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10 CEUs Treating Locking In & Blocking Out: ADHD Adults

Section 24
Conducting a Workplace Assessment for a Client with Adult ADHD

Question 24 | Test | Table of Contents | ADHD CEU Courses
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Let us consider career assessment before returning to a discussion of Garber’s resilience factors. The extent of assessment should be determined in response to each client’s individual situation. A full assessment would include the following: • Clinical interview to take a work history and assess current workplace functioning, • Neurocognitive testing to measure strengths and weaknesses, • Psychological testing to evaluate comorbid psychiatric conditions, • Personality testing to assess temperament and values related to career, and • Interest testing to assess goodness of fit between career choice and interests. Not every client, however, needs such a thorough and costly evaluation before beginning treatment. I will address each aspect of the assessment process, discussing the circumstances under which each might be advisable.

Current Workplace Concerns. The first consideration in a career consultation should be to understand the multiple factors involved in current workplace difficulties. Whether a client who has ADHD seeks to remain in his or her current position for an extended period or will only be there short term while considering other options, it is important to focus on helping the client to understand how ADHD factors are related to the current problems and to seek ways to decrease stress and improve the current situation.

Past Employment History. Although the client may want only to focus on leaving his or her current employment, there is much to be learned in carefully evaluating current and past employment history. Through this process much can be learned that will contribute to a more informed, ADHD-friendly job choice in the future. The clinician can guide the client through an analysis of current job problems, helping him or her to consider many different aspects of the job that may contribute to current problems. A job analysis is often more complete and accurate if it is guided by the clinician in a structured way. Degree of Job Match With Strengths and Weaknesses. Assist your client to think about her strengths and interests as well as weaknesses and how they are matched with her current job. The clinician should always keep in mind that undiagnosed learning disabilities frequently accompany ADHD. It is important to explore reading speed, reading retention, spelling, and writing ability. Degree of Match With Client’s Supervisor. Does the client’s supervisor have traits that may directly exacerbate his ADHD? For example, a highly critical supervisor may increase the client’s anxiety and thereby increase ADHD symptoms. A micromanaging supervision style may feel diminishing to an adult who has ADHD, leading to feelings of demoralization and reduced motivation. A supervisor who is forgetful and disorganized will only contribute to similar traits in the client. Compare Client’s Concerns and Those of the Supervisor. Problems identified by the client and by the supervisor are often quite different. For example, your client might feel that required overtime work and unclear instructions from the supervisor create her greatest challenges. The supervisor, however, might be more concerned about chronic late arrival at work or about lack of follow-through with paperwork. The clinician needs to help the client address both sets of concerns if she is to succeed in her current job. Explore ADHD Traits That May Affect Interpersonal Interactions at Work. ADHD traits that may lead to interpersonal difficulties include missing nonverbal cues, interrupting, and overreactioning emotionally. Other ADHD traits can be misinterpreted by coworkers or supervisors as poor motivation, for example, chronic lateness or missing deadlines. The clinician may want to refer to my book ADHD in the Workplace (Nadeau, 1996) for a more detailed discussion of ADHD tendencies that can lead to interpersonal conflict or performance problems on the job. Explore ADHD Traits That Affect Performance. The cluster of executive function challenges often associated with ADHD in adults can lead to numerous difficulties. For example, impulsivity can lead an employee to overcommit and then be unable to fulfill a promise or may lead him to jump from task to task with little follow-through and task completion. Restlessness and hyperactivity may lead an individual to find excuses to roam the halls rather than work productively. Memory difficulties can lead an individual who has ADHD to be seen as unreliable when verbal requests are repeatedly forgotten. Patterns of procrastination can lead coworkers and supervisors to see the employee who has ADHD as unreliable or unmotivated. And general messiness, which so often accompanies ADHD, not only is a very public display of disorganization but also greatly increases the challenge of keeping track of and completing the multiple tasks. Explore Match Between Client and Work Organization. Some organizational features may exacerbate ADHD symptoms, for example, reduced administrative support, downsizing, demands for overtime, or unrealistic productivity, or a crisis-prone poorly organized firm.

Neurocognitive Testing: A full neurocognitive assessment can be very helpful in guiding the client but should not be initiated automatically because of its significant cost. If the client plans to return to school, a full up-to-date neurocognitive evaluation is necessary in order to obtain reasonable academic accommodations. A full evaluation will also be required if the client is in the process of disclosing ADHD as a workplace disability in order to obtain workplace accommodations. In a general sense, the same tests designed to measure IQ and academic achievement can be used to identify both areas of strength and areas of weakness. At minimum, an IQ test and selected Woodcock-Johnson achievement tests can help the clinician create a profile of strengths and weaknesses. Tests of memory and executive functioning are often useful in such an assessment. The clinician who chooses to refer the client to a specialist for such testing should nevertheless be knowledgeable about these tests and able to make his own career-focused interpretations of the findings. The clinician should be the primary person who provides feedback of test results and makes specific recommendations to the client on the basis of these test results.

Psychological Testing: The majority of adults who have ADHD also struggle with comorbid psychiatric conditions. The presence of comorbid conditions does not ipso facto call for psychological testing. Possibly these comorbid conditions have already been evaluated and are currently being treated. I recommend psychological testing only if the clinician believes that there are hidden disorders that need assessment or if differential diagnostic issues require it. The clinician can opt for a general, computer-scored psychological test, such as the Minnesota Multiphasic Personality Inventory—II (MMPI-II) or the Millon Clinical Multiaxial Inventory- III (MCMI-III), as a screening tool and can make a decision about the need for further testing after reviewing test results.

Personality Testing: A good (or bad) match between career choice and personality type can have a major impact upon the satisfaction and success that an individual is likely to attain. I use the Myers-Briggs Type Inventory (MBTI) in career assessments because I find it helpful in considering aspects of personality, preferences, and values not measured by tests designed to measure psychopathology.

Interest Testing: A standard interest test, such as the Strong Interest Inventory, can help match the client’s interests with those of people who have been successful in a variety of fields. In my experience, the specific Strong occupational scores are of limited usefulness. Of greater utility are the broader themes—Is the client more interested in the investigative sciences, in the helping professions, in entrepreneurial activities, in artistic endeavors, in more routine office-related work, or in some combination of these fields? Interest in a particular career is crucial, of course, but if interest and abilities are incompatible, the task of clinician and client together is to chart a new career direction that respects both stated career interest and client abilities.

Building Recommendations Based on Assessment Findings
Once the clinician has a clear picture of the client’s workplace challenges and career directions, she should develop a set of recommendations based on of the assessment. A discussion of recommendations is a point of departure for future work together. It is at this point that the clinician becomes the psychotherapist/career counselor, guiding the client in implementing the recommendations.

Environmental Resilience Factors
Let us now return to our discussion of the common factors shared by successful adults who have ADHD and/or a LD and consider how the assessment process functions to help the client find or create these external factors that so strongly relate to career satisfaction and success.

Goodness of Fit: A central purpose of the assessment process is to enable the client and the clinician working with him to assess the "goodness of fit" between client and job. Goodness of fit relates to many topics discussed earlier, including fit • Between strengths and weaknesses and job requirements, • Between the job’s stress level and the client’s stress tolerance, • With the client’s interests, • With the client’s temperament and values, • Between the client’s sensory sensitivities and the physical environment (i.e., space, temperature, lighting, noise), • Between the degree of structure provided and the client’s need for structure, and • Between the client’s capacity for speed and efficiency and the productivity demands of the job.

Supportive Social Environment: The second external factor concerns the people whom one surrounds oneself with—the interpersonal aspects of the environment that are characteristic of successful adults who have ADHD. These include certain characteristics: Mentoring. Garber found that most successful adults who had ADHD had experience early in their career with a mentor. The clinician can provide structure and support for the client to help guide him to seek such a relationship, either in the current workplace environment or in a future job. Supportive and Encouraging People. The importance of support and encouragement to an adult who has ADHD cannot be overemphasized. Many adults who have ADHD have experienced a lifetime of criticism, exasperation, and irritation from people who cannot tolerate their ADHD tendencies. In my experience working with adults struggling with low self-esteem and performance problems at work, the opportunity to work for people who appreciate and encourage them had a positive, often life-changing impact. Support Services—If the Shoe Fits, Wear It. A lifetime of struggling with tasks for which one is ill suited is like a life of never wearing shoes that fit. Sure, you can walk, but you will have blisters, your feet will ache, and you will never be graceful or fast. Working in a job that calls on your strengths, to continue the metaphor, is comparable to wearing well-fitting running shoes. With these one can sprint or go the distance without stumbling or struggling to accomplish what others seem to do with ease. Support services are a key component to creating a job that "fits" as those wonderful running shoes do! Successful adults who have ADHD and LD find others—personal assistants, business partners, office managers, accountants, computer specialists, professional organizers, or spouses—whose skills lie in their areas of weakness to perform critical tasks for which the adult who has ADHD is ill suited. The clinician may need to work with clients on several levels to bring about needed change. Clients may feel that they must wear shoes that resemble those of the people around them, even if they hurt. A basic step in psychotherapy is to help the client reach a level of self-acceptance—to reach a point at which she can celebrate her strengths without apologizing for his weaknesses—to wear shoes in which she can move with comfort. A subsequent task is to problem-solve, to find ways to surround herself with people whose strengths are complementary, to allow each individual in the workplace to wear shoes that fit.

Differentiating Between a "Job" and a "Career"
There are important distinctions between a job and a career, as these terms are used in this article. The term job is used to refer to specific employment. A job entails a specific employer, a specific supervisor, a specific workplace, and a specific set of tasks and responsibilities. One can have many different jobs within the same career. The term career, by contrast, refers to a general field of endeavor. One can have a career in sales, in medicine, in teaching, or in office work. When one changes jobs within a career, one maintains employment that requires a core set of skills and knowledge. Even if the client enters therapy with a clear intention to change careers, it is usually valuable to work with the client to improve her current workplace situation. First, this gives her practice in dealing with many workplace challenges related to ADHD that will likely exist in any job. Second, by improving the current workplace setting, the client is able to consider career changes with less urgency and stress. If the clinician and client have agreed that a change is in order, the best plan of attack is to focus simultaneously on short-term improvements in the current work situation and on the beginning of the longer process of a job or career change.

Setting a Plan of Action
Adults who have ADHD are poor at judging how much they can take on at one time. Impatience, poor time awareness, and unrealistic expectations combine to create goals that are doomed to failure. Using a brain-based approach that takes these ADHD tendencies into account, the clinician should carefully guide and structure the client in setting a goal and then determining the intermediate steps to reach the goal. For example, the clinician might say one of the following: "I know that you have many different concerns about how things are going at work, but in my experience, you’ll get there faster if you take things one at a time. Let’s focus on getting to work on time for the next couple of weeks, and then we can move on to working on getting your office more organized so that you can be more efficient. My bet is that if you get to work early, you’ll have a few minutes each morning to plan your day better and even clear your desk off a bit. Probably, when you come rushing in, already half an hour late, you don’t have time to plan or organize. You might be surprised how many other things improve by just getting to work a little early each morning. So, let’s do some talking about what makes it so hard to get up and get to work." The clinician then begins to engage the client in a detailed discussion of her evening routine and morning routine. He may learn that the client is a night owl who regularly stays up too late and then feels exhausted in the morning, in which case the clinician will address the need for major changes in the client’s routine each evening. Or the clinician might learn that the client has always had trouble with feeling groggy and slow in the morning, no matter how much sleep he gets, a common problem among slower-paced inattentive type adults who have ADHD. In this case, she might counsel the client to adhere to the following procedure: Set an alarm a half-hour earlier than he needs to get out of bed. When the alarm sounds, the client takes his first dose of stimulant medication and goes back to sleep. Half an hour later, when it’s time to get up, the stimulant medication has had time to take effect and the client feels more alert and energetic: less likely to go back to sleep, more likely to move efficiently through his morning routine and get out the door on time. This kind of concrete problem solving goes hand in hand with attention to psychological matters that may prevent on-time arrival at work, such as a passive-aggressive reaction to feeling overworked and underappreciated. Effective ADHD-focused psychotherapy always involves the intricate interweaving of the practical and the psychological, always from a brain-based perspective.
- Nadeau, Kathleen G.; Career Choices and Workplace Challenges for Individual with ADHD; Journal of Clinical Psychology; May 2005; Vol. 61 Issue 5, p549

Personal Reflection Exercise #10
The preceding section contained information about conducting a workplace assessment for a client with adult ADHD.  Write three case study examples regarding how you might use the content of this section in your practice.

According to Nadeau, what is one strategy you might use with a client who is continually late for work? Record the letter of the correct answer the Test.


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