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September 2001 Vol. 16, No. 9   RSS Feed for Undercurrent Issues
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The Minds and Bodies of Children

_ are they really suited to scuba?

from the September, 2001 issue of Undercurrent   Subscribe Now

Make no mistake. More children at increasingly younger ages are going scuba diving.

Many diving parents want their children to experience the colors, creatures, calm and curiosity of the underwater world. And, the dive industry wants to expand the market. By marketing diving to families and certifying children, the entire industry — the training agencies, the manufacturers, dive stores, and dive travel — benefits econ omically.

With an eye toward promoting the sport, in 1999 the Recreational Scuba Training Council, a standard- setting body whose membership is composed of training agencies, eliminated its recommended age of 15 for junior certification. No longer fettered by minimum age limits, several major training agencies lowered the age for extended dive experiences and conditional certifications. For example, today PADI’s “Seal Team” and SSI’s “Scuba Rangers” offer scuba experiences to children as young as age 8, and junior open water certification at age 10.

Despite the undeniable appeal of introducing youngsters to the underwater world and making scuba a family activity, several psychological and physiological reasons demand consideration in opening scuba to 8-yearolds.

To understand the psychological and physiological concerns requires recognizing the age variation at which children make the cognitive, behavioral and physical transition from one developmental stage to the next. In fact, this well-known variability itself forms a basis for questioning the policy of lowering ages.

Cognitive Issues

Among cognitive concerns is the child’s ability to acquire and manipulate information. According to Jean Piaget’s widely influential system, three developmental periods are germane to child scuba divers.

The first, the Pre-Operational stage, begins about age 2 and extends to about age 7. In the later years, a child has an intuitive though rudimentary grasp of some logical concepts. A child’s perceptions still dominate his judgment. He will tend to focus attention on one aspect of an object while ignoring others. He is unable to understand the principles underlying proper behavi or, relying on the do’s and don’t simposed by authority.

While it is uncommon, some children 8 and older are delayed in the Pre-Operational stage and the dive agencies have no explicit criteria for screening them out. But, a late-developing child could forget to continue to exhale while making an emergency ascent or may not place anothers’ safety on par with his own. It is up to the instructor (who could himself be a teenager of 18) to recognize cognitive immaturity and refuse to teach the child.

During the next, or Concrete Operational stage (covering approximately age 7-11 years), logical thought develops. But it remains dependent upon concrete referents. While the child is developing the ability to appreciate concepts such as length, mass and volume, and to arrange objects in a logical sequence, it remains linked to objects present — not objects in the abstract. One can assume that the child at age 11 is much more capable than the child at age 8 in this stage .

The leadership in this conservative industry
has taken a “relaxed” attitude regarding
diving safety.

The new policy for PADI, SSI and others clearly allows children in the Concrete Operational stage (7-11 years) to enroll in scuba programs. The risks are not inconsequential. For example, a child in this period may be able to understand basic scuba theories such as Boyle’s law and solve a few problems. However, he will be unable to hypothesize from such principles and extend them to a wider application — such as appreciating that an empty tank may allow for a few more breaths as one ascends. More worrisome, when faced with a scuba emergency, such as a BC inflator mechanism stuck in the open position, they will unlikely be able to generate multiple solutions to the situation. And, they would unlikely be able to select the best alternative: attempting to vent the BC continuously rather than disconnecting the inflator hose.

In the final stage of Formal Operations (covering approximately age 11-15 years), thought gradually becomes less tied to concrete reality and becomes more abstract. The ability to generate abstract propositions and multiple hypotheses and assess their possible outcomes becomes evident. This development allows individuals to think about what might be, rather than just what is. The levels of cognitive ability evident when a child completes this stage are those most appropriate to safe scuba.

Behavioral Issues

Children are notorious for being exuberant, impulsive and feeling invincible. These are normal childhood traits that typically aren’t mastered until the mid to late teens, or even later. This has obvious implications for the appreciation and avoidance of risk — and the ability to act as a responsible dive buddy.

Physical Issues

Patent foramen ovale (PFO): During fetal development, blood flows through a small opening between the right and left upper chambers of the heart. The lungs are inoperative and the mother oxygenates blood. At birth, however, this opening is supposed to close, shunting blood to the now-functioning lungs. While this “hole in the heart” usually seals by the third month of life, it does not always. Estimates of incomplete closures in older children and younger teens run higher than 50 percent in certain groups. Whatever the exact figures, the research suggests an increased incidence of PFO as age decreases below 20.

Without complete closure, blood can flow from the right to the left side of the heart without passing through the lungs. Increases in right chamber pressure that occur with common equalization techniques like the Valsalva maneuver — squeezing your nose, closing your mouth, and blowing — can move blood through the hole and bypass the lungs. When this happens, nitrogen bubbles that can form in the bloodstream may pass directly into the arteries and not be filtered by the lungs. This of course can lead to an embolism or DCS.

Possible reta rdation of bone growth : Long bones, like the humerus and femur, mature from growth plates, the active ends of bones where increases in length occur. The last of the growth plates generally do not cease activity until the late teens or early twenties. As these growth plates depend upon nearby blood vessels for oxygen and nutrition, physicians have long been concerned that nitrogen bubbles in the bloodstream may result in damage to these critical tissues. In addition, the development of bone and connective tissue involves molecular oxygen, raising the possible adverse effects of the elevation of oxygen partial pressures occurring during diving.

Heat regulation : Due to a relatively large skin mass to body mass ratio, children do not regulate body heat as well as adults. Until the mid-teens or so, youth are far more vulnerable to hypothermia. And, alarmingly, a child may be hypothermic yet have no complaints, and still feel warm to the touch .

Eustachian tube development : In younger children, the Eustachian tube is narrower and more horizontal than later in development. While this is unlikely to be problematic in children over age 12, it has implications for equalizing, including potentially damaging reverse squeeze, for children closer to age 8. Furthermore, young divers with immature Eustachian tubes may be subject to more frequent middle ear infections. Since a diver must be able to clear his ears safely and comforta bly, a person with a middle ear infection should not dive. So, a child must recognize it, tell someone, and not dive.

“ There is insufficient information available to
make any evidence-based medical judgment
for or against children in scuba diving.”

The Response of the Dive Training Community

The positions of several agencies are based on conclusions expressed by John Kinsella, Director, Training and Quality Management of PADI America, in his article entitled “Kids and Diving” (The PADI Undersea Journal— First Quarter, 2001). After reviewing the evidence for potential medical concerns expressed by DAN, he concluded: “There is insufficient information available to make any evidence- based medical judgment for or against children in scuba diving . ”

SSI allows children as young as age 8 to have a shallow water scuba experience in their “Scuba Rangers” program. Children 10 to 12 may receive a junior open water certification with certain limitations. Once they turn 12, they may upgrade to a regular open water diver. Those 12 and older are eligible to become a Nitrox specialty diver.

When we asked Dennis M. Pulley, SSI Director of Training , about their program, he told us that “SSI is aware of medical and psychological concerns in divers as young as 12.” However, he cited the RSTC position that medical experts are unable to provide any documentation or proof why an individual must be at least 12 years of age to begin scuba training. Pulley also remarked that, “Psychologically, one could argue that many young males between the ages of 16 and 30 could have the same attitude of being invincible.”

It is true that many theoretical medical and behavioral concerns have not been subjected to controlled studies on humans. And may never. The ethical issues are obvious. For those issues that may be studied, it will be a long and painstaking process, as evidenced by how difficult gathering useful data on DCS has been.

It seems, then, to drop the training age with no longitudinal, hard data about the effect on children is questionable at best. Historically, the response of training agencies to incomplete knowledge has been to err on the side of safety. Think about how the agencies have treated dive tables for all gases, how they fought against Nitrox because it was unsafe and unstudied, how conservative they have been on dive-to-fly estimations, depth limits, and clearance to dive for medical disorders that may pose a risk to scuba divers. Yet the leadership in this conservative industry has taken a “relaxed” attitude regarding the diving safety of children.

However, while there may be no formal studies of the effect of diving on children, PADI and European-based CMAS have long offered swimming pool scuba to children as young as age 4, and restricted open water certification for those to age 8. To date, the results cause no alarm. Even allowing for the extent to which good PR may influence disclosure of adverse events, if children were sustaining harm in significant numbers, liability issues would presumably force this information into the open.

“The medical and developmental concerns
a re sufficiently compelling to preclude scuba
for those less than age 12.”

To their credit, PADI and SSI have taken sensible steps to address medical and developmental concerns. For example, the Seal Team , Bubblemaker and Scuba Rangers programs are restricted to a pool or pool-like environment. Both agencies require that certified divers ages 10-11 be accompanied by a certified parent, legal guardian, or professional dive leader, and limit maximum depth to 40 feet. We should note, however, that while these depth limits do control the partial pressures of nitrogen and oxygen, an embolism can occur in as little as four feet of water. PADI has taken special educational efforts to alert instructors to the safety issues. And while current instructors haven’t been trained to certify children but still can, future instructors will find extensive material incorporated into upcoming revised Instructor Development Courses.

Nonetheless, not all agencies have been willing to embrace scuba experiences for kids. Neither NAUI nor the YMCA — both nonprofit organizations in contrast with PADI and SSI — offer scuba programs for children less than 12 years of age. Frank Toal, of the NAUI training office, told Undercurrent that the agency found the medical and developmental concerns sufficiently compelling to preclude consideration of scuba for those less than age 12. Additionally, NAUI’s junior scuba certification, for ages 12-14, imposes a 60-foot maximum depth limit and requires supervision by a certified diver age 18 or older.

Such reservations are not limited to these two training agencies and many experts have been outspoken in their opposition (see sidebar). World-recognized dive medicine expert Dr. Ernest Campbell has expressed misgivings about allowing his children to be certified at a young age, and said that he probably would have waited until their midteens if he had it to do again.

So, what’s a parent to do?

Admittedly the issues are complex. Yet it is clear, children face greater risks than adults. Parents or guardians must be thorough and responsible when considering whether to enroll in a PADI or SSI program.

Any child being considered for a compressed air at depth experience or scuba certification should receive a pediatric examination with the expressed purpose of clearance for diving. The child’s psychological maturity for diving should be evaluated through open and honest discussions between the child, parent or guardian, and a knowledgeable instructor. If any party has substantial reservations, wait until these resolve. Under no circumstances should an unwilling child be coerced into scuba. If all signs are go, make sure the youngster has gear he or she can manage, wears adequate thermal protection, and is enrolled in a class of similar aged children. Finally, for those children receiving certifications with restrictions, ensure that all conditions are scrupulously observed. Attend the classes with your child and if you have any doubts about the child, the instruct or, or the class, work them out or consider other classes later.

—Doc Vikingo

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