ATLANTA— The impact of ADHD continues into adulthood for many people, and the effects of the disorder often create problems in a work environment. In adults, symptoms of ADHD frequently manifest as difficulty in reading, thinking critically, regulating performance, dealing with unfamiliar events, multitasking, and working as a member of a team—skills all relevant in the workplace.

Researchers from the Clinical and Research Program in Pediatric Psychiatry and Adult ADHD at Massachusetts General Hospital and Harvard Medical School in Boston sought to evaluate adults with and without ADHD in a full-day work-simulation experience. “We hypothesized that [adults with ADHD] would show impairments on work-simulated tasks, be observed with more off-task behavior, and relate more feelings of ADHD symptoms than matched controls,” the investigators said at the 158th Annual Meeting of the American Psychiatric Association.

The study, which simulated a workday, compared 18 adults who met full DSM-IV criteria for ADHD with 18 controls on measures of self-reported ADHD symptoms, objective observations, and a variety of written tasks. The investigators noted that all participants with ADHD were asked to abstain from taking their stimulant medication on the day that they took part in the simulation.

AN EIGHT-HOUR DAY

Members of the study participated in an eight-hour work-simulation day, which the investigators believe represents the first assessment of simulated workplace performance in adults with ADHD. “What is different about this study is that instead of [having participants perform] each of these tasks in and of themselves, we created a full day [experience] so that they had to get up early, come in, fill out forms, and be at that level of arousal that people expect at work. We were simulating the workday as well as the type of tasks that somebody might have,” explained lead author Ronna Fried, EdD, Supervising Neuropsychologist in the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at Massachusetts General Hospital. In fact, the team modeled the tasks after a report from the US government documenting what skills are required to be successful at work.

Activities included sitting at classroom-style tables and completing questionnaires and two of each of the following: reading passages, logic problems, writing samples, math fluency subtests, and video sessions. These activities were conducted twice, in both a morning and an afternoon session.

Participants were observed and rated blindly using the Swanson, Kotkin, Agler, M-Flynn, and Pelham (SKAMP) Rating Scale (revised for the present study to be more congruent with behaviors observed in adults in workplace settings). The SKAMP-R rates two aspects of workplace performance—attention and behavior. Participants were also asked to complete a self-report questionnaire on subjective feelings of being overwhelmed, being bored, and having trouble focusing, sitting still, and keeping quiet. These self-reports were filled out after each task and reflected patients’ experiences during the specific task.

OBSERVED WORK-RELATED TASK DEFICITS

“We did math fluency tests a few times a day that were very adaptable to the kinds of things [that might be required in a work environment], such as being told, ‘Make three copies for each of the 10 people here,’” Dr. Fried said. Compared with controls, participants with ADHD demonstrated impaired performance on math fluency. Also, on a reading comprehension task completed in the morning there was an observable impairment for attention problems, she noted.

In contrast, performance on tasks assessing problem solving (logic), comprehension of video presentations, and writing was not impaired in participants with ADHD relative to controls; however, despite this lack of performance deficits on problem-solving and video questions, patients with ADHD demonstrated significantly more behavioral impairments during these tasks.

The investigators believe the findings demonstrate that ADHD in adults is associated with significant deficits in performance on structured work-related tasks as well as on internal experiences and external observations of core symptoms of ADHD. According to lead investigator Joseph Biederman, MD, Chief of the Clinical and Research Program in Pediatric Psychopharmacology at Massachusetts General Hospital, the simulated workday experience served to objectify the deficits patients with ADHD may demonstrate in the workplace.

SUBJECTIVE DIFFERENCES

For subjective self-ratings of inattention and hyperactivity, the overall profile of differences between people with ADHD and controls was statistically significant for the behavior scale but not for the attention scale. Those with ADHD reported subjective difficulty with hyperactivity on all tasks completed, with the exception of the problem-solving task in the afternoon. Despite the lack of overall difference in the profile of subjective feelings of difficulty maintaining attention, participants with ADHD rated themselves as more impaired during the reading comprehension, math fluency, and writing tasks. What surprised Dr. Fried was the level of internal restlessness in the adults, as so much of the literature has documented significantly diminished hyperactivity in adults with ADHD, while also reporting inattention. “What we saw, especially from their self-report, was that they are feeling the hyperactivity but have just learned to compensate for it. We call it the ‘duck syndrome,’ where they look like they are just floating on top of the water but underneath they are paddling as fast as they can.” Bearing in mind that those participants with ADHD had not taken medication on the day of the simulation, Dr. Biederman said, “We hope that treatment for ADHD will mitigate these deficits.”

—Heidi W. Moore

Suggested Reading
Brown TE, ed. Attention Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, DC: American Psychiatric Press; 2000.
US Department of Labor Employment and Training Administration. Secretary’s commission on achieving necessary skills. Available at: wdr.doleta.gov/SCANS. Accessed August 11, 2005.

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