Working at sea with ADHD

As part of Nautilus's ongoing work to advise and support members with neurodiverse conditions, we are looking in this article at ADHD. Sarah Robinson discussed the condition with the MCA chief medical adviser Dr Sue Stannard, who oversees the UK's approved doctors – the people in charge of issuing fitness certificates to seafarers and cadets

Sarah Robinson (SR): Applicants for seafarer fitness certificates must declare existing health conditions at their medical assessments, and recently, some of the approved doctors have observed an increase in declarations of Attention Deficit Hyperactivity Disorder – better known as ADHD. What is ADHD, and how can it affect seafarers' work?

Dr Sue Stannard (SS): In broad terms, ADHD is a condition that affects an individual's behaviour. They may seem restless, have difficulty concentrating or seeing tasks through to completion, and be impulsive, tending to act before they think through the consequences of those actions. ADHD is complex and doesn't affect all people in the same way.

It's important that the seafarer is honest and open with their approved doctor about ADHD and any other medical condition. Failure to do so may put themselves at risk, most importantly, but might also put others at risk. We want to see seafarers go to sea safely.

Having ADHD does not automatically mean that a seafarer is unfit to work at sea. We need to understand how ADHD affects that individual, and therefore make sure that it's safe for them to be working and potentially living onboard.  

In addition, some people are prescribed medication for ADHD, which may help them manage their symptoms, but may also come with side effects. Again, all medications should be declared at a medical examination, and it's really important that the seafarer is well-established on a stable dose with a good effect on their symptoms, but with no side effects that can cause issues and affect safety at sea. It's not a good idea to be starting, stopping or changing medication onboard, because that can have a direct impact on the underlying condition.

SR: I understand that some medication prescribed for ADHD is described as 'controlled'. Can you tell us what that means, and how controlled drugs can be managed onboard vessels?

SS: Controlled drugs are subject to a high level of regulation by governments. In general terms, they can often only be issued for a set period of time. They must be signed-for on receipt and they need to be stored safely.

It's important that the seafarer discusses this with the healthcare professional who's prescribing them and with the pharmacist who's distributing them, and to make sure that they have enough medication to cover their contract onboard if they're not coming home frequently.

Onboard, these drugs must be declared to the master and must be stored securely. It's important that the seafarer always carries a prescription, and they should also be given a 'conditions letter' from the approved doctor to accompany the medication. These medications may actually be illegal in some countries, and therefore the company and the master should be aware, as this may affect route planning, contract planning, etc. Likewise, if a seafarer is travelling to join a ship, they must ensure that it's legal to carry the medication into the country they're travelling to, or into any they're transiting through.

SR: What does all this mean for somebody with ADHD who's seeking an ENG1 or ML5 medical certificate so that they can work onboard ship? What information and documentation do they need to bring to the approved doctor who's carrying out their assessment?

SS: I'm glad you asked me that! The symptoms and the severity of ADHD can vary hugely, but what matters for the approved doctor is how those symptoms affect the individual's ability to perform their routine and emergency duties and to live safely onboard.

So what's really helpful is information about how the individual does these things at home. It's very useful to have a letter from the treating doctor describing the seafarer's symptoms, the medication they're on, how long they've been on that medication, whether there are side effects, etc.

We appreciate, however, that it can be very difficult to get a formal diagnosis, as waiting lists are so long. If it's not possible to get a full medical report on the diagnosis and management plan, it's useful to get a report from a current employer. And if this is the applicant's first medical, we could look at a report from a school or a college, a sports team coach, a Scout leader – someone who knows the individual well in a work or team environment.

In the report, we'd be interested to hear how the individual interacts with others, and how they behave in different situations. Can they follow spoken and written instructions to perform a task to completion? Can they follow two or three lots of instructions to perform two or three tasks to completion, either under pressure or at the same time? Can they prioritise and make decisions, and importantly, how do they react to working under pressure, such as may be required in an emergency situation?

SR: What happens if the seafarer is not happy with the outcome of their medical assessment?

SS: There is an appeals process, and the details of that are found on the back of the ENG3 certificate, which must be issued along with an ENG1 if restrictions are placed on an ENG1 certificate.

The ENG3 can also be issued in isolation if a seafarer is made temporarily or permanently unfit. Any appeal must then be made within one month of the ENG3 being issued. If a seafarer is made temporarily unfit for less than three months, they cannot appeal, as this time is required to gather additional information about the seafarer's condition.

The appeal process involves an independent review of the approved doctor's decision by one of seven medical referees, who will also meet the seafarer so they can present their situation. The referee may uphold the approved doctor's decision, or they may change it, but I think it's important to say that there is always the chance that this may not go the way the seafarer might wish.

If you're not happy with the approved doctor's decision, please don't try going to another approved doctor to get a different decision with the same information, or by not declaring the information you've already declared to one doctor.

All approved doctors and referees have access to all seafaring medical examination records through a secure online system, and going to another approved doctor – so-called 'doctor shopping' – is not advisable. The second doctor will simply refer them back to the original doctor and tell them to follow the correct procedure.

SR: Is there anything else you'd like to say to Nautilus members with ADHD about their medical assessment and maritime careers?

I think it's very important for everybody to understand that having any medical condition, including ADHD, does not necessarily prevent people from becoming seafarers or continuing to work as seafarers.

Many individuals with ADHD do go on to have a successful career in the maritime industry, and the MCA fully supports prospective seafarers in that endeavour. We're keen for people to work at sea, and we aren't trying to stop them – it's about safety for all involved.  

So for those with any pre-existing condition, including ADHD, my top tip would be to acknowledge that a medical certificate may not be given at the first assessment. Please don't arrange your medical for the day before you intend to embark on the vessel, and do allow sufficient time for the process. It may be the case that more information is required and gathering it could take time.

• The official documents governing the conduct of UK seafarer medical assessments are the M-notice MSN 1886 and the Approved Doctor's Manual. Both of these can be found through a search on www.gov.uk.