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.

Job Satisfaction & Work Stress in the IT Industry

Work stress and low job satisfaction are the primary drivers for help-seeking in IT professionals. PR a 34-yr old software engineer employed in an IT company came to us for guidance while considering a career change. He felt stressed, and experienced his work as meaningless. He felt alienated from his colleagues and his job dissatisfaction was high.

PR’s is not a one-off case. A PPC Worldwide study reported that 62% of all employees experience work stress. Responses to a poll specifically studying IT related work stress are as depicted in the chart above.

Work stress contributes to job dissatisfaction and increased attrition in the workforce. Most burnout prevention methods focus on personal responsibility for wellness. They require sacrifice of personal time with the perverse goal of being more effective at work. We have already seen what the individual needs to do to manage stress with a health promoting lifestyle,  Even 15 minutes of exercise is effective. We now need to look at the organisational factors resulting in committed employees.

Job satisfaction involves certain obligations that exist in an employment relationship. Pay is largely considered to be the single-most contributor to job satisfaction, and perceptions of fairness in compensation have a direct influence on commitment to the organisation. However, intrinsic motivators contribute greatly to resistance to work stress. These include

Nature of work

Nature of work is an intrinsic motivator measured by an individual’s feeling that their job is meaningful. They feel engagement, and a sense of pride in the job. Humiliation at work does not foster this sense of engagement. For many of our clients humiliation is a prime driver to distress and burnout.

RK came to us when he was thinking of quitting his job. He had been 'de-promoted' into his own team when they were unable to meet a target. His self-esteem was low and he was depressed. He recovered with treatment and counselling. He could then decide his next career move from a position of strength.

Relationship with co-workers

Work plays an important part in fulfilling an individual’s social needs. Co-worker acceptance and a sense of belonging to a group and culture affect job satisfaction. Unfortunately the culture in many IT organisations continues to reflect the ‘in’ and ‘out’ groupings of the college hostels through which their managers have emerged. This only adds to the job dissatisfaction of IT professionals who may be contributing at their jobs but do not feel a part of the organisation.

The motivated and stress tolerant employee shows commitment to the organisation in two ways

1. Emotional
 Job dissatisfaction is inversely associated with emotional commitment. IT professionals who are satisfied feel more emotionally attached to and involved with their organisations.
2. Obligational
Job satisfaction is associated with feeling more obliged to remain with the organisation.
3. Continuance
Continuance commitment (cost associated with leaving the company) is not related to job satisfaction; pay does not matter disproportionately to the IT professional.

Work stress and work pressure are correlated with job dissatisfaction and poor employee engagement. The IT professional’s decision to stay with the company due to feelings of attachment and obligation results from job satisfaction rather than the costs associated with leaving the company. A working atmosphere that validates the individual and their differences will enhance that attachment and commitment to the organisation.

References

1. E.J. Lumley, M. Coetzee, R. Tladinyane, N. Ferreira. Exploring the job satisfaction and organisational commitment of employees in the information technology environment. Southern African Business Review Volume 15 Number 1 2011.
2. Kaluzniacky, Eugene. Stress Management. In: Managing psychological factors in information systems work : an orientation to emotional intelligence. Idea Group. London, 2004. Pg238-245.
3. Psychol Rep. 2009 Dec;105(3 Pt 1):759-70. Employee engagement and job satisfaction in the information technology industry. Kamalanabhan TJ, Sai LP, Mayuri D.
4. Saradha.H. Employee engagement in relation to organizational citizenship behaviour in information technology organizations. Submitted in partial fulfillment of the requirements for the degree of Master of Philosophy. Institute of Management, Christ University, Bangalore. 2010.

Treatment of social anxiety, phobia and self-consciousness

Avoiding social situations because they make you self conscious and anxious? You are likely to have a social phobia or social anxiety disorder. One in 10 persons experiences social phobia between the age of  9-33years. The incidence is highest in adolescence (Beesdo et al 2007). Men and women are equally likely to suffer. However, men are more likely to seek treatment when their performance at work is impaired.

Social anxiety usually begins in childhood or early adolescence. There is often a history of childhood shyness. A stressor or humiliating social experience can precipitate the problem. In fact paediatric social phobia affects 5-10% of children. In children it is often associated with ADHD (Attention Deficit Hyperactivity Disorder), depression or separation anxiety disorder. Longstanding social phobia increases the risk of depression, substance abuse, and alcoholism later in adulthood.

Recognising social phobia

“My mind went blank during the interview. I break into a sweat, my voice changes. I know what is being asked but I am just not able to concentrate and answer with confidence.”

You have social phobia when you feel that everyone is staring at you or judging you during social interactions. There is a persistent and intense fear of being embarrassed and humiliated by your own actions. This especially occurs in public places such as at work, during office 14meetings, while shopping and at social gatherings. The feelings persist even though rationally you know its not true. These fears may become so severe that they interfere with your work, school or college. They make it hard for you to socialise and make or keep friends.

When you decide to confront these fears and join the party or attend a meeting, you are anxious for days beforehand in anticipation of the dreaded situation. Thoughts of a discussion with your boss make you break into a sweat. You may have panic attacks. Your sleep may be increasingly disturbed as the day of the meeting approaches. Reasoning and reassuring yourself as to the non-threatening nature of the situation brings no relief. You are sweating and can feel your heart race during the encounter. After the encounter you worry about how you were judged for hours afterwards. You feel ashamed that you did not perform better. It becomes easier for you to just stay away from social situations and avoid other people altogether.

“I hesitate to enter the room when the group is already seated. When it comes to my turn to speak my mouth goes dry and I feel choked. I don't speak a word during the meeting even when I have something to contribute.”

People with social anxiety can present with different secondary symptoms

• Some people cannot write in public (as on a blackboard), their hand will shake, their cheques bounce
• They experience severe anxiety about eating and drinking in public and often spill food and drop their cutlery
• Others find it a torture to speak in front of people, they just ‘clam up,’ speak in monosyllables or stammer
• One of the worst circumstances is meeting people who are authority figures- bosses, supervisors, interviewers at work; or teachers & examiners at school. A job interview is torture, more so because the person knows that he would be good at the job if only he could get through the interview.

People with social phobia avoid situations in which they feel embarrassment and anxiety. Initially they are comfortable with this avoidance. Later, they see avoidance as an impediment to achieving their full potential in their chosen careers. They see their social lives as stale and restricted. To address these problems people mistakenly enrol for ‘personality development’, meditation and other courses. But this is not the shyness of introversion. This shyness results from overwhelming anxiety and embarrassment. They are frustrated when there is no resolution. The underlying social phobia has not been addressed.

In a child with social phobia this anxiety expresses itself as tantrums, crying or just “freezing up”. In school, the child typically does not participate in classroom activities, is reluctant to stand up and answer, has no friends and frequently misses school with complaints of stomach ache or headache. Outside school these children have few or no friends. They may communicate only with family members.

“My daughter doesn't speak a word when we have visitors. The other children are playing together, she has to be pulled out of her room to join them.”

How is social phobia best treated?

The best treatments of social anxiety include

1. Medication: is usually for a limited period, under supervision. Do not stop taking medication abruptly. Discuss any side effects, if any, with your psychiatrist.
2. Cognitive Behaviour Therapy – CBT: and systematic desensitisation properly administered for 6-12 sessions can produce long lasting, permanent relief. You have to be motivated to persist in the practice of the simple methods and techniques that are explained to you. Do not use any advice available online without due thought and discussion with your psychiatrist

What you can do for a family member with social phobia

• Be supportive. Help the individual seek psychiatric treatment. Many a career has been advanced or saved by a supportive spouse. Family interaction and communication also improves.
• Don’t trivialise (‘its normal to be nervous when you meet new people, you do not have to go for therapy’).
• Don’t perpetuate their symptoms (‘let it be, stay at home if you are not feeling well’).

Family support helps during behavioural desensitisation therapy and decreases the social isolation of the individual. Social phobias and anxieties are treatable conditions. Treatment and therapies are effective and easily accessed.

References

1. Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, Wittchen HU. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007 Aug;64(8):903-12.