ADHD ‘under-diagnosed, under-treated’

Recent case reveals challenges; accommodation requests could be on the rise
By Sarah Dobson
|Canadian HR Reporter|Last Updated: 12/16/2013

Attention deficit hyperactivity disorder (ADHD) can take a toll in the workplace. Problems with organizational tasks and distractibility can lead to poor job performance and higher absenteeism, resulting in lower occupational status for workers with the disorder and less job satisfaction, according to the Centre for ADHD Awareness, Canada (CADDAC).

“ADHD costs us billions of dollars each year in lost productivity,” said the centre’s report Paying Attention to the Cost of ADHD: The Price Paid by Canadian Families, Governments and Society.

About five per cent of adults have the disorder, though many are unaware of it, and 90 per cent of adults have had no treatment, according to Candice Murray, co-director of the provincial ADHD program at B.C. Children’s Hospital in Vancouver.

“It’s under-diagnosed and definitely under-treated,” she said.

ADHD involves problems with hyperactivity, impulsivity and attention. Challenges for workers with ADHD can include emotional control, sustained attention, task initiation and time management, said Murray, who spoke at a CADDAC conference in November.

“Sometimes, the workplace seems to trigger that frustration they felt in high school or elementary school and it’s often difficult for people with ADHD in that, in a tense situation, they might get angry quickly or get frustrated quickly,” she said. “If you have somebody who is responsible for organization, planning and being independent in certain areas, then you see a lot more impairment.”

But there’s a spectrum and people with ADHD can also be very talented, brilliant even, and their symptoms don’t always show up in their workplace productivity or interactions with co-workers, said Heidi Bernhardt, president and executive director of CADDAC in Toronto, adding medications work well for some people.

“It’s so hugely a complex disorder that can show itself in so many different ways in different people, that it’s hard to pinpoint (symptoms),” she said. “There are a lot of jobs that are very well-suited for people with ADHD and sometimes minimal accommodations can make a huge difference.”

Diagnosis

While ADHD is currently under-diagnosed, that could change with the release of the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) from the American Psychiatric Association. The manual is used by many insurance companies and physicians in diagnosing mental health.

The criteria for adult ADHD have been loosened somewhat, which could trigger more requests for accommodation. An adult now needs to meet five symptoms in the domains of inattention and impulsivity/hyperactivity, instead of the six required for younger people.

The symptoms can also be confused with simple boredom or a dislike of certain tasks — and may be easily faked, said Kevin MacNeill, a partner at Heenan Blaikie, citing research such as the Allen Frances book Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.

“You have to look at each case on its own merits... most of the cases are legitimate when they’ve been properly diagnosed. But subject to that proviso, those are the reasons why there may be a rise if it’s easier to claim that condition,” said MacNeill.

“Much of what I do now in employment litigation has a human rights component to it and disability is the most commonly advanced human rights ground. I can’t say employees are slicker and that’s why we may have a rise, but it is a potential factor to keep in mind.”

Case highlights challenges

A recent decision by the Human Rights Tribunal of Ontario highlights the challenges for employers when it comes to workers with ADHD. In Stewart v. Ontario (Government Services), project manager Heather Stewart was dismissed from her job based on poor performance. In one of her discrimination complaints, she claimed she was not accommodated with respect to her “process learning disorder” and ADHD.

Stewart did not disclose she had these disorders but felt her employer should have known because of her behaviour at work, such as a preference for visual learning aids, stating her children had learning disabilities, and performance problems, such as not being organized, being forgetful, failing to complete tasks and lacking time management skills.

But the tribunal disagreed, saying the employer should not have been expected to know of her condition and provide accommodation:

“It was not unreasonable for the (government) to conclude that the applicant’s statements, behaviours and performance problems were simply indicative of someone struggling to do the job… and it was entirely reasonable for the (government), without clearer information on which it might connect those struggles with the applicant’s disabilities, to conclude the problems were entirely skill-related.”

Accommodation

When you have this type of case, there’s no duty to inquire unless the employee has been more explicit, said MacNeill. But if an employee does disclose he has ADHD, the employer should follow up for clarification, if needed, he said.

“When you’re dealing with mental disability, which is a lot harder to diagnose than physical disabilities, employers may be entitled to push for a little more substance in terms of the medical information provided to them… (however) you have to always temper what your strict legal rights are with a sense of pragmatism and good labour relations.”

An employer should approach such a claim in good faith, so it might implement a temporary accommodation on a without-prejudice basis, pending verification of the claim, said MacNeill.

A good clinical interview will help with the assessment and while employers won’t know the actual diagnosis, they will be told of the functional limitations, said Murray.

There are a variety of accommodations that can work well for adults with ADHD, she said, such as regular meetings to monitor progress, structured feedback (written if needed), a flexible schedule (to do work at quieter times of the day), ear plugs, paper planners and shorter meetings.

An ADHD coach can also help re-organize office space and develop time management and organizational strategies, said Bernhardt. Sometimes it’s a matter of a manager taking time each day to discuss how a person is doing with her assignments and, if needed, breaking down work into chunks.

But there is still so much stigma around ADHD — along with misinformation and misunderstanding — that a lot of employees are quite concerned about telling their employer they have it, she said.

“A lot of employees with ADHD could be far more productive and... if they knew it was an environment where they could be accepted and talk about what they needed, it would be much better for everybody. Really, a lot of these (accommodations) are not costly, they’re not a huge inconvenience for the employer. A lot of it is just understanding and goodwill, and open discussion with the employee to say, ‘What do you feel would help?’” said Bernhardt.

“Probably the most important (strategy) is that everybody understands what’s going on, so they understand it as a medical disorder and this is the way it can come across and it doesn’t mean this person is lazy or not trying very hard or a jerk or whatever unfair labels are put on a person.”

People with ADHD have a lot of strengths, she said.

“With simple accommodations, they can be highly productive and highly functioning. It’s identifying those strengths and working with them, and then putting in accommodations to offset the weaknesses.”

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