For 13 years neurologist James Robertson practiced at the Neuromedical Center ("NMC"). Robertson received numerous letters and memoranda reprimanding him for his failure to complete patients' charts and to timely interpret test results. After undergoing tests at the suggestion of one of his colleagues, Robertson was diagnosed with attention deficit hyperactivity disorder ("ADHD"). Four months later, he was fired. Robertson brought an action under the Americans with Disabilities Act ("ADA") alleging that he was wrongfully terminated because of his diagnosis of ADHD. The defense moved for summary judgment.
Holding: Summary judgment was granted for the defense. The court ruled that no genuine material issue of fact existed and that Robertson had failed to assert a valid claim under the ADA. To prevail under the ADA, an employee must show that he was disabled, that he was qualified to perform a job (with reasonable accommodations, if necessary), and that adverse employment action was taken against him because of his disability.
The court first focused on the issue of whether Robertson was qualified. Robertson argued that he was qualified because it was merely the administrative portion of his job that was impacted by his ADHD, and that these responsibilities were not part of the "essential function' of his job. The court disagreed, finding that charting and interpreting test results were clearly essential functions of a neurologist's position.
Next the court considered if Robertson was qualified to perform these essential functions. Relying heavily on Robertson's application for disability insurance in which he stated that he was totally disabled due to his ADHD, the court found that he was not qualified to perform the essential functions of the job.
The court then addressed the issue of whether NMC could have reasonably accommodated Robertson, allowing him to become qualified for the position. Noting that Robertson's requests for no "call duty" and administrative assistance would require NMC to hire more employees and to increase the call duty and caseload of the other doctors, the court held that Robertson's requested accommodations were not reasonable. The court viewed the safety of NMC's patients as the paramount concern in making this determination, pointing to the fact that administrative assistants would not be able to interpret test results or complete charting in the same manner as a neurologist.
Media hype has transformed adult ADHD into a diagnosis du-jour.
 | Michael First, M.D. Psychiatrist The Forensic Panel |
Dr. First comments: One issue that immediately jumps out in this case is whether the plaintiff actually has a diagnosis of ADHD. In the past few years, media hype has transformed adult attention deficit disorder into a diagnosis-du-jour, providing people with a medical explanation for their poor concentration, short attention spans, rocky marriages, and difficulties in controlling anger and other impulses. The reality is that although a majority of individuals diagnosed with ADHD in childhood continue to have some residual symptoms that persist into adulthood, only a small minority of those (less than 5%) experience significant impairment related to their symptoms.
As with most psychiatric diagnoses, there are no objective tests available to definitively indicate a diagnosis of adult ADHD. Instead, the diagnoses depends on a clinician's judgment as to whether the patient's symptoms occur at a severe enough level to cause clinically significant impairment (i.e. meet the threshold requirements of the DSM-IV diagnostic criteria). The clincher for making the diagnosis in adults, however, is being able to convincingly document a childhood history of undiagnosed ADHD with symptoms starting by age seven. Most typically, there is a history of doing poorly in elementary and junior high school and/or significant conduct problems attributed to such factors as underachieving, poor study skills, or chronic misbehavior. Consultation with observant parents and other family members, as well as a review of elementary school report cards (containing comments such as "never sits still," "always interrupts other children, or "can't follow instructions") are often necessary to convincingly document childhood onset. The absence of such evidence (e.g. unremarkable report cards, good grades, lack of corroborative evidence from family members) thus virtually rules out a diagnosis of adult ADHD.
A childhood history of ADHD is essential to a diagnosis of ADHD in an adult.
I question the diagnosis of ADHD in Robertson because the progression of the plaintiff's illness is inconsistent with the natural course of ADHD. ADHD starts early and then either eases over time, responds to treatment, or else persists at more or less the same level of severity. Dr. Robertson's problems, however, seem to have become significant only in the past few years. The plaintiffs long history of successful educational and occupational functioning (i.e. doing well enough in college to get accepted into medical school, successfully completing the rigorous education and training requirements of both medical school and a neurology residency, and pulling his weight for at least the first 10 years of his association with NMC) are similarly inconsistent with a lifelong struggle with inattention and hyperactivity.
If not ADHD, what then are the diagnostic possibilities? One feature of this case which is not typical of ADHD is his short-term memory loss that is severe enough to compromise his ability to function as a physician. Severe longstanding substance dependence (on alcohol, sedatives, or barbiturates in particular) can explain both the memory loss (from alcohol or sedative-induced dementia or amnestic disorder) as well as the difficulty in attention and concentration (as a result of recurrent periods of intoxication or withdrawal). Medical conditions (e.g. brain tumor) can cause memory loss, inattention, and distractibility. Severe depression or bipolar disorder can also cause severe cognitive impairment of the nature described in this case. Finally, one should not overlook the possibility that Dr. Robertson may be malingering mental illness, especially given the context of the plaintiffs application for total disability.
