employees getting back on duty after rejecting initial test; testing based upon reasonable cause; and follow-up testing for returning to duty staff after failing/refusing an initial one (Sellers, 2013). 

The consequences for pilots identified to be utilizing ADHD medications based on amphetamine could be extremely adverse (Sellers, 2013) . Those who use non-permissible drugs when performing safety-sensitive roles or those who have two confirmed positive drug test results are disqualified on a permanent basis and can no longer do safety-sensitive functions. In extreme situations, employment may be terminated after initially failing a drug test. Employees may be suspended temporarily at the very least. 

Similar sanctions may be impounded if pilots refuse to take a drug test (Sellers, 2013) . They include revocation and suspension of any authorization, rating, or certificate issued; and denial of any application for any issued authorization, rating, or certificate. In addition, although a pilot certified as a private, recreational, or sports pilot is normally not subject to these tests, he/she would need to undergo drug tests if he/she applied for a position to maintain a commercial aircraft (Bishop et al., 2018) . Refusal to be subjected to such tests by private, recreational, or sports pilots would be subject to same consequences as commercial pilots leading to the suspension or revocation of any current certificates or denial of any future ones. As a result of such intense drug testing and sanctions, most airmen would have to rethink prior to taking ADHD medications. 

Conclusion 

While the FAA has recently made some progress to include antidepressants in ADHD medications, the procedures for the medical certification process, drug testing, and self-grounding have hindered pilots with ADHD in their ability to obtain medication and therefore obtain or retain a job . This has enormously impacted both the pilots and third parties. To demonstrate significant improvements to address these concerns, therefore, the FAA should keep up through creating policies that motivate pilots to appropriately treat their condition so that they stay safe while conducting their obligations. Even though the agency acknowledged this in 2010 when it developed its new selective serotonin reuptake inhibitors (SSRIs) policy, it never implemented the same for pilots under ADHD medications. As such, the FAA needs to change the narrative of hiding ADHD diagnoses through the creation of a new ADHD medication policy based on its SSRIs policy. This amendment would likely encourage information disclosure by those with ADHD disorder and get the needed treatment while reducing/eliminating the risks related to medications. Finally, the policy change needs to enhance safety, since it will be safer for pilots to take medication compared to continuing to fly without treatment. Overall, they would obtain/retain their jobs. 

References  

Curatolo, P., D'Agati, E., & Moavero, R. (2010). The neurobiological basis of ADHD. Italian Journal of Pediatrics , 36 (1), 79. doi:10.1186/1824-7288-36-79 

Federal Aviation Administration. (2018, February 23). Guide for aviation medical examiners. Retrieved November 21, 2018, from https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/dec_cons/disease_prot/adhd/ 

Kliegel, M., McDaniel, M. A., & Einstein, G. O. (Eds.). (2008). Prospective memory: Cognitive, neuroscience, developmental, and applied perspectives . Taylor & Francis. 

Konopka, L. M. (2014). Understanding attention deficit disorder: A neuroscience prospective. Croatian Medical Journal , 55 (2), 174-176. doi:10.3325/cmj.2014.55.174 

Laukkala, T., Bor, R., Budowle, B., Sajantila, A., Navathe, P., Sainio, M., & Vuorio, A. (2017). Attention-deficit/hyperactivity disorder and fatal accidents in aviation medicine. Aerospace medicine and human performance , 88 (9), 871-875. 

NHS. (2017, October 20). Attention Deficit Hyperactivity Disorder (ADHD). Retrieved November 21, 2018, from https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/symptoms/ 

Sellers, B. (2013). Focusing on ADHD: A Second Look at the FAA's Ban on ADHD Medication in the Cockpit. J. Air L. & Com. , 78 , 417. 

Silk, T. J., Vance, A., Rinehart, N., Bradshaw, J. L., & Cunnington, R. (2008). Dysfunction in the frontoparietal network in attention deficit hyperactivity disorder (ADHD): An fMRI study. Brain Imaging and Behavior , 2 (2), 123-131. 

Vohs, K. D., & Baumeister, R. F. (Eds.). (2016). Handbook of self-regulation: Research, theory, and applications . Guilford Publications. 

Ahmed, R., & Aslani, P. (2013). Attention-deficit/hyperactivity disorder: An update on medication adherence and persistence in children, adolescents and adults. Expert Review of Pharmacoeconomics & Outcomes Research, 13 (6), 791-815. 

Bishop, H., Boe, L., Stavrinos, D., & Mirman, J. (2018). Driving among adolescents with autism spectrum disorder and attention-deficit hyperactivity disorder.  Safety, 4 (3)