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To cite this article: Eric Patton PhD (2009) When Diagnosis Does Not Always Mean Disability: The
Challenge of Employees with Attention Deficit Hyperactivity Disorder (ADHD), Journal of Workplace
Behavioral Health, 24:3, 326-343
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Journal of Workplace Behavioral Health, 24:326–343, 2009
Copyright # Taylor & Francis Group, LLC
ISSN: 1555-5240 print=1555-5259 online
DOI: 10.1080/15555240903176161
326
Employees with ADHD 327
Researchers (Florey & Harrison, 2000; Freedman & Keller, 1981; Hall &
Hall, 1994; Stone & Colella, 1996) have suggested and demonstrated that
there can exist social and psychological barriers operating in the workplace
that have a negative impact on disabled workers. These social and psycholo-
gical barriers, involving stigmas, attitudes, fear, and judgments on legitimacy
cannot be adequately dealt with through ADA legislation. As noted by
Murphy and Adler (2004), media coverage has led to misconceptions, myths,
and confusion surrounding ADHD. Given the association of ADHD with
children, controversies surrounding the use of medications such methyl-
phenidate (Ritalin), and media presentations that often portray ADHD in
adults as a phony ailment that is simply an outgrowth of our increasingly
hectic lives or as an invention of pharmaceutical companies, adult sufferers
of ADHD face some unique obstacles compared with other employees with
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adults. Although children with ADHD are often identified as hyper and
somewhat unruly, adults with ADHD often present different but related
symptoms. Inattention for adults with ADHD manifests itself through an
inability to get organized and to focus on something for an extended period
of time, which causes difficulty in time management and procrastination.
Childhood hyperactivity is replaced in adulthood with impulsivity and
overactivity ( Jackson & Farrugia, 1997). Impulsivity is manifested in beha-
viors such as the inability to delay gratification, not thinking through the
consequences of actions, disregarding the feelings, thoughts and actions of
others, and an unwillingness to wait in lines. Overactivity can be seen
through nervousness, anxiety, restless tapping of pens and pencils, feeling
uncomfortable sitting in meetings, and overreacting to frustrations.
Over the last several years, new assessment tools for identifying ADHD
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in adults have been developed. The Wender Utah Rating Scale (Wender,
1985) is a tool developed specifically for adults that, in addition to hyperac-
tivity and poor concentration, requires the presence of two of the following
five symptoms to make a positive diagnosis: (1) brief, intense emotional out-
bursts that can swing dramatically in a short period of time; (2) hot temper;
(3) disorganization or the inability to complete tasks; (4) stress intolerance;
and (5) impulsivity (Searight et al., 2000). For the Wender scale, it is impor-
tant to note that symptoms must have been present since age 7. When using
the DSM-IV to detect ADHD in adults, in addition to the presence of symp-
toms, childhood onset must also be established and impairment must affect
at least two domains in life among school=work life, social life, home=family
life (Adler, 2004). Recently, Kessler, Adler, Ames, Demler, et al. (2005) have
developed the World Health Organization Adult ADHD Self-Report Scale
that features a short 6-item version, which demonstrates strong capacity to
identify adults with ADHD. The full version of the Kessler, Adler, Ames,
Demler, et al. (2005) tool is useful for classifying adults with ADHD into
the subgroups (i.e., mainly inattentive, mainly hyperactive, mixed). Clinical
interviews conducted by psychiatrists are also commonly used to identify
adult ADHD (Jackson & Farrugia, 1997; Murphy & Adler, 2004). In most of
these modes of diagnosis, the establishment of symptoms in childhood is a
key element. For adults, this can represent a difficulty as retrospective mea-
sures can be subject to different biases. To corroborate the childhood onset
and the presence of symptoms in different life domains, input from parents,
siblings, former teachers, and spouses is often necessary for diagnosis (Murphy
& Adler, 2004). Although this may be sometimes difficult, the determination
that the adult with ADHD has had symptoms since childhood and that these
symptoms span different life domains is crucial for assessment, particularly
because many symptoms (procrastination, anxiety, discomfort in meetings,
frustrations) are common for most adults to some degree or in certain situa-
tions, which often fuels the misconceptions surrounding the disorder and the
opinion that either everybody has it or that it is a phony disorder. As noted by
330 E. Patton
Murphy and Adler (2004), there is no single litmus test, either through a
single scale or neurological testing, that can be used to diagnose adult ADHD.
As such, a multifaceted assessment program is recommended. Still, ongoing
research in the neurosciences may shed clear light on the disorder in the future,
and the creation of the short World Health Organization (Kessler, Adler, Ames,
Demler, et al., 2005) screener is an important development.
Another element that complicates the diagnosis of ADHD in adults is the
high level of comorbidity between ADHD and other problems. Adults with
ADHD often suffer from depression, substance abuse, hyperthyroidism,
learning disabilities, and personality disorders (Biederman et al., 1993).
ADHD as an actual problem is a lack of resources and support for those suf-
fering from this disorder as adults. In their large sample study, Kessler, Adler,
Ames, Barkley, et al. (2005) found that only 16% of adults they identified as
having ADHD were receiving any treatment for the disorder; however, more
than 32% reported seeking help for some form of emotional problems. Given
the links between ADHD and depression, substance abuse, and so on, many
individuals may be receiving help with problems without getting to the root
cause of their issues. As noted by Weiss and Murray (2003), though child psy-
chologists who have expertise in this area are not interested in treating adult
patients, most family doctors are not familiar with the condition in adults. In a
2003 Harris poll, 77% of doctors reported that ADHD in adults is not under-
stood by the medical community (Szegedy-Maszak, 2004). Still, treatment
options for adults suffering from ADHD exist. Although the condition cannot
be cured, its management is possible through various treatment techniques.
On of the most important steps in the treatment of ADHD for adults is
education about the disorder (Jackson & Farrugia, 1997; Murphy, 2005; Weiss
& Murray, 2003; Weiss & Weiss, 2004). After a lifetime of frustrations and
disappointments, of being labeled lazy, stupid, or difficult, and a general
sense that something is wrong, it can come as a tremendous relief to learn
that there is an actual disorder involved that can be managed. Although relief
may occur, there is also the chance that fear and anger could also be experi-
enced as sufferers come to grips with having a psychiatric disorder and
realize the effect it has had on their lives. Still, information on the condition
from a medical professional is an important first step in creating awareness
and fostering hope (Murphy, 2005).
In terms of interventions, researchers and other experts have made sev-
eral suggestions to help adults with ADHD (Murphy, 2005; Nadeau, 2005;
Weiss & Murray, 2003; Weiss & Weiss, 2004). Self-management skills training
are strongly advocated to help adult sufferers become more organized and
systematic in their approach to tasks and issues. The use of calendars,
agendas, and creating an organized, clutter-free environment are regular
332 E. Patton
more side effects than Ritalin or Dexedrine. Although effective, many are
hesitant to take ADHD medications given the negative publicity surrounding
overmedication of children. Furthermore, some fear that the predisposition
of adults with ADHD for substance abuse makes a pharmacological approach
to ADHD treatment risky. Experts, however, suggest that such fears are
unfounded noting that it is the absence of ADHD medication that creates a
risk of substance abuse and that proper medication will negate the desire
for illicit drugs (Lamberg, 2003; Pliszka, 2000; Sanders, 2005).
Overall, as noted by Weiss and Weiss (2004), an important facet of
managing ADHD involves identifying the treatment targets, that is, finding
out where the symptoms are causing problems.
(2003) illustrated many of these problems, as the focal worker struggled with
monotonous tasks, self-organization, concentration, impulsiveness, and
relationships in various jobs when the environment was not supportive.
The inability to prioritize, difficulty getting organized, and socially
inappropriate behavior have consequences for organizations as well
(Kessler, Adler, Ames, Barkley, et al., 2005; Murphy & Barkley, 1996; Weiss
& Hechtman, 1993). Adults with ADHD change jobs more frequently, have
high rates of absenteeism, and are more apt to have accidents at work. All
of these outcomes entail important costs for organizations. Kessler, Adler,
Ames, Barkley, et al. (2005) found that adults with ADHD had an average
of 35 days of work lost through absenteeism and nonproductive attendance.
Extrapolating this estimate to the entire civilian labor force of the United
States, these findings suggest a total of 120,800,000 lost days of work per year
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with a salary equivalent of $19.6 billion. Adding turnover and accidents costs
to this figure underscores the tremendous financial impact that ADHD has on
organizations. Given the links between adult ADHD and crime, it would also
be interesting to study the links between ADHD and deviant workplace
behavior. The impulsivity and difficulty in thinking through the conse-
quences of actions that contributes to the propensity of ADHD sufferers to
abruptly quit their job could also lead to such things as workplace theft. From
an interpersonal standpoint, the hot temper, low agreeableness, and socially
inappropriate behavior that often characterize adults with ADHD can lead to
problems with coworkers and supervisors. The result can be a high level of
workplace conflict. Research has consistently shown that interpersonal rela-
tionship conflict has negative outcomes for individuals and organizations
( Jehn, 1995; Jehn, Northcraft, & Neale, 1999). Even task conflict, which is
sometimes viewed as constructive, has been shown to be generally harmful
as task conflict often escalates into relational conflict (De Dreu & Weingart,
2003). Links between ADHD and workplace conflict are research areas that
would benefit from additional study.
In terms of career prospects, adults with ADHD often have low occupa-
tional status (Weiss & Hechtman, 1993). It is reasonable to assume that
educational problems suffered as children and the aforementioned low
completion rates in college contribute to this state of affairs. Unfortunately,
low-status occupations are exactly the type of jobs in which individuals with
ADHD will have the most difficulty and the poorest performance. The rest-
lessness that many adult ADHD sufferers experience on a chronic basis
can be severely compounded in blue-collar or clerical jobs, which offer very
little discretion and are characterized by monotonous, routine tasks. Kessler,
Adler, Ames, Barkley, et al. (2005) found that blue-collar workers with ADHD
had by far the worst work performance measured through days lost=poor
productivity. Although blue-collar workers with ADHD lost an average of
55.8 days of work productivity a year, the number of days of lost work
productivity for professional workers with ADHD stood at 12.2 days.
334 E. Patton
In fact, several authors (Lamberg, 2003; Weiss & Weiss, 2004; Wyld,
1996) have suggested that adults with ADHD can be very productive in
fast-paced management positions that involve a busy and hectic environ-
ment. Consistent with this, studies have shown that a significant percentage
of entrepreneurs suffer from ADHD (Arnst, 2003; Carroll & Ponteretto, 1998).
The fast-paced environment that characterizes entrepreneurial work coupled
with the fact that entrepreneurs are not necessarily required to have a strong
record of academic achievement creates a situation in which adults with
ADHD can flourish. Unfortunately, for adults with ADHD who do not
become entrepreneurs, the management=professional career paths that
would match well with their characteristics are often cut off at an early
age, and these individuals end up in jobs that only exacerbate their condi-
tion. Given that ADHD sufferers often have a high level of intelligence, the
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inability to progress in a meaningful career and the fact that they become
stuck in low-status occupations will only add to the chronic sense of disap-
pointment and frustration felt by these individuals. At the same time, the
combination of ADHD and a management career is not a panacea as Weiss
and Weiss (2004) found that adults with ADHD are susceptible to become
workaholics.
Overall, adults with ADHD face a number of problems that can be detri-
mental to their personal well-being, to their social and family circle, and to
their employers. As such, helping adults with ADHD and the role that HR
professionals can play becomes an important concern. However, workers
with ADHD face particular challenges in terms of workplace support for their
condition. In the following section, three main barriers are explained: The
positioning of HR professionals vis-à-vis mental illness in general and ADHD
in particular, the vagueness of the ADA in regards to mental illness and
ADHD, and, perhaps most important, the attitudes of managers, coworkers,
and the general public concerning adult ADHD.
As noted in the previous section, the prevalence of adults with ADHD and
the individual and organizational outcomes linked to the condition are
strong reasons for HR professionals and managers to work toward helping
accommodate these workers. However, for several reasons, workers with
ADHD do not get the help they need. Although some of the employment
problems for ADHD workers stem from a history of academic failures,
even university educated and highly qualified employees with ADHD face
barriers in the workplace. Although most universities in North America
have services to help students deal with learning and psychiatric dis-
abilities including ADHD, these services evaporate once graduates with
Employees with ADHD 335
but relies on a set of criteria. In the case of mental conditions, this leads to
confusion; so much so that the U.S. Equal Employment Opportunity
Commission (EEOC) on two occasions (1997 and 2004) has deemed it neces-
sary to release interpretation bulletins to provide guidance about the ADA
concerning mental disabilities (Sanders, 2005). For a condition to be pro-
tected under the ADA, one of the following criteria must be met: (1) the exis-
tence of a physical or mental impairment that substantially limits one or more
life activities including working and learning, (2) a record of impairment,
and=or (3) others regard you as impaired. Given this broad definition, the
ADA covers such conditions as illness and disease, losses (e.g., sight, limbs,
hearing), emotional or mental illness, and recovery patients (e.g., drugs,
alcohol). It can also cover adults with ADHD. The provisions of the ADA
prohibits the denial of employment solely by reason of ADHD and requires
employers to provide reasonable accommodations in the workplace for
individuals with ADHD who are otherwise qualified for employment (Carroll
& Ponteretto, 1998). For workers with ADHD, examples of reasonable
accommodations include the use of personal digital assistants, checklists,
color coordination to help with time management and organizational pro-
blems, quiet work areas and clutter-free environments to help with concen-
tration problems, and interpersonal training and assignments with little
contact with others to help with social skills problems (Kitchen, 2006).
Although these guidelines seem clear, there are several challenges that
exist. First, as previously noted, the onus is on the employees with ADHD to
disclose their condition to the employer. Given that most adults who have
ADHD are unaware that they even have the condition, protection under
the ADA is quite meaningless. It is also important to note that protection
under the ADA is not available if the employee does not disclose a condition
prior to a disadvantage brought on by the disability. More serious is the
difficult determination if an employee’s ADHD is eligible for protection
under the ADA. According to the Job Accommodation Network (Kitchen,
2006), the EEOC has determined that the difficulty in performing cognitive
Employees with ADHD 337
functions represents a disability as per the first criteria of the ADA. At the
same time, individuals who suffer from ADHD may not require any accom-
modation depending on the job. As such, accommodations for ADHD under
the ADA require a case-by-case analysis. Given that ADHD symptoms can
vary from person to person and is not a ‘‘one-type-fits-all’’ disability (Katz,
2003), determining eligibility under ADA and proper accommodations repre-
sent a challenge. In fact, sometimes ADHD will only be covered in conjunc-
tion with another condition such as depression or bipolar disease (Equal
Employment Opportunity Commission [EEOC], 2004). The fact that, unlike
workers with physical or disease-related disabilities, outcomes for employees
with ADHD can include poor performance in certain tasks, absenteeism,
tardiness, and interpersonal conflict also complicates the reasonable accom-
modation request process. According to the EEOC (2004), companies are not
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perceptions, stereotypes, and attitudinal biases. Hall and Hall (1994) noted
that mental impairments create special barriers since, due to their invisibility,
others often don’t believe they exist or, alternatively, will have irrational fears
regarding such conditions. According to the Society for Human Resource
Management (SHRM) (Hastings, 2006b), the World Health Organization
and the World Psychiatric Association consider stigmas to be the number
one problem in the field of mental health. In another SHRM report (Hastings,
2006c), it was noted that although a survey by the APA found that 26.2% of
adults report having a psychological=psychiatric condition, 44% of the U.S.
public reports having little or no knowledge of such illnesses. Furthermore,
33% of respondents believed that emotional weakness is a major cause of
mental illness.
Murphy (2005), Katz (2003), and Wadsworth and Harper (2007)
emphasized this point specifically for ADHD by noting that, given its invi-
sibility, others perceive the adult with ADHD as capable, intelligent, and
normal, and as such often attribute the negative or inconsistent behavioral
patterns to poor character, low motivation, or willful misconduct as
opposed to the behavior’s neurological basis. In fact, Wadsworth and
Harper (2007) noted that the first definition provided of ADHD by Still in
1902, clearly presented the condition as a personal failing. Specifically, Still
(1902) suggested that a lack of moral control and an individual failure to
conform to social expectations caused ADHD symptoms. In addition to
the invisibility of the disorder, the characteristics of the symptoms can
amplify the negative reactions of others and create further barriers for
adults with ADHD. Research by Stone and Colella (1996) and Florey and
Harrison (2000) underscored this point. Stone and Colella (1996) developed
a theoretical model exploring the factors affecting the treatment of disabled
workers in organizations and how the negative perceptions of others play
an important role. They suggest that disabled workers who have displayed
strong work performance in the past and who have a pleasant interperso-
nal style will face fewer barriers in the workplace. For adults with ADHD,
Employees with ADHD 339
both of these factors would work against them. The impulsivity and poor
social judgments that hamper adults with ADHD and is manifested through
low agreeableness and a high degree of conflict with supervisors and
coworkers will increase the negative affective response of others to their
impairment. In terms of work performance, Florey and Harrison (2000)
demonstrated that managers were more likely to approve accommodation
requests from disabled workers with good past performance as opposed
to poor. Given the history of poor work performance that characterize most
adults with ADHD, this represents a further barrier for acceptance. Finally,
several authors (Florey & Harrison, 2000; Freedman & Keller, 1981; Sanders,
2005; Stone & Colella, 1996) have underlined that managers often have
equity concerns when dealing with requests for accommodation. Freedman
and Keller (1981) noted that the broad definition of what constitutes a dis-
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with this condition are often talented, creative, and can flourish in the right
situation. The lack of knowledge and the misconceptions surrounding men-
tal illness in our society is troubling, and HR researchers and professionals
need to be part of the conversation. The research recommended in this
article is not only important from an employee and organizational well-being
perspective, but is also necessary given the greater acknowledgement of
adult ADHD and its protection under the ADA. Adults with ADHD are
present in organizations. They can be valuable and productive members
who can flourish through their special talents or through reasonable accom-
modation in understanding workplaces. For the benefit of those who suffer
from the disorder and of the organizations who employ them, more research
is needed in this area.
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