My article “Do we have an ADHD blind spot in our occupational health and safety management systems?” prompted requests for more information about adult ADHD as it affects worker safety and productivity. In this article, I explore the differences in ADHD between the sexes, summarised the common medications used to treat ADHD, and explain how these can affect worker safety and performance.

Why is this relevant to OHS Professionals?

As many enlightened employers (notably Microsoft and Goldman Sachs) have discovered, people with ADHD can bring huge benefits to a workplace, including natural creativity, energy and passion, ability to hyper-focus, an ability to see the big picture and think outside the box, empathy and entrepreneurship.

But it is important to address the challenges they face. The effects of ADHD and its treatment can affect a person’s enjoyment of work and their ability to perform their role safely. In order for workers with ADHD to thrive, they need safe, open and honest communication, sound risk management planning, reasonable adjustments, reassurance and protection from discrimination.

The reality is that most people with ADHD never disclose their condition at work because they are afraid of being judged, misunderstood and discriminated against, and do not ask for adjustments or help.

To recap….

ADHD is prevalent in the adult population. While around 800,000 people in Australia have been diagnosed with ADHD, a 2018 international study found the condition is underdiagnosed, both in children and adults. In Australia, researchers estimate that only 1 in 10 people with ADHD are diagnosed and treated.

ADHD is usually (in about 70% of cases) a genetically inherited, lifelong neurodevelopmental condition. And while around 35% of children diagnosed with the condition learn to manage their symptoms to the extent that it no longer causes significant impairment into adulthood, the rest will continue to experience the effects of the condition throughout their lives.

What do people with untreated ADHD have?

 About half of adults with ADHD have at least one comorbid psychiatric condition, usually anxiety, depression, bipolar disorder or substance abuse disorder. ADHD can also coexist with other neurodevelopmental conditions such as autism and dyslexia.

 All of this makes ADHD notoriously difficult to diagnose and treat – indeed it is the most commonly misdiagnosed psychiatric condition. This matters because people with untreated ADHD:


  • Experience mortality rates four times higher than the general population.
  • Live on average 13 years less than the general population.
  • Are more likely to suffer accidental injuries, including from motor vehicle and pedestrian accidents.
  • Have higher rates of substance abuse including alcohol, tobacco and drugs.
  • Have higher rates of type 2 diabetes.
  • Are more likely to suicide.

Additionally, women with ADHD are at a higher risk of intimate partner violence than the general female population.

To understand this, it is important to understand the neurobiological features of the ADHD brain. Not so long ago, ADHD was commonly regarded as a behavioural problem – a condition that sufferers could choose to control if they “just tried harder”. Now we know there are structural differences in the

ADHD brain, particularly in the:

  • pre-frontal cortex, which controls attention, executive functioning, working memory and organisation;
  • limbic system, which regulates emotion and attention;
  • basal ganglia, which, when combined with deficiencies in neurotransmitters dopamine and norepinephrine, interrupts inter-brain communication, resulting in inattention or impulsivity; and
  • reticular activating system, which regulates arousal and sleep-wake transitions7.

There are also three types of ADHD based on the DSM-V criteria:

  1. inattentive type.
  2. hyperactive-impulsive type, and
  3. combined type.

Thought leaders in this area have proposed that the name “attention deficit-hyperactive disorder” is misleading. The condition is better described as a spectrum rather than a disorder, since it encompasses a wide range of symptoms that can vary from person to person and even within the person. It is also proposed that it is not a deficit in attention that is the problem but rather a dysregulation of attention. Perhaps in time the preferred terminology will be “attention dysregulation hyperactive spectrum”, but for the purposes of this article, I’ll stick with ADHD.

ADHD in Men

Boys are three times more likely to be diagnosed with ADHD in childhood than girls, and on average are diagnosed five years earlier. This means treatment and executive functioning skills development can begin earlier, which leads to better educational and social outcomes.

Boys are more commonly affected by the hyperactive-impulsive ADHD type. So, both in the classroom and at home they may exhibit those stereotypical symptoms of hyperactivity and impulsivity that are generally associated with ADHD and that trigger the alarm for teachers and parents or caregivers.

Increased levels of testosterone during puberty can exacerbate the symptoms of ADHD. During the teen years, as they are becoming more independent, boys with ADHD may also become more impulsive and hyperactive and at increased risk of accidental injury than their neurotypical peers.

As they mature, men with ADHD may learn to curb some of the more impulsive behaviours, but emotional dysregulation and anger management often remain problematic. Since many men define themselves by and draw self-esteem from their work, if they struggle to perform or to get along with their co-workers – or if holding down a job becomes difficult – the impact on their mental health can be profound.

This can have a knock-on effect outside of work, creating problems with relationships, both within the family and the wider social support network. It can be a vicious cycle: Increased anxiety exacerbates ADHD symptoms, leading to a decline in functioning and a reduction in capacity to deploy coping strategies, which in turn impacts interpersonal relationships and increases anxiety, and so it goes on.

ADHD in women

ADHD often presents differently in girls than boys and as a result they may be diagnosed later. Girls typically do not fit the fidgety, hyperactive, disruptive stereotype; they are more likely to have the inattentive type of ADHD, which presents as forgetfulness, distractibility and inattention.

Girls are more likely to sit quietly in class daydreaming, doodling in their exercise books, picking fingernails or twirling their hair. They may struggle to perform well academically even though they may be highly intelligent, and they may be forgetful and messy, frequently losing personal items.

They can have a deep sense that they do not fit in and report feeling misunderstood, as well as psychological pain at the thought of being rejected by peers (rejection sensitivity).

As with boys, symptoms often get worse during puberty. Without a diagnosis and treatment at this age, girls may be primed for lifelong battles with low self-esteem, anxiety and depression, believing they are lazy or unintelligent and constantly worrying about not finishing things, fearing rejection or failure, and being hypercritical of their own abilities and performance.

It is during the adolescent years that 40% of teens with ADHD begin to experiment with alcohol and drugs, compared with 22% of their non-ADHD peers. The effects of alcohol, and amphetamine-based drugs can temporarily improve ADHD symptoms and so they may begin unconsciously self-medicating, which is a strong predictor of alcohol and substance abuse in adulthood.

The influence of reproductive hormones can continue to affect women with ADHD throughout their reproductive years. They can experience more severe symptoms of postnatal depression, premenstrual dysphoric disorder and menopause than the general female population8, and if they take ADHD medication, they may find the therapeutic benefits are negatively impacted by their menstrual cycle.

Many women decide to discontinue their ADHD medication during pregnancy and breastfeeding, because the effect of medication on the baby is not known and there is no safe or ethical way to study this. The combination of ceasing medication, rapid hormonal changes and the emotional impact of childbirth can increase symptoms and reduce the woman’s capacity to cope with both her ADHD and the challenges of parenthood.

What are the challenges that can affect working women with ADHD?

In just the same way as ADHD creates challenges for children in school, it can create challenges for adults at work that can impact their safety, productivity, interpersonal relationships and enjoyment of work and the safety and productivity of others. The challenges below do not affect all ADHD workers all the time, but they are the most common.


Workers with ADHD can have difficulty focussing when there are distractions such as noise and movement in the external environment, and they may also be prone to internal distractions such as daydreaming, zoning-out or rumination. These can impact their ability to concentrate, manage time, pay attention to detail and observe hazards in their location.


Workers with ADHD can act or speak impulsively, without thinking through the consequences or risks. This may manifest in constantly interrupting others or acting in unsafe ways, without thinking through the risk.


Workers who have the hyperactive-impulsive presentation will struggle to perform in sedentary tasks where they are required to stay in one place for too long. They will find it easier to perform in physically active roles.

Difficulty managing long-term or complex projects.

Managing complex or long-term projects can be challenging because they require executive functioning skills including planning, organising, time management, monitoring progress and adjusting requirements, and communicating, all of which can be compromised by ADHD.

Poor working memory.

This is a very common challenge for adults with ADHD. In the occupational setting this can result in work tasks or critical steps in a process being missed or duplicated and the need for verbal instructions to be repeated. ADHD workers may repeat conversations, which can create interpersonal tension and frustration for others.


ADHD can impact a person’s motivation. When combined with poor working memory, distractibility and boredom, procrastinating results in tasks or projects not being completed and can create problems for co-workers if they can’t complete their part of the project until the ADHD worker has completed theirs.


Adults with ADHD can have a very low threshold for boredom and need high levels of stimulation. This creates particular challenges if their role requires them to carry out routine tasks, like reading policies and procedures, completing training or managing paperwork, that they may not find interesting.

Time blindness

ADHD can affect a person’s perception of time, which is controlled in the prefrontal cortex. For the worker with ADHD this can create problems with getting to or leaving work on time, taking breaks when required, sticking to a schedule, and completing work tasks on time.

Hyper focus

Contrary to the belief that people with ADHD are unable to focus, it is more accurate to say that they are unable to regulate their attention. They are capable of intense focus on a task that is stimulating for them, which can be beneficial. But when combined with time-blindness, hyper-focus can result in workers obsessively working long hours on one thing and doing this exceptionally well, while failing to complete other tasks.

Interpersonal/social skills

Where a person with ADHD has a poor working memory and impulsivity, they often find it difficult to interact with others and they can inadvertently cause offence by impulsively blurting out a thought or idea that came into their head, or interrupting others before they forget what they want to say.


Around 80% of adults with ADHD experience a delayed circadian rhythm and other sleep disorders. When combined with hyperactivity and the stimulating effects of some ADHD medications, sleep can be elusive. Add shift work into the mix and the fatigue-related risk for the ADHD worker is significantly higher than for their neurotypical peers.


A quick disclaimer here – I am not advocating for or against the use of medication in the treatment of adult ADHD. Patients should always be guided by their own treating medical specialist.

I’m also not suggesting that medication is the only treatment available. There are many behavioural, psychosocial and educational strategies that can be deployed to help people with ADHD manage their symptoms and improve functioning under the guidance of psychologists and coaches. For adults, the employer can play a vital role in accommodating, supporting, and reinforcing those strategies, to ensure the worker’s safety, productivity, and enjoyment of work.

When assessing risks and deciding on controls to ensure the ADHD worker’s safety, I recommend seeking advice both from the worker’s treating specialist and also from an Occupational Physician trained to assess occupational risks to the health and safety of workers.

There are two categories of ADHD medications available: stimulants and non-stimulants. The lists below are not exhaustive but are most commonly prescribed.

Psychostimulants: These are usually the first choice of treatment of ADHD and have been shown to improve symptoms in 70 – 80% of people. These include:

  • methylphenidate – also called Ritalin and in the sustained release formula, Concerta.
  • dextro-amphetamine – branded as Adderall, or Vyvanse, which provides a sustained release alternative.

In all Australian states and territories, psychostimulant medications are regulated as controlled drugs under Section 8 of the Poisons Standard 2021 (previously the Standard of the Uniform Scheduling of Medicines and Poisons). There are strict rules around the prescribing and dispensing of these medications because of the high potential for abuse and addiction. The possession of these medications without a valid prescription is an offence and only doctors who carry an S8 permit are permitted to prescribe them. In practice, this means the prescription of stimulants is restricted to specialist medical practitioners, although in limited circumstances, GPs may be able to prescribe for ongoing treatment.

Whilst it may seem counterintuitive for a person who already has hyperactive traits to be prescribed a psychostimulant, these medications work by stimulating the production of neurotransmitters (norepinephrine and dopamine). This restores the synaptic cleft (the gap between the nerve cells), enabling signals to be transmitted between nerve cells and restoring inter-brain communication, thereby improving attention and reducing impulsivity.

What is important for the OHS Professional to know about stimulant medication:

Drug Screening

If you require workers to submit to drug and alcohol screening (DAS), it is important to have a Drug and Alcohol Policy that complies with the Australian Standards, and that all workers have been educated about that policy. It must provide a mechanism for workers to safely and confidentially disclose their legitimate use of prescribed stimulant medication. A lack of awareness and fear of failing a drug screen and then losing their job is a significant disincentive for disclosure or an incentive for deceit or discontinuance of the prescribed medication. Stimulant medication will be detected with an instant DAS and give a “non-negative result” for amphetamines. In this case, comprehensive testing can be ordered (GC-MS and LabDAS), which should confirm the type of amphetamine taken, the dosage and when it was taken. The worker should provide a letter from the prescribing doctor, and a copy of their prescription, which would then be confirmed by this testing. If there is any doubt about the ADHD worker’s DAS result and their fitness for work, advice should be sought from an Occupational Physician.

Medication Management

If a person with ADHD loses their medication or prescription it may not be easy for them to obtain a replacement, and there can be serious and uncomfortable effects from rapid withdrawal. A person with ADHD who struggles with inattention, poor working memory and losing things may need to be prompted to make a conscious backup plan.

Side effects

Many newly diagnosed adults who take stimulant medications for the first time describe an almost instant improvement in functioning. But they can quickly develop a tolerance, which results in a worsening of symptoms. They may require increasing doses until the optimal level is determined. Side effects can include worsening insomnia and fatigue and increased anxiety and risk-taking behaviour, all of which can impact worker safety and should be factored into any risk-management planning. It’s a delicate balancing act that can take many months to work out, and patience and flexibility is essential in supporting the employee as they work this out with their treating specialist.

Non-stimulants: Stimulant medication is not suitable for everyone, or it may not be enough to manage symptoms on its own. In these cases, non-stimulant medication may be prescribed instead of, or alongside, the drugs listed above. These include:

  • Atomoxetine, which is sold as Straterra. This is a selective norepinephrine reuptake inhibitor, which works by increasing the concentration of those critical neurotransmitters, dopamine and norepinephrine in the pre-frontal cortex.
  • Clonidine (Kapvay) and Guanfacine (Intuniv), which are alpha2 adrenergic antagonists, are thought to work by mimicking the effects of norepinephrine on the prefrontal cortex.

Non-stimulant medications do not carry the same potential for abuse and are not habit-forming so they are not controlled S8 drugs. But while GPs may prescribe them, this can only be done with evidence of a specialist diagnosis.

Non-stimulants on their own are less efficacious than stimulant medication and they take longer to take effect. They also do not come without side effects. These include: increased fatigue, which can affect safety performance; mood swings, which can impact on interpersonal relationships; dizziness, which can increase falls risks and decreased appetite; and nausea and vomiting, which can impact a worker’s energy and capacity to perform physically demanding tasks.

Non-stimulant medication can give a false positive in urine testing if it has been taken within the previous three days. But it is not normally detected in saliva. As with stimulants, workers treated with these medications should provide a letter from their prescribing doctor and a copy of their prescription to validate DAS results.


The good thing about ADHD is that while it is the most commonly misdiagnosed psychiatric condition, it can be one of the most successfully treated and managed, and doing so can bring improvements in comorbid mental health conditions, overall quality of life and work performance. Any workplace mental health program is not complete if it does not factor in the needs of workers with ADHD, and other forms of neurodiversity for that matter.

What employers and OHS Professionals need to understand and appreciate about workers with ADHD, is that their condition doesn’t just affect them at work. ADHD affects every aspect of their life, and they can’t just turn it off when they go home.

What’s not good, is that at the present time, adults with ADHD are exclusively diagnosed and treated within the private health system. There is no provision for adults with ADHD to be treated in the public health system.

Whilst stimulant medication has been available on the Pharmaceutical Benefits Scheme (PBS) for some time, it was only in February 2021, after much lobbying, that Vyvanse became available on the PBS for newly diagnosed adults. Other long-acting medications such as Concert, Ritalin LA and Straterra are not available on the PBS for newly diagnosed adults.

With the cost of diagnosis often amounting to several thousands of dollars, ongoing psychiatric management, psychological counseling and executive function/ADHD coaching, and ADHD medication that is not subsidised under the PBS, ADHD workers are significantly disadvantaged.

Even if they can afford to see a psychiatrist for diagnosis and treatment, there is a shortage of psychiatrists who specialise in the diagnosis and treatment of ADHD with reports of many closing their books for new patients until the end of 2022.

So, with all this in mind, OHS professionals and employers can play a significant role in supporting the worker with ADHD at work. People with ADHD can bring enormous advantages to their work. While they face significant challenges, there are many effective strategies that can be used to control and reduce risks, improve performance and ensure employment satisfaction.

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