Occupational health professionals are finding themselves having to advise management on issues relating to employees suffering from the condition called adult Attention Deficit Hyperactivity Disorder (ADHD).
This is not a condition many OH nurses will have come across in their careers, but with the advent of the Disability Discrimination Act, it has become one that employers are seeking advice about from OH. The two case studies are based on the experiences of two OH practitioners who have recently had to manage issues relating to individuals who have been diagnosed with the condition.
The National Attention Deficit Disorder Information and Support Service (ADDISS) describes ADHD as a genetically determined condition affecting those parts of the brain that control attention, impulses and concentration. Although this condition would have been present from childhood, the Attention Deficit Disorder Association (ADDA) say that the diagnosis of ADHD is applied to adults who consistently display certain characteristic behaviours over a period of time. The key features of ADHD are:
- Distractibility or inattention
- Hyperactivity or overactive behaviour.
This means that sufferers can be talkative with difficulty in listening and concentrating, are forgetful, have poor organisational skills, and can be anxious and have relationship difficulties. However, the Royal College of Psychiatrists says that more research is needed to quantify the contribution of ADHD to psychiatric disorders in adulthood.
For occupational health nurses, the following two case studies show how this situation can be handled, both at the pre-employment stage and when ADHA comes to light in an existing employee. What must always be remembered is that the definition of a disability under the DDA is a physical or mental impairment that has a substantial and long-term adverse effect on the ability to carry out normal day-to-day activities. ‘Substantial’ means neither minor nor trivial ‘long term’ means the effect of the impairment has lasted or is likely to last for at least 12 months, and ‘normal day-to-day activities’ include tasks such as eating, washing, walking and going shopping. A normal day-to-day activity must affect one of the ‘capacities’ listed in the Act which include mobility, manual dexterity, speech, hearing, sight and memory. It is therefore advisable for employers to consider that ADHD may be likely to come under the Act, and to put reasonable adjustments in place.
These two cases studies serve to demonstrate the positive contribution that occupational health can make in supporting both employers and employees in making reasonable adjustments for overcoming a disability.
Case study 1
An OH nurse consultant was asked by an employer to meet with an employee, Norman, who was diagnosed with ADHD in the US at the age of 13. He had tried a number of drug regimes over the years and had also had periods when he tried to manage his condition without medication. He now takes 10mg of Adderall once a day, or twice a day, if required. He says that he has to buy this medication in the US, because he believes it is not licensed in the UK. This involves a trip to the US and appointments with three different doctors to acquire three prescriptions so that he can have several months’ supply.
Norman is employed in a creative informal office environment. The business has had a number of concerns over the past year regarding his behaviour at work. They are aware that he has ADHD, but do not know whether or not his behaviour is directly related to his medical condition. The main areas of concerns are listed below:
- Lack of concentration. At a very important two-day meeting with a valued client, colleagues observed Norman was distracted, fidgety and apparently sleepy, sometimes resting his head on his arms.
- Misuse of company credit card. For example, Norman used his company credit card for a number of items that were not strictly business related, and had also claimed for 12 hours’ work instead of four hours.
- Seeking constant approval. His senior colleagues and his peers feel that he is constantly seeking approval and repeatedly checking what he has to do.
- Interrupting inappropriately. Norman frequently interrupts colleagues and seems unaware that this is not always appropriate behaviour and can be disruptive.
The business had discussed these issues formally with Norman. However, while on the surface this could be considered to be a performance issue, the business wanted to establish whether his medical condition is a contributory factor. The business wanted to help him manage his condition and offer him appropriate support. They asked me to meet with him to discuss his condition, the concerns outlined above, and how he feels his condition affects him at work and in life generally.
Norman is very open about his condition. He is anxious for his condition not to affect his life and he wants to be treated normally. He has accepted the business’s concerns and wants to address the issues. He also discussed with the OH consultant the fact that her experience of ADHD was limited to reading some information available on the internet. They talked through the main signs and symptoms as listed and graded them on a scale of one to five according to severity, with five being the worst (see box, left).
The OH consultant advised him of some coping techniques he could try to reduce some of the difficulties he experienced. For example, to deal with his forgetfulness, he could:
a) Keep a notebook with him to record instructions and action points to help him remember and to avoid the need to try and retain all the information in his mind
b) Keep a pen and paper by his bed to write down thoughts as well as things he needs to remember for the next day that are playing on his mind and preventing him from sleeping.
The OH adviser also advised Norman that he would benefit from improving his lifestyle, improving his diet and undertaking regular exercise. This would increase his self-esteem. She also suggested he would benefit from more specific support from an ADHD counsellor, and also needed to sort his medication out in the UK.
She also wrote to Norman’s GP for advice and asked the following questions:
- Can you prescribe Adderall for Norman?
- Do you know of a local ADHD support group that I could contact to try and get him specific support to help with work?
- Do you know whether these behavioural issues can be reduced or stopped by specific counselling?
- Are there any additional resources, support that we need to consider?
- Is it safe for Norman to drive while on Adderall?
- Do you believe it is reasonable for Norman to travel overseas?
- Do you consider a change of role to be the most suitable solution?
The GP was unable to help. Consequently, the OH adviser took advice from a specialist on ADHD (support for adults suffering with ADHD are almost non-existent in the UK) who recommended that Norman should be referred to a psychiatrist who can and should monitor his symptoms. She also strongly felt that Norman was taking the wrong medication and at such a low dose that it would have little if any effect.
While Norman’s behavioural traits are relatively minor, they must be assessed in the context of his role. The company has a duty of care towards Norman and other members of staff, but it also has to run an efficient business that is not compromised by inappropriate behaviour by employees.
The OH nurse believes Norman’s behaviour can be managed if he seeks professional advice from a consultant psychiatrist who can prescribe him with the most suitable medication, and recommended that Norman arranged an appointment with his GP for a referral to the Maudsley Hospital. This was felt to be an improvement on having a specialist in the US who could not monitor the condition remotely. The OH adviser also recommended that Norman contact ADDISS for telephone support and guidance, as it offers a service free of charge.
The OH nurse and Norman now meet regularly to review his behaviour, monitor the effectiveness of his medication, and assist in the reviews with his specialist.
Case study 2
A 26-year-old female was applying for the position of training specialist within a public sector organisation. The post required the candidate to deliver training on the use of data systems to an external customer, and to support training of new graduate employees on the systems. This candidate had held a similar post for the previous two years.
On the pre-employment health questionnaire, the candidate declared that she suffered from adult ADHD and took Adderall as medication. This health concern could mean the candidate would be disadvantaged at work if her health needs as an employee were not fully explored, so an assumption was made that the employer would want to make reasonable adjustments if they were to know about the candidate’s disability.
The OH adviser contacted the candidate and after further assessment she said she did not want the employer to know of the disability, as she was fearful of being labelled and the affect this might have on her promotional prospects. However, she did want the occupational health department to discuss her individual difficulties with the line manager and with HR.
She was keen to have support with organisational skills as she could become intensely focused on one task to the detriment of other tasks and responsibilities. This was already evident by the length of time that had elapsed between initial contact with the candidate, and her replies to calls and letters. She felt she would benefit from support with planning, prioritising and regular review.
The candidate described the tools that she was already using including a palm top computer to diarise deadlines and itemise tasks, and a notepad to jot down important information or tasks, and explained that she is well supported by her family, her GP and ADDISS.
A case conference with the line manager and HR agreed that the candidate met the needs of the post and had excellent credentials. It was agreed that she could be supported by the following mechanisms:
- Induction process to include a run-through of the job description and information of the workplace strategy and goals to highlight the focus of activities.
- Appraisal process to include discussion on the timetabling of tasks, to balance activities throughout the year with allocation of a mentor to offer guidance and direction on the tasks and actions required. Regular review dates throughout the year were organised to act as early indicators of successes and difficulties.
- Case reviews with the employee, line manager, HR and OH as necessary, so that ongoing and early access to support is encouraged for issues that may arise at work. OH was also able to access support from counselling services for onward referral if that became necessary.
This article involved contributions from Jan James, consultant OH nurse, JLM Health, Greta Thornbory and Melanie Wyatt, consultant OH nurse, Wellaware OH Service.