What career adjustments are recommended for a 33-year-old female with untreated Attention Deficit Hyperactivity Disorder (ADHD) and post-concussion syndrome, who has been experiencing increased complexity in her current career field after 7 years, and is currently taking Qelbree (viloxazine), Wellbutrin XL (bupropion), and Prozac (fluoxetine)?

Career Adjustments for Post-Concussion Syndrome with ADHD

This patient requires immediate workplace accommodations with reduced cognitive demands and a structured, gradual return-to-work protocol, similar to return-to-school guidelines for concussion recovery, while optimizing her ADHD treatment to address the compounded cognitive deficits from both conditions.

Immediate Workplace Modifications

Implement "cognitive rest" principles in the workplace by reducing workload complexity, shortening work hours, and allowing extended time for task completion. 1 The American Academy of Pediatrics emphasizes that cognitive activities exacerbate post-concussion symptoms, and this applies equally to occupational settings as it does to academic environments. 1

• Reduce daily work hours initially, starting with 2-4 hours per day and gradually increasing as tolerated, following the same stepwise progression used in return-to-school protocols 2
• Simplify job responsibilities temporarily by removing complex decision-making tasks, multi-tasking requirements, and high-pressure deadlines 1
• Request extended deadlines and reduced project loads until cognitive function returns to baseline 2
• Minimize exposure to symptom triggers including bright screens, loud environments, and prolonged concentration periods 1

Understanding the Dual Cognitive Burden

Post-concussion syndrome causes persistent neurocognitive deficits including impaired concentration, memory problems, and executive dysfunction that directly overlap with untreated ADHD symptoms, creating a compounded disability. 1 Approximately 15-20% of concussion patients develop persistent symptoms that result in long-term cognitive impairment and decreased quality of life. 1

• Preexisting ADHD is a significant risk factor for prolonged post-concussion symptoms and worse outcomes 1
• Cognitive deficits may persist even after subjective symptoms resolve, requiring objective assessment rather than relying solely on self-reported improvement 1
• The combination creates executive function deficits in working memory, inhibitory control, vigilance, and planning that make complex career responsibilities overwhelming 1

Structured Return-to-Work Protocol

Follow a graded, stepwise return-to-work protocol with minimum 24-48 hours between each advancement level, progressing only when symptom-free at the current level. 2

Step 1: Initial Modified Duties (Weeks 1-2)

• Work 2-4 hours daily with simple, routine tasks only 2
• No deadlines, meetings, or complex problem-solving 1
• Frequent breaks every 30-60 minutes 1

Step 2: Gradual Complexity Increase (Weeks 3-4)

• Extend to 4-6 hours daily if symptom-free 2
• Introduce moderately complex tasks with extended timelines 2
• Limited multitasking and decision-making 1

Step 3: Near-Full Duties (Weeks 5-8)

• Progress to 6-8 hours daily 2
• Resume most pre-injury responsibilities with accommodations 2
• Continue avoiding high-stress, time-pressured situations 1

Step 4: Full Return

• Resume normal work hours and full responsibilities only when completely symptom-free for at least one week 2, 3

Optimizing ADHD Medication Management

The current medication regimen (Qelbree, Wellbutrin XL, Prozac) requires careful monitoring as these medications can affect post-concussion recovery, particularly regarding cardiovascular effects and cognitive function. 4

• Monitor blood pressure and heart rate closely as Qelbree can cause elevations that may worsen post-concussion symptoms 4
• Watch for increased somnolence and fatigue from Qelbree, which compounds post-concussion fatigue 4
• Screen for suicidal ideation as Qelbree carries increased risk (0.9-1.6% in trials) and post-concussion syndrome increases depression risk 4
• Consider that viloxazine (Qelbree) is a non-stimulant option that may be better tolerated than stimulants during concussion recovery, though evidence is limited 5, 6, 7

Active Rehabilitation Interventions

Implement graded aerobic exercise below symptom-exacerbation threshold, performed at least weekly for minimum 4 weeks, to accelerate recovery. 2 This is distinct from complete rest, which may actually worsen outcomes. 1

• Begin with light aerobic activity (walking, stationary cycling) at 60-70% maximum heart rate for 10-15 minutes 2
• Gradually increase intensity and duration by 5-10% weekly if symptoms do not worsen 2
• Add cognitive training exercises as these show potential efficacy for persistent post-concussion symptoms 1
• Consider vestibular rehabilitation if dizziness or balance problems are prominent symptoms 2

Specialist Referral Criteria

Refer to a traumatic brain injury specialist immediately, as symptoms persisting beyond 3 weeks require specialized evaluation and management. 2, 3

• Symptoms lasting longer than expected (1-6 weeks) warrant specialist consultation 3
• Female gender is a risk factor for prolonged symptoms and worse outcomes 8
• Psychiatric comorbidities (ADHD, depression/anxiety from Prozac use) predict persistent symptoms 1, 8

Critical Pitfalls to Avoid

• Never push through worsening symptoms as this can prolong recovery and worsen outcomes 1, 2
• Avoid prolonged complete rest beyond 24-48 hours as this may be detrimental to recovery 1
• Do not rely solely on patient-reported symptom resolution as objective cognitive deficits may persist 1
• Avoid NSAIDs for headache management due to theoretical risk of intracranial bleeding; use acetaminophen instead 1, 2
• Never discontinue ADHD medications without medical supervision as untreated ADHD will compound cognitive difficulties 1

Long-Term Career Considerations

If symptoms persist beyond 3 months despite optimal treatment, consider permanent job modifications or career transition to less cognitively demanding roles. 1 Post-concussion syndrome can result in permanent cognitive impairment in some cases, and insufficiently treated ADHD negatively affects long-term employment outcomes. 1

• Explore accommodations under disability laws (ADA in US) for permanent modifications 1
• Consider positions with reduced complexity in the same field rather than complete career change initially 1
• Maintain close collaboration between healthcare providers, occupational health, and employer 2