Adult ADHD - Attention Deficit Hyperactivity Disorder at work

ADHD (Attention Deficit Hyperactivity Disorder) is thought to be a childhood disorder. However ADHD persists in adults in up to 50% of children diagnosed with the disorder. Hyperactivity, impulsivity and inattention; the hallmark symptoms of Attention Deficit Disorder in childhood have been described earlier. In Adult ADHD, symptoms change to reflect the child's development into adulthood. The symptoms related to hyperactivity gradually disappear by adulthood; however, those related to inattention persist. Adults with attention deficit disorder (ADD) are often distracted, and avoid tasks requiring sustained mental effort. This impairs functioning at home and at work.

Adult ADHD at work

Adults with ADHD experience employment impairments at every level; from the initial job search, to the interview and then during the employment itself. People with Attention Deficit Disorder are more likely to be have poor job performance, lower occupational status, less job stability and absenteeism. Men and women with attention deficit disorder earn less money, and are more likely to be unemployed.

Attention Deficit Disorder (ADD) has at times been portrayed as advantageous from a work perspective, as in the Economist, "in praise of misfits". This may be so in certain sectors where

• Hyperactivity and distractability find an outlet in the need to multi-task with multiple apps at a time.
• Impulsivity manifests as risk taking and an apparent fearlessness. 

This works for Attention Deficit Hyperactivity Disorder adults at the entry level of the IT industry. The physical, social and cultural environment help overcome functional limitations of adult ADD. However, the lack of focus, disorganisation and procrastination become evident when they are promoted in the organisation. It is at this mid-career stage that the adult with Attention Deficit Disorder seeks our help.

ADHD friendly workplace adjustments

Symptom	Adjustment
Inattention and impulsivity	Quieter room/positioning in office Flexi-time arrangement Headphones to reduce distractions Regular supervision to maintain course Buddy system to maintain stimulation
Hyperactivity/ restlessness	Allow productive movements at work Encourage activity Structure breaks in long meetings
Disorganisation, procrastination, and forgetfulness	Provide beepers/alarms, structured notes Regular supervision with feedback, mentoring Delegate tedious tasks Incentive/reward systems Regularly introduce change Break down targets and goals Supplement verbal information with written material

Adult ADHD is a treatable medical condition. Medication to correct the underlying neurochemical imbalance is the cornerstone of treatment for ADHD adults. The adverse impact of adult ADHD is experienced by the employee and the organisation. At the organisational level, workplace adjustments can provide a safe nidus for the ADHD adult to function effectively. At the individual level treatment can help reduce the associated emotional problems and absenteeism of adult ADHD.

References

1. Marios Adamou and colleagues. Occupational issues of ADHD adults. BMC Psychiatry 2013, 13:59 doi:10.1186/1471-244X-13-59
2. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry. 2000 May;157(5):816-8.
3. de Graaf R, et al: The prevalence and effects of Adult Attention-Deficit/hyperactivity Disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occup Environ Med. 2008.
   
4. Jane L. Ebeje, Sarah E. Medland, Julius van der Werf, Cedric Gondro, Anjali K. Henders, Michael Lynskey, Nicholas G. Martin, and David L. Duffy. Attention Deficit Hyperactivity Disorder in Australian Adults: Prevalence, Persistence, Conduct Problems and Disadvantage. PLoS One. 2012; 7(10): e47404. Published online 2012 October 10. doi: 10.1371/journal.pone.0047404
5. Schultz S, Schkade JK. Occupational adaptation: toward a holistic approach for contemporary practice, Part 2. Am J Occup Ther. 1992 Oct;46(10):917-25.

How to stop copycat suicides in students

Over the last two months three teenage students from the same Pune school have died by copycat suicide. 'Copycat’ suicides are frequent among adolescents aged 15-19 years. They occur more often than expected by chance alone. There has been an increase in teenage clusters in more recent years (Gould et al1990).

Patterns of ‘copycat’ suicide

There are two patterns of suicide clusters: point clusters, which are localised in both space and time (spatio-temporal), and mass clusters, which are localised in time only.

Point clusters

A point cluster is a temporary increase in the frequency of suicides within a small community or institution like a school or hospital. This differentiation is important as even limited resources can be effectively mobilised for prevention.

Mass cluster

A mass cluster is a temporary increase in the frequency of suicides within an entire population. Mass clusters are typically associated with high-profile celebrity suicides that are publicised and disseminated in the mass media. Prevention here is mainly by media restraint.

This article is concerned with point cluster copycat suicides that occur in schools.

Causes of ‘copycat’ suicide

Modelling

One of the causes of suicide is social learning. ‘Copycat’ suicides are caused at least in part by exposure to another individual's suicide and through the imitation of suicidal behaviour. Suicide modeling is a real phenomenon and there is ample evidence of its impact on suicide clusters (Mesoudi 2009, Insel and Gould 2003).

Homophily

Point clusters may also occur due to of homophily, the tendency for individuals with similiar interests and outlook to preferentially associate with one another. Students who are have poor academic performance, are delinquent or abuse drugs tend to associate together. These high-risk clusters may form suicide clusters due to each member's independently high risk of suicide (Joiner 1999).

Poverty

Community household poverty increases the risk of adolescent suicidal behavior. These communities place adolescents at a higher risk for associating with suicidal others. Adolescents brought up in poor communities would thus be subjected to the processes of both homophily and social modelling for suicide behaviour (Bernburg JG et al 2009 ).

Prevention of copycat suicide

One suicide in the school is tragic by itself. However, given the tendency for teenage suicides to occur in clusters urgent action needs to be taken to prevent further deaths. Successful suicide prevention programs have three general strategies - universal, selected and indicated. (Goldsmith et al 2002).

Universal approaches

These are strategies that target the entire school population. What the school does after the index suicide is important for prevention of point cluster suicides (Doan et al 2003).　
DO

• Respond within 24 hours of the suicide
• Show concern and empathy
• Inform all staff members about the suicide and provide a debriefing session where staff may voice their concerns, apprehensions, and any questions they may have.
• Inform school board members
• Ensure all teachers announce the death of the student by suicide to their first class of the day
• Provide counseling sites throughout the school for students
• Assign a school liaison to handle all media inquiries in order to avoid sensationalistic stories concerning the suicide
• Monitor the school’s emotional climate (Has there been an increase in fights or school delinquency following a death by suicide?).
• Evaluate all activities done following a death by suicide (How did your school respond? What worked and what did not work?).
• Utilize an established linkage system or community network in order to make referrals to the appropriate services as well to exchange information concerning the appropriate steps for treating those affected by the suicide.
• Utilize an established school response crisis team, which should include a diverse group of school professionals, such as the principal, counselor, teacher and possibly the school nurse.

DON'T

A major aspect of preventing cluster suicides lies in not glamourising or memorialising the act in any way. This would include attention to points as below.

• DON'T plant a tree or object in order to honor the student.
• DON'T hold a memorial service for the student at the school.
• DON'T describe in great detail the suicide (method or place).
• DON'T dramatise the impact of suicide through descriptions and pictures of grieving relatives, teachers or classmates.
• DON'T glamorise or sensationalise the suicide.

Selected approaches

Further specific strategies are for at-risk student groups. This would include screening and counselling of the student's known friends and group. Other at-risk children such as those with a previous history of attempted suicide, those known to have mood disorders, or substance use problems should also be specifically screened.

Indicated approaches

Students who show signs of suicidal potential should not be left alone. They should be given empathic support until they can be assessed by a psychiatrist, psychologist or counsellor and more definitive measures instituted. The signs of suicide potential include

• statements about suicide or that things would be better if the student was dead
• talking or writing about death, dying, or suicide

Every Pune school should have a mechanism in place to deal with the aftermath of student suicide to prevent copycat suicides in teenagers.

References

1. Bernburg JG, Thorlindsson T, Sigfusdottir ID. The spreading of suicidal behavior: The contextual effect of community household poverty on adolescent suicidal behavior and the mediating role of suicide suggestion.Soc Sci Med. 2009 Jan;68(2):380-9. Epub 2008 Nov 18.
2. Doan, J., Roggenbaum, S., & Lazear, K.J. (2003). Youth suicide prevention school-based guide (c/p/r/s)—Checklist 7a: Preparing for and responding to a death by suicide: Steps for responding. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute. (FMHI Series Publication #219-7a).
3. Goldsmith SK, Pellmar TC, Kleinman AM, Bunney WE, eds. Reducing suicide: a national imperative. Washington, DC: National Academy Press; 2002.
4. Insel BJ, Gould MS. Impact of modeling on adolescent suicidal behavior. Psychiatr Clin North Am. 2008 Jun;31(2):293-316.
5. Joiner JTE. The clustering and contagion of suicide. Current Directions in Psychological Science. 1999;8:89–92
6. Mesoudi A. The cultural dynamics of copycat suicide. PLoS One. 2009; 4(9): e7252. Published online 2009 September 30. doi: 10.1371/journal.pone.0007252.