C L I N I C A L F O C U S : A D H D, P S Y C H I AT R I C D I S O R D E R S , A N D S T R O K E A N D N E U RO L O G Y
Addressing Attention-Deficit/Hyperactivity Disorder in the Workplace
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DOI: 10.3810/pgm.2014.09.2797
Elias Sarkis, MD Sarkis Family Psychiatry, Gainesville, FL
Abstract: Although generally considered a childhood disorder, attention-deficit/hyperactivity disorder (ADHD) can persist into adulthood and impede achievement in the workplace. Core ADHD symptoms of inattention, hyperactivity, and impulsivity can be associated with poor organization, time management, and interpersonal relationships. Employment levels, earning power, and productivity are reduced among individuals with ADHD compared with those without ADHD. Furthermore, the costs of employing individuals with ADHD are higher because of work absences and lost productivity. The primary care provider plays an integral role in managing ADHD symptoms and providing the necessary resources that will help individuals with ADHD succeed in the workplace. Pharmacotherapy can reduce ADHD symptoms and improve functioning; however, it is also important to consider how positive traits associated with ADHD, such as creative thinking, can be used in the workplace. Workplace accommodations and behavioral therapies, such as coaching, can also enhance time management and organizational skills. This review describes how ADHD symptoms affect workplace behaviors, the effect of ADHD on employment and workplace performance, and the management of ADHD in working adults. Keywords: adult; attention-deficit/hyperactivity disorder; employment; functional impairment; work productivity; coaching
Introduction
Correspondence: Elias Sarkis, MD, Sarkis Family Psychiatry, 611 NW 60th St, Gainesville, FL. Tel: 352-331-5100 Fax: 352-332-9607 E-mail: [email protected]
Although considered a disorder of childhood, attention-deficit/hyperactivity disorder (ADHD) can persist into adulthood, with the severity of adult symptoms being correlated with those observed during childhood.1 Worldwide prevalence of ADHD in adults has been estimated to range from 3.4%2 to 4.4%.2,3 Although the core symptoms of inattention, hyperactivity, and impulsivity are present in adults, there are subtle differences in their manifestation in adults compared with that in children. Hyperactivity is the most frequently observed symptom among children, whereas inattention, which is associated with distractibility, lack of organization, and forgetfulness, is the predominant symptom among adults.4 Only about 50% of adults with ADHD display symptoms of hyperactivity, which is characterized by chronic restlessness, fidgeting, and an inability to relax.4 In adults with ADHD, impulsivity can result in poor social skills, such as impatience with others and frequently interrupting people when they are speaking.4 Adults with ADHD use various compensatory mechanisms to cope with daily living.4,5 These mechanisms can include the use of organizational tools or dependence on other people.4 Many of the adaptations that allow individuals with ADHD to function at their potential outside the work environment can be extended and adapted to
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Elias Sarkis
situations at work; however, others cannot.5 This narrative review describes the prevalence, consequences, and management of ADHD in the workplace and how the primary care provider (PCP) plays an important role in supporting adults with ADHD in the workplace.
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Methods
A search of PubMed was conducted on April 9, 2012, using the search terms attention deficit/hyperactivity disorder, ADHD, AD/HD, work productivity, work, coaching, and coach. The references obtained from this search, and their respective bibliographies, were reviewed for relevance. Additional references that were not obtained from the literature review were included based on the author’s knowledge of the literature.
Prevalence and Consequences of ADHD in the Workplace
The prevalence of ADHD in the workplace is similar to that in the general population, ranging from 3.5% to 4.2%6,7 and is similar across age, sex, education level, and occupation.7 However, among those outside the workforce, the conditional estimated prevalence rate of ADHD in adults aged 18 to 44 was reported to be relatively high in the unemployed (5.5%) and relatively low in homemakers (1.9%) and students (2.2%) in an epidemiologic survey based on data from the World Health Organization’s World Mental Health Initiative.2 The core ADHD symptoms of inattention, hyperactivity, and impulsivity manifest in a variety of ways that affect job performance (Table 1). For example, inattention and the ensuing problems with time management can result in poor attendance8–10 and an inability to accomplish personal or corporate objectives.5,10–13 Hyperactivity and impulsivity symptoms may result in interpersonal problems with colleagues.8 The ability to maintain effective interpersonal relationships can be compromised by the tendency of those with ADHD to act without thinking,4,12 interrupt others,4,11,12 and be defensive5,14 or hostile.9,15 In addition, executive functioning often is impaired in adults with ADHD, even in those individuals with greater intellectual capacity.10,16 As a result, the organizational skills required for proper job performance may be impaired.13 Lastly, the irritability commonly observed among individuals with ADHD can result in impatience and difficulties getting along with others, outbursts of anger, and increased hostility in the workplace.13 Barkley and colleagues17 reported a strong relationship between ADHD symptoms and work impairment as rated by the employer in a variety of workplace functioning domains, 26
including relations with coworkers, supervisors, and clients; completing assigned work; punctuality and absenteeism; and managing responsibilities. In addition, Gjervan and colleagues18 reported that the association of ADHD inattentiveness with poor occupational outcome was mediated by social function. This reflects the negative consequences of emotional distress, impaired physical health, and dissatisfaction with achievements on workplace outcomes in individuals with ADHD.18 Comorbidities are frequently observed among individuals with ADHD and can include mood disorders (such major depressive disorder and bipolar disorder), anxiety disorders (such as generalized anxiety disorder and obsessive-compulsive disorder), impulse control/personality disorders (such as oppositional defiance disorder and antisocial personality disorder), learning disabilities, and sleep disorders.13,14,19 Substance use disorder, including tobacco and alcohol, can also be prevalent among individuals with ADHD, especially among those with comorbid conduct disorder.19,20 Therefore, it is important to take an individual’s specific comorbidities into account, to decide which disorder needs to be treated first based on relative severity, and to individualize workplace accommodations based on the individual’s strengths and weaknesses. In addition, evaluating personality types based on personality tests, such as the Myers-Briggs Type Indicator, has been suggested to help individualize interventions and accommodations.10 For instance, it is conceivable that an adult with ADHD and comorbid anxiety might respond differently when encountering criticism in the workplace relative to those with comorbid oppositional/defiant disorders. This narrative review focuses mainly on managing the negative ramifications of ADHD in the workplace; however, Table 1. Recognizing Symptoms of ADHD in Adults in the Work Environment4,6,12–14,17 ADHD Symptom
Expression in the Workplace
Inattention
Inability to focus on instructions or activities that require sustained mental effort Difficulties with information recall Increased number of errors Inability to meet goals or timelines Ineffective time management Procrastination Lack of organization Tardiness Absenteeism Increased accidents and injuries Inability to sit still Roams, disrupts other with restlessness Speaks out of turn, interrupts others
Hyperactivity Impulsivity
Abbreviation: ADHD, attention-deficit/hyperactivity disorder.
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ADHD in the Workplace
it has been suggested that although some aspects of ADHD can be considered an impairment in one environment, they can be considered a positive attribute in another.21 For example, the broadened attentional focus and increased distractibility observed in children with ADHD has been suggested to enhance certain aspects of creative thinking,22 a trait that could be valuable in the workplace. In support of the idea that high creativity can be associated with ADHD, it has been reported that among highly creative children, 40% exhibit ADHD symptomatology.23 Moreover, resilience skills developed by some individuals to cope with their ADHD10 could be helpful in the work environment. Given this information, it is not unreasonable to speculate that adults with ADHD whose skills are well matched with their type of employment can excel in the workplace.10
Employment, Earning Power, and Lost Productivity With ADHD
Adults aged 23 to 32 years diagnosed with ADHD in childhood are more likely to be unemployed compared with those without ADHD24; the percentage of adults with ADHD who are fully employed is also lower.25 In addition, the length of time an individual with ADHD holds a job is shorter, with greater rates of employment turnover due to dismissal by the employer or resignation by the individual resulting from disliking the job, boredom, or impulsivity.9,13,24 Individuals with ADHD also are more likely to work in unskilled versus clerical or professional occupations compared with non-ADHD adults.24 Furthermore, use of public assistance is higher among adults with ADHD, possibly as a consequence of underemployment and lower wages.26 Individuals with ADHD display decreased earning power in the workplace. Average household income was found to be lower in 25- to 64-year-old working individuals with ADHD compared with a matched control group regardless of education status in 1 study; even individuals with ADHD and a postgraduate degree earned approximately 40% less than their non-ADHD counterparts.25 Based on these findings, the aggregated projected loss of income in the United States ranged from $67 to $166 billion annually.25 Another report found an approximate 30% reduction in annual earnings for individuals with ADHD.26 Individuals with ADHD also can place additional burdens on their employer. Employed ADHD workers are absent more often than those without ADHD,6,27 and adults with ADHD have a greater number of days in which work productivity is decreased in terms of quantity (21.7 days) and quality (13.6 days) compared with workers without ADHD.6 In 1
retrospective survey, lost salary costs due to sickness-related absence and lost work performance were estimated to be approximately $4300 per worker with ADHD.27 In the same survey, ADHD was associated with a significantly higher probability of having a workplace-related accident or injury.27 The overall loss of workforce productivity attributable to ADHD is considerable, with a projected 143.8 million lost days of productivity each year across 10 countries in Europe, North and South America, and the Middle East.6 A systematic review of studies conducted in the United States reported that productivity losses due to absenteeism, poor work performance, and disability or workers’ compensation equated to annual incremental costs of $88 billion to $141 billion.28 This suboptimal performance of some individuals with ADHD is acknowledged across a range of individuals in the workplace. A study by Halbesleben and colleagues29 reported that job performance was rated lower in individuals with ADHD by the individual, coworkers, and supervisors. Poor “in-role” performance was most highly correlated with ADHD, which was interpreted as an indication that the individual is not focusing on task-relevant behaviors.
Addressing ADHD in the Workplace
Given the effect of ADHD on productivity and performance among working adults, addressing the issues associated with ADHD in the workplace makes economic sense. There are several approaches toward accomplishing this goal. Pharmacotherapy can play an important role in addressing the occupational needs of adults with ADHD.30 A meta-analysis concluded that stimulant and nonstimulant medications effectively reduce ADHD symptoms in adults31; individuals treated with pharmacotherapy also report improvements in concentration, anxiety, and confidence.13 In addition, a recent literature review reported that quality of life and role functioning were improved in adults with ADHD treated with stimulant medications.32 However, not all functional impairments resolve with pharmacotherapy. Furthermore, current treatments for ADHD (pharmacologic, nonpharmacologic, or multimodal) improve daily functioning in individuals with ADHD but not always to the point of normalization.33 In the context of the workplace, symptomatic remission and no functional impairment due to residual ADHD symptoms is an important goal.34 Both ADHD and its associated psychiatric comorbidities, such as depression and substance abuse disorder, are considered disabilities according to the Americans with Disabilities Act (ADA)35 and the Rehabilitation Act of 1973;
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Elias Sarkis
therefore, individuals with ADHD have protections against discrimination in employment, and reasonable workplace accommodations are required if the individual with ADHD discloses the diagnosis.36 The concept of “reasonable accommodations” is flexible35 and can take several forms.5,10–12,37 The physical workplace can be customized to organize materials and minimize distractions. If feasible, the employer could provide a flexible work schedule so the employee with ADHD can work during times of higher productivity or be able to “burn off” excess energy through exercise. Job responsibilities could be structured so that ADHD behavioral proclivities become assets; in particular, workers with ADHD may thrive while focusing on projects that require multitasking, open discussion, creative thinking, or perfectionism. Reporting relationships could be streamlined to eliminate confusion and to foster periodic feedback; ideally, a supportive mentoring relationship between the supervisor and the employee with ADHD should be established. Lastly, technologies (eg, day planners, timers, electronic devices) could be employed to assist in scheduling, planning, and other issues relating to time management. Technology implementation should be accompanied by adequate training and regular use for maximal effectiveness. Coaching also has been explored in the management of ADHD in adults.5,14,38 Coaching for adults with ADHD can parallel the support and structure provided by parents, teachers, and other caregivers for children with ADHD. Coaching focuses on the development and application of practical strategies to help these individuals be more effective in their daily activities.37,38 In 1 study, college students with ADHD who underwent personalized coaching focused on areas such as improving organization and time management, managing stress, and balancing academic and personal life reported an increased ability to attain goals, decreased anxiety over academic issues, and an enhanced awareness of the effect of executive function challenges on their functioning.39 In another study, college students with ADHD who received coaching reported improvements in time management and organizational skills.40 In a randomized study of college students with ADHD who received coaching services compared with those who received no intervention, significantly improved executive functioning was reported, as measured on the skill, will, and self-regulation domains of the Learning and Study Strategies Inventory.41 Quantitative data on coaching for adults with ADHD outside the college setting is lacking; however, the use of coaching in the workplace has been recommended as a means for improving the performance of employees with ADHD.5 This recommendation 28
is supported by a study of adults (aged 40–59 years) with known or suspected ADHD that reported a positive effect from coaching in areas that could affect workplace functioning (ie, inattentiveness, distractibility, cognition, social outcomes, and behavioral outcomes).42 It has also been suggested that the implementation of programs for screening and treating ADHD in the workplace may be an effective strategy for reducing the overall costs of ADHD to the individual and the employer.15 However, the implementation of screening for ADHD raises the potential for discriminatory practices in regard to hiring or promoting employees. As such, screening and treatment recommendations should be made available to employees upon their request for such information. Additionally, at the time of an employee’s performance review, if deficits in performance are observed that could be consistent with ADHD, part of the employee’s counseling could include the suggestion for screening and assessment for ADHD by a physician, with coaching being considered as 1 treatment option. These procedures could also promote employee retention and retain the investment in training put forth by the employer. The use of such multimodal strategies for managing ADHD at work, involving a combination of coaching and workplace accommodations, may also optimize overall work performance in individuals with ADHD. It is also important to stress that employees must advocate for themselves and should make verbal or written requests for accommodations under the ADA. Importantly, employees who would benefit from workplace accommodations for ADHD and its associated comorbidities should establish this need before their work performance begins to suffer. Online resources, such as the Employee’s Practical Guide to Negotiating and Requesting Reasonable Accommodations Under the Americans with Disability Act (Job Accommodations Network; www.askjan.org), are available to help employees in this process.
Role of the PCP
The PCP plays an important role in symptom recognition and in the coordination of treatment or referrals. Primary care providers are in a position to recognize and diagnose ADHD because of their access to the individual’s medical history, including comorbidities and concomitant medications, and to information from family members on behavior patterns and employment. Multiple diagnostic tools are available to aid in the PCP’s assessment of adult ADHD symptoms, including the Adult ADHD Self-Report,43,44 the Conners Adult ADHD Rating Scale,45,46 and the Current Symptoms Scale,47,48 as
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ADHD in the Workplace
well as in the assessment of functional impairment in the workplace in adults with ADHD, including the Weiss Functional Impairment Rating Scale49 and the Endicott Work Productivity Scale.50 If needed, the PCP can prescribe appropriate pharmacotherapy for treatment of ADHD symptoms and provide appropriate referrals for psychosocial therapy. However, there are additional ways in which PCPs can provide support for their patients in regard to workplace functioning. As noted earlier (see Addressing ADHD in the Workplace), individuals with ADHD are afforded protections under the ADA and Rehabilitation Act of 1973. Therefore, it is important for PCPs to be familiar with these laws and to be able to provide patients with resources that explain their rights. For example, online resources (such as those provided at http://add.about.com/od/adhdinadults/a/jobrights.htm) are available that provide information related to the protections provided to individuals with ADHD under the ADA and that describe the process for requesting workplace accommodations. Being familiar with specific workplace accommodations, such as those outlined in the section Addressing ADHD in the Workplace, above, is also important. Lastly, the PCP should also be aware of and able to communicate information on external resources that are available to assist in resolution of work performance issues, such as patient advocacy groups, coaches, or career counselors who specialize in working with clients with ADHD.51 The importance of understanding the utility of workplace accommodations can be highlighted in 2 examples from my own practice. In 1 instance, I was managing an individual with ADHD who was a high-performing salesman in a small company that was sold to another company. The previous owner had allowed salespersons to begin working at 10 am because the managers felt that this would optimize each individual’s productivity. However, the new ownership insisted that the workday begin at 8 am. One consequence of the lack of work time flexibility was that my patient’s productivity decreased dramatically. The patient was eventually terminated, and the company lost an employee with a history of high productivity. This example highlights the importance of understanding how the expression and severity of functional impairments in the workplace can be context-dependent and the utility of accommodations in promoting productivity. In a second example, from a more positive perspective, another patient who exhibited with time management problems had a supervisor who was willing and able to take the time to break down daily tasks into smaller portions. With time, this individual needed less supervision and was successful.
Conclusion
The effect of ADHD on performance in the workplace has economic consequences for the employee with ADHD as well as the employer. Individuals with ADHD may benefit from implementation of personalized strategies to address their specific symptoms and reduce the effect of these symptoms on workplace functioning. To resolve job performance issues resulting from ADHD, a multimodal approach to treatment that encompasses pharmacotherapy, workplace accommodations, and psychosocial therapy, such as coaching, is suggested. As the initial point of contact for health care services, PCPs are integral to establishing the diagnosis of ADHD, prescribing medication for symptom management when appropriate, and referring the ADHD patient to the appropriate resources to receive additional assistance.
Acknowledgments
The author would like to acknowledge Margaret D. Weiss, MD, PhD, who provided valuable insight during the development of this manuscript. Shire Development LLC provided funding to Complete Healthcare Communications, Inc. (CHC; Chadds Ford, PA) for support in writing and editing this manuscript. Under the direction of the author, writing assistance was provided by Diane DeHaven-Hudkins, PhD, Robert Axford-Gatley, MD, and Craig Slawecki, PhD (employees of CHC). Editorial assistance in the form of proofreading, copyediting, and fact checking was also provided by CHC. The content of this manuscript, the ultimate interpretation, and the decision to submit it for publication in Postgraduate Medicine was made by the author.
Conflict of Interest Statement
Elias Sarkis, MD, has conducted clinical research for Alcobra, AstraZeneca, Eli Lilly, Forest, GlaxoSmithKline, Lundbeck, Merck, Nanotherapeutics, Naurex, Neurim, Orexo, Otsuka, Pfizer, Purdue, Roche, Schwarz-UCB, Shionogi, Shire, Sunovion, Takeda, and Upsher-Smith.
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Addressing Attention-Deficit/Hyperactivity Disorder in the Workplace
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DOI: 10.3810/pgm.2014.09.2797
Elias Sarkis, MD Sarkis Family Psychiatry, Gainesville, FL
Abstract: Although generally considered a childhood disorder, attention-deficit/hyperactivity disorder (ADHD) can persist into adulthood and impede achievement in the workplace. Core ADHD symptoms of inattention, hyperactivity, and impulsivity can be associated with poor organization, time management, and interpersonal relationships. Employment levels, earning power, and productivity are reduced among individuals with ADHD compared with those without ADHD. Furthermore, the costs of employing individuals with ADHD are higher because of work absences and lost productivity. The primary care provider plays an integral role in managing ADHD symptoms and providing the necessary resources that will help individuals with ADHD succeed in the workplace. Pharmacotherapy can reduce ADHD symptoms and improve functioning; however, it is also important to consider how positive traits associated with ADHD, such as creative thinking, can be used in the workplace. Workplace accommodations and behavioral therapies, such as coaching, can also enhance time management and organizational skills. This review describes how ADHD symptoms affect workplace behaviors, the effect of ADHD on employment and workplace performance, and the management of ADHD in working adults. Keywords: adult; attention-deficit/hyperactivity disorder; employment; functional impairment; work productivity; coaching
Introduction
Correspondence: Elias Sarkis, MD, Sarkis Family Psychiatry, 611 NW 60th St, Gainesville, FL. Tel: 352-331-5100 Fax: 352-332-9607 E-mail: [email protected]
Although considered a disorder of childhood, attention-deficit/hyperactivity disorder (ADHD) can persist into adulthood, with the severity of adult symptoms being correlated with those observed during childhood.1 Worldwide prevalence of ADHD in adults has been estimated to range from 3.4%2 to 4.4%.2,3 Although the core symptoms of inattention, hyperactivity, and impulsivity are present in adults, there are subtle differences in their manifestation in adults compared with that in children. Hyperactivity is the most frequently observed symptom among children, whereas inattention, which is associated with distractibility, lack of organization, and forgetfulness, is the predominant symptom among adults.4 Only about 50% of adults with ADHD display symptoms of hyperactivity, which is characterized by chronic restlessness, fidgeting, and an inability to relax.4 In adults with ADHD, impulsivity can result in poor social skills, such as impatience with others and frequently interrupting people when they are speaking.4 Adults with ADHD use various compensatory mechanisms to cope with daily living.4,5 These mechanisms can include the use of organizational tools or dependence on other people.4 Many of the adaptations that allow individuals with ADHD to function at their potential outside the work environment can be extended and adapted to
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Elias Sarkis
situations at work; however, others cannot.5 This narrative review describes the prevalence, consequences, and management of ADHD in the workplace and how the primary care provider (PCP) plays an important role in supporting adults with ADHD in the workplace.
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Methods
A search of PubMed was conducted on April 9, 2012, using the search terms attention deficit/hyperactivity disorder, ADHD, AD/HD, work productivity, work, coaching, and coach. The references obtained from this search, and their respective bibliographies, were reviewed for relevance. Additional references that were not obtained from the literature review were included based on the author’s knowledge of the literature.
Prevalence and Consequences of ADHD in the Workplace
The prevalence of ADHD in the workplace is similar to that in the general population, ranging from 3.5% to 4.2%6,7 and is similar across age, sex, education level, and occupation.7 However, among those outside the workforce, the conditional estimated prevalence rate of ADHD in adults aged 18 to 44 was reported to be relatively high in the unemployed (5.5%) and relatively low in homemakers (1.9%) and students (2.2%) in an epidemiologic survey based on data from the World Health Organization’s World Mental Health Initiative.2 The core ADHD symptoms of inattention, hyperactivity, and impulsivity manifest in a variety of ways that affect job performance (Table 1). For example, inattention and the ensuing problems with time management can result in poor attendance8–10 and an inability to accomplish personal or corporate objectives.5,10–13 Hyperactivity and impulsivity symptoms may result in interpersonal problems with colleagues.8 The ability to maintain effective interpersonal relationships can be compromised by the tendency of those with ADHD to act without thinking,4,12 interrupt others,4,11,12 and be defensive5,14 or hostile.9,15 In addition, executive functioning often is impaired in adults with ADHD, even in those individuals with greater intellectual capacity.10,16 As a result, the organizational skills required for proper job performance may be impaired.13 Lastly, the irritability commonly observed among individuals with ADHD can result in impatience and difficulties getting along with others, outbursts of anger, and increased hostility in the workplace.13 Barkley and colleagues17 reported a strong relationship between ADHD symptoms and work impairment as rated by the employer in a variety of workplace functioning domains, 26
including relations with coworkers, supervisors, and clients; completing assigned work; punctuality and absenteeism; and managing responsibilities. In addition, Gjervan and colleagues18 reported that the association of ADHD inattentiveness with poor occupational outcome was mediated by social function. This reflects the negative consequences of emotional distress, impaired physical health, and dissatisfaction with achievements on workplace outcomes in individuals with ADHD.18 Comorbidities are frequently observed among individuals with ADHD and can include mood disorders (such major depressive disorder and bipolar disorder), anxiety disorders (such as generalized anxiety disorder and obsessive-compulsive disorder), impulse control/personality disorders (such as oppositional defiance disorder and antisocial personality disorder), learning disabilities, and sleep disorders.13,14,19 Substance use disorder, including tobacco and alcohol, can also be prevalent among individuals with ADHD, especially among those with comorbid conduct disorder.19,20 Therefore, it is important to take an individual’s specific comorbidities into account, to decide which disorder needs to be treated first based on relative severity, and to individualize workplace accommodations based on the individual’s strengths and weaknesses. In addition, evaluating personality types based on personality tests, such as the Myers-Briggs Type Indicator, has been suggested to help individualize interventions and accommodations.10 For instance, it is conceivable that an adult with ADHD and comorbid anxiety might respond differently when encountering criticism in the workplace relative to those with comorbid oppositional/defiant disorders. This narrative review focuses mainly on managing the negative ramifications of ADHD in the workplace; however, Table 1. Recognizing Symptoms of ADHD in Adults in the Work Environment4,6,12–14,17 ADHD Symptom
Expression in the Workplace
Inattention
Inability to focus on instructions or activities that require sustained mental effort Difficulties with information recall Increased number of errors Inability to meet goals or timelines Ineffective time management Procrastination Lack of organization Tardiness Absenteeism Increased accidents and injuries Inability to sit still Roams, disrupts other with restlessness Speaks out of turn, interrupts others
Hyperactivity Impulsivity
Abbreviation: ADHD, attention-deficit/hyperactivity disorder.
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ADHD in the Workplace
it has been suggested that although some aspects of ADHD can be considered an impairment in one environment, they can be considered a positive attribute in another.21 For example, the broadened attentional focus and increased distractibility observed in children with ADHD has been suggested to enhance certain aspects of creative thinking,22 a trait that could be valuable in the workplace. In support of the idea that high creativity can be associated with ADHD, it has been reported that among highly creative children, 40% exhibit ADHD symptomatology.23 Moreover, resilience skills developed by some individuals to cope with their ADHD10 could be helpful in the work environment. Given this information, it is not unreasonable to speculate that adults with ADHD whose skills are well matched with their type of employment can excel in the workplace.10
Employment, Earning Power, and Lost Productivity With ADHD
Adults aged 23 to 32 years diagnosed with ADHD in childhood are more likely to be unemployed compared with those without ADHD24; the percentage of adults with ADHD who are fully employed is also lower.25 In addition, the length of time an individual with ADHD holds a job is shorter, with greater rates of employment turnover due to dismissal by the employer or resignation by the individual resulting from disliking the job, boredom, or impulsivity.9,13,24 Individuals with ADHD also are more likely to work in unskilled versus clerical or professional occupations compared with non-ADHD adults.24 Furthermore, use of public assistance is higher among adults with ADHD, possibly as a consequence of underemployment and lower wages.26 Individuals with ADHD display decreased earning power in the workplace. Average household income was found to be lower in 25- to 64-year-old working individuals with ADHD compared with a matched control group regardless of education status in 1 study; even individuals with ADHD and a postgraduate degree earned approximately 40% less than their non-ADHD counterparts.25 Based on these findings, the aggregated projected loss of income in the United States ranged from $67 to $166 billion annually.25 Another report found an approximate 30% reduction in annual earnings for individuals with ADHD.26 Individuals with ADHD also can place additional burdens on their employer. Employed ADHD workers are absent more often than those without ADHD,6,27 and adults with ADHD have a greater number of days in which work productivity is decreased in terms of quantity (21.7 days) and quality (13.6 days) compared with workers without ADHD.6 In 1
retrospective survey, lost salary costs due to sickness-related absence and lost work performance were estimated to be approximately $4300 per worker with ADHD.27 In the same survey, ADHD was associated with a significantly higher probability of having a workplace-related accident or injury.27 The overall loss of workforce productivity attributable to ADHD is considerable, with a projected 143.8 million lost days of productivity each year across 10 countries in Europe, North and South America, and the Middle East.6 A systematic review of studies conducted in the United States reported that productivity losses due to absenteeism, poor work performance, and disability or workers’ compensation equated to annual incremental costs of $88 billion to $141 billion.28 This suboptimal performance of some individuals with ADHD is acknowledged across a range of individuals in the workplace. A study by Halbesleben and colleagues29 reported that job performance was rated lower in individuals with ADHD by the individual, coworkers, and supervisors. Poor “in-role” performance was most highly correlated with ADHD, which was interpreted as an indication that the individual is not focusing on task-relevant behaviors.
Addressing ADHD in the Workplace
Given the effect of ADHD on productivity and performance among working adults, addressing the issues associated with ADHD in the workplace makes economic sense. There are several approaches toward accomplishing this goal. Pharmacotherapy can play an important role in addressing the occupational needs of adults with ADHD.30 A meta-analysis concluded that stimulant and nonstimulant medications effectively reduce ADHD symptoms in adults31; individuals treated with pharmacotherapy also report improvements in concentration, anxiety, and confidence.13 In addition, a recent literature review reported that quality of life and role functioning were improved in adults with ADHD treated with stimulant medications.32 However, not all functional impairments resolve with pharmacotherapy. Furthermore, current treatments for ADHD (pharmacologic, nonpharmacologic, or multimodal) improve daily functioning in individuals with ADHD but not always to the point of normalization.33 In the context of the workplace, symptomatic remission and no functional impairment due to residual ADHD symptoms is an important goal.34 Both ADHD and its associated psychiatric comorbidities, such as depression and substance abuse disorder, are considered disabilities according to the Americans with Disabilities Act (ADA)35 and the Rehabilitation Act of 1973;
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Elias Sarkis
therefore, individuals with ADHD have protections against discrimination in employment, and reasonable workplace accommodations are required if the individual with ADHD discloses the diagnosis.36 The concept of “reasonable accommodations” is flexible35 and can take several forms.5,10–12,37 The physical workplace can be customized to organize materials and minimize distractions. If feasible, the employer could provide a flexible work schedule so the employee with ADHD can work during times of higher productivity or be able to “burn off” excess energy through exercise. Job responsibilities could be structured so that ADHD behavioral proclivities become assets; in particular, workers with ADHD may thrive while focusing on projects that require multitasking, open discussion, creative thinking, or perfectionism. Reporting relationships could be streamlined to eliminate confusion and to foster periodic feedback; ideally, a supportive mentoring relationship between the supervisor and the employee with ADHD should be established. Lastly, technologies (eg, day planners, timers, electronic devices) could be employed to assist in scheduling, planning, and other issues relating to time management. Technology implementation should be accompanied by adequate training and regular use for maximal effectiveness. Coaching also has been explored in the management of ADHD in adults.5,14,38 Coaching for adults with ADHD can parallel the support and structure provided by parents, teachers, and other caregivers for children with ADHD. Coaching focuses on the development and application of practical strategies to help these individuals be more effective in their daily activities.37,38 In 1 study, college students with ADHD who underwent personalized coaching focused on areas such as improving organization and time management, managing stress, and balancing academic and personal life reported an increased ability to attain goals, decreased anxiety over academic issues, and an enhanced awareness of the effect of executive function challenges on their functioning.39 In another study, college students with ADHD who received coaching reported improvements in time management and organizational skills.40 In a randomized study of college students with ADHD who received coaching services compared with those who received no intervention, significantly improved executive functioning was reported, as measured on the skill, will, and self-regulation domains of the Learning and Study Strategies Inventory.41 Quantitative data on coaching for adults with ADHD outside the college setting is lacking; however, the use of coaching in the workplace has been recommended as a means for improving the performance of employees with ADHD.5 This recommendation 28
is supported by a study of adults (aged 40–59 years) with known or suspected ADHD that reported a positive effect from coaching in areas that could affect workplace functioning (ie, inattentiveness, distractibility, cognition, social outcomes, and behavioral outcomes).42 It has also been suggested that the implementation of programs for screening and treating ADHD in the workplace may be an effective strategy for reducing the overall costs of ADHD to the individual and the employer.15 However, the implementation of screening for ADHD raises the potential for discriminatory practices in regard to hiring or promoting employees. As such, screening and treatment recommendations should be made available to employees upon their request for such information. Additionally, at the time of an employee’s performance review, if deficits in performance are observed that could be consistent with ADHD, part of the employee’s counseling could include the suggestion for screening and assessment for ADHD by a physician, with coaching being considered as 1 treatment option. These procedures could also promote employee retention and retain the investment in training put forth by the employer. The use of such multimodal strategies for managing ADHD at work, involving a combination of coaching and workplace accommodations, may also optimize overall work performance in individuals with ADHD. It is also important to stress that employees must advocate for themselves and should make verbal or written requests for accommodations under the ADA. Importantly, employees who would benefit from workplace accommodations for ADHD and its associated comorbidities should establish this need before their work performance begins to suffer. Online resources, such as the Employee’s Practical Guide to Negotiating and Requesting Reasonable Accommodations Under the Americans with Disability Act (Job Accommodations Network; www.askjan.org), are available to help employees in this process.
Role of the PCP
The PCP plays an important role in symptom recognition and in the coordination of treatment or referrals. Primary care providers are in a position to recognize and diagnose ADHD because of their access to the individual’s medical history, including comorbidities and concomitant medications, and to information from family members on behavior patterns and employment. Multiple diagnostic tools are available to aid in the PCP’s assessment of adult ADHD symptoms, including the Adult ADHD Self-Report,43,44 the Conners Adult ADHD Rating Scale,45,46 and the Current Symptoms Scale,47,48 as
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ADHD in the Workplace
well as in the assessment of functional impairment in the workplace in adults with ADHD, including the Weiss Functional Impairment Rating Scale49 and the Endicott Work Productivity Scale.50 If needed, the PCP can prescribe appropriate pharmacotherapy for treatment of ADHD symptoms and provide appropriate referrals for psychosocial therapy. However, there are additional ways in which PCPs can provide support for their patients in regard to workplace functioning. As noted earlier (see Addressing ADHD in the Workplace), individuals with ADHD are afforded protections under the ADA and Rehabilitation Act of 1973. Therefore, it is important for PCPs to be familiar with these laws and to be able to provide patients with resources that explain their rights. For example, online resources (such as those provided at http://add.about.com/od/adhdinadults/a/jobrights.htm) are available that provide information related to the protections provided to individuals with ADHD under the ADA and that describe the process for requesting workplace accommodations. Being familiar with specific workplace accommodations, such as those outlined in the section Addressing ADHD in the Workplace, above, is also important. Lastly, the PCP should also be aware of and able to communicate information on external resources that are available to assist in resolution of work performance issues, such as patient advocacy groups, coaches, or career counselors who specialize in working with clients with ADHD.51 The importance of understanding the utility of workplace accommodations can be highlighted in 2 examples from my own practice. In 1 instance, I was managing an individual with ADHD who was a high-performing salesman in a small company that was sold to another company. The previous owner had allowed salespersons to begin working at 10 am because the managers felt that this would optimize each individual’s productivity. However, the new ownership insisted that the workday begin at 8 am. One consequence of the lack of work time flexibility was that my patient’s productivity decreased dramatically. The patient was eventually terminated, and the company lost an employee with a history of high productivity. This example highlights the importance of understanding how the expression and severity of functional impairments in the workplace can be context-dependent and the utility of accommodations in promoting productivity. In a second example, from a more positive perspective, another patient who exhibited with time management problems had a supervisor who was willing and able to take the time to break down daily tasks into smaller portions. With time, this individual needed less supervision and was successful.
Conclusion
The effect of ADHD on performance in the workplace has economic consequences for the employee with ADHD as well as the employer. Individuals with ADHD may benefit from implementation of personalized strategies to address their specific symptoms and reduce the effect of these symptoms on workplace functioning. To resolve job performance issues resulting from ADHD, a multimodal approach to treatment that encompasses pharmacotherapy, workplace accommodations, and psychosocial therapy, such as coaching, is suggested. As the initial point of contact for health care services, PCPs are integral to establishing the diagnosis of ADHD, prescribing medication for symptom management when appropriate, and referring the ADHD patient to the appropriate resources to receive additional assistance.
Acknowledgments
The author would like to acknowledge Margaret D. Weiss, MD, PhD, who provided valuable insight during the development of this manuscript. Shire Development LLC provided funding to Complete Healthcare Communications, Inc. (CHC; Chadds Ford, PA) for support in writing and editing this manuscript. Under the direction of the author, writing assistance was provided by Diane DeHaven-Hudkins, PhD, Robert Axford-Gatley, MD, and Craig Slawecki, PhD (employees of CHC). Editorial assistance in the form of proofreading, copyediting, and fact checking was also provided by CHC. The content of this manuscript, the ultimate interpretation, and the decision to submit it for publication in Postgraduate Medicine was made by the author.
Conflict of Interest Statement
Elias Sarkis, MD, has conducted clinical research for Alcobra, AstraZeneca, Eli Lilly, Forest, GlaxoSmithKline, Lundbeck, Merck, Nanotherapeutics, Naurex, Neurim, Orexo, Otsuka, Pfizer, Purdue, Roche, Schwarz-UCB, Shionogi, Shire, Sunovion, Takeda, and Upsher-Smith.
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