New York Times Magazine
By Lisa Belkin
When Vivienne Sales finally broke her silence, she did so loudly, losing her temper in the hushed library where she worked. It was August 2003, and she had been hanging on to her job as a reference librarian by the most fragile of threads. For more than a year her supervisors at the Embry-Riddle Aeronautical University in Prescott, Ariz., had been warning her that she was sometimes sloppy and inaccurate. She was late for work too often, they said. She didn't dress neatly and appropriately. Her desk was always a mess.
Sales knew all this. She also knew why. Three years earlier, when she was 36, she was told she had attention-deficit and hyperactivity disorder. (That's the full name of the condition, and while its initials are technically A.D.H.D..., not all who have it exhibit the hyperactivity symptoms, so it is often referred to conversationally as simply A.D.D.) The news was a relief because it seemed to explain everything -- why she rarely seemed to fit into a workplace, why she left nine different jobs in 1999 alone, why, despite two master's degrees and years of dogged hard work, she never seemed to get anywhere.
Although the diagnosis was illuminating, Sales was determined to keep her condition to herself. ''Work isn't like school, where they have to give you more time on the tests'' if you have A.D.D., she explained. ''In the real world, if you tell during the interview, they won't hire you. And if you tell after you're hired, they can fire you.''
That's not a precise reading of the law, but it is an accurate reading of the stigma, and of the dilemma that will probably become more common in the coming years. First there was A.D.D. in children, and the debate over whether too many are being medicated for what is arguably normal behavior. Now that conversation has widened to include adults. Psychiatrists used to assure parents that A.D.D. was something their children would outgrow, but more recent research shows that the disorder is longer-lasting than originally thought. A.D.D. does not develop in adulthood, but neither does it always disappear after childhood.
Instead, up to 60 percent of children with A.D.D. grow up to be adults who still have A.D.D., and experts estimate that more than eight million grown-ups in the United States have the disorder. These numbers, presented by researchers from Harvard and the World Health Organization at the annual meeting of the American Psychiatric Association this spring, mean that attention-deficit disorder affects 4.4 percent of the adult population, making it the second-most-common psychological problem in adults after depression.
A mere 15 percent of those eight million actually know they have A.D.D., however, and they have learned that fact recently -- within the last decade, give or take -- because psychiatric textbooks didn't even recognize adult A.D.D. as an official diagnosis until 1987. Now that A.D.D. is an accepted part of the psychiatric repertory, however, doctors are seeing a surge in adults looking for a label for their lifelong restlessness. And just as the rise in the number of children given a diagnosis of A.D.D. brought measurable change to the world of education, the wave of adults with the same constellation of quirks and needs is affecting the world of work.
''A.D.D. makes work more complicated,'' said Harold Meyer, whose organization, the A.D.D. Resource Center, in Manhattan, advises both employers and employees on how to manage the condition in the workplace. Already employers are expected to be exquisitely sensitive -- granting maternity, paternity and adoption leave; subsidizing programs for weight loss and smoking cessation; providing domestic-partner benefits; adapting physical space for every category of handicap; allowing for flextime, telecommuting and job sharing. Adding yet another responsibility -- and particularly for a syndrome whose symptoms look suspiciously like bad work habits -- creates some skepticism. Meyer is regularly invited to address large companies, and whenever there are ''15 or 20 managers in a room, they all think they have employees with A.D.D., and they don't know what to do about it,'' he said. ''They want to help. But they also ask: 'Is it real? Or an excuse?'''
Cheryl Moreno, a manager of human resources at Embry-Riddle, who has spent months working with Vivienne Sales, trying to save her job, said she feels the same tug -- a desire to do the right thing mixed with frustration. ''We're feeling our way here,'' she said. ''Years ago this wasn't on the radar. Now we're seeing more of it. There's a climate here for helping people with impairments,'' she continued, ''but sometimes the impairments are too great.''
It was Moreno, in fact, who inadvertently led Sales to reveal her diagnosis last summer. Sales's job description included being backup for the specialist in charge of interlibrary loans, but she said she felt shaky in that role and had been told during her training for it that she had an ''accuracy problem.'' As it happened, Moreno needed to borrow a book from another library, and she came in on a day when the interlibrary-loan specialist was out. Sales said she is certain that she entered that request into the computer and also printed out a copy for the specialist's records. But when Moreno returned to pick up her book a few weeks later, it wasn't there. Neither was the paperwork, nor any record in the computer.
What resulted was a heated argument between Sales and the specialist who ran interlibrary loans. It ended with Sales sending a memo to her supervisor saying that she had a ''documented disability'' and was requesting an ''accommodation plan.''
''My decision to come out of the closet was one of desperation,'' Sales told me. When she speaks, her head darts in a nervous, birdlike way, her eyes magnified behind glasses that constantly slide down her nose. ''The library director was ready to let me go,'' she said. ''I was playing the A.D.H.D.. card.''
On the third floor of the New York Helmsley Hotel, in the red-carpeted Knickerbocker Suite, a steady stream of adults sat at long, cloth-draped tables and filled out a short six-question form. ''How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?'' the questionnaire asked. ''How often do you have difficulty getting things in order when you have to do a task that requires organization?''
''How often do you have problems remembering appointments or obligations?'' it continued. Then: ''When you have a task that requires a lot of thought, how often do you avoid or delay getting started?'' And: ''How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?'' Finally: ''How often do you feel overly active and compelled to do things, like you were driven by a motor?''
The participants answered in gradations, from ''Never'' to ''Very Often.'' When they finished, they met one on one with staff members from the Adult A.D.H.D... Program at New York University, who were there to tell them whether they were, as one counselor put it, very good candidates for A.D.H.D..Between 8:30 a.m. and 3:45 p.m. on this weekday in May, about 450 people registered for the screening. Of those who took the test, 85 percent were found to be at high risk for the disorder.
''That's far higher than in the population at large,'' said Dr. Lenard Adler, the associate professor of psychiatry and neurology at the N.Y.U. School of Medicine. ''This is a self-selecting group, and they came here in the first place because they were highly suspicious that they have this.''
What Adler was saying is this: Yes, the numbers from this screening are high, but final determinations, the real diagnoses, are not made willy-nilly; everyone who loses his keys once in a while or drives off with the coffee cup on the roof of the car does not have a syndrome. The reason Adler makes his point so carefully is that he understands that many people, whether they say so outright or not, have a sneaking suspicion that A.D.D. is little more than spaciness redefined as disease.
''You can't see it, you can't touch it, there's no litmus test for it,'' said Dr. John Ratey, co-author (with Dr. Edward Hallowell) of ''Driven to Distraction,'' which, when it was published in 1994, brought adult A.D.D. to a mainstream audience for the first time. ''It's a spectrum diagnosis. There's no real test for depression either, but we accept that people are depressed. There are no real tests for a lot of things.''
What is different about A.D.D., though, is that its symptoms are a cluster of behaviors that nearly every human has at some point: forgetfulness, disorganization and restlessness, along with the seemingly incongruous ability to focus intensely on one task to the exclusion of everything else. It is that very familiarity that breeds a level of contempt. So researchers like Adler and Ratey spend a lot of time explaining the difference between A.D.D. and run-of-the-mill messiness.
For starters, there are the physical differences. ''Brain scans show a difference in prefrontal cortex glucose metabolism in people with A.D.H.D..compared to control groups,'' said Dr. David W. Goodman, assistant professor in the psychiatry and behavioral sciences department at the Johns Hopkins University School of Medicine. ''And dopamine receptor density is greater in A.D.H.D... brains. Also, volumetric changes. In general, A.D.H.D.. brains are smaller. If you have a patient do a color/word sorting test, A.D.H.D... lights up in a different area of the brain than non-A.D.H.D... The hard-wiring of the A.D.H.D.. brain is different.''
Then there is the genetic evidence. ''If your child has it,'' Adler said, ''there's a 40 percent chance that a parent has it. If a parent has it, there's a 50 percent chance that a child will.''
These tendencies are not diagnoses, however. Brain imaging and genetics aside, A.D.D. really exists only if it affects your life. ''What makes this real is the impairments,'' said Dr. Margaret Weiss, director of the A.D.H.D.. clinic at the Children's and Women's Health Center in Vancouver, British Columbia. ''There is a tremendous difference between having some of the qualities and having the disorder. What we are talking about here is chronic, it's prevalent, it causes severe impairment.''
In other words, doctors know it when they see it. And what they see is a cohort of people who ping-pong from career to career and job to job; who are dynamite salesmen but who never fill out expense accounts; who look like workaholics because they are at their desks until midnight, but only because they don't really start to concentrate until panic sets in at 11 p.m.; who are creative geniuses but forget to bring the data to meetings.
I've seen it, too, in recent months, while doing the research for this article. The interviews have been qualitatively different from those I have done with any other group in 20 years of reporting. The conversations could not be kept on track; the people I spoke to jumped from one subject to the next. And they were longer than most interviews I usually do, because the subjects were unusually animated, articulate and chatty.
They arrived late. They fidgeted while we talked. They started to ask questions but forgot where they were headed. They kept saying, ''One more thing,'' until I learned to be blunt to the point of rude in my goodbyes. One woman sent me long, bursting e-mail messages, sometimes several of them a day, one of which literally ended, ''running off to my next projecttttttttttttttttttttttttttttttttttt zoommmmmmmmmmmmmmmmmmm!'' One man called me on my cellphone at 8 on a Saturday night because he thought of a question he had to ask. He would not be deterred, even when I told him I couldn't really talk because I was visiting my father in the hospital. Robert Tudisco, a lawyer whose A.D.D. was not diagnosed until he was an adult and who now represents clients with the disorder, tried to explain how it feels to live inside an A.D.D. brain. ''As I sit here and talk to you in a relatively calm conversation,'' he said, ''there's an amusement park going on in my head.''
But even once you come to accept the reality of A.D.D., the question lingers, Why now? If A.D.D. is a function of biology as old as humankind, then why this growing clamor for diagnosis at this particular moment? One answer is that medical diagnoses ebb and flow with the times. Looked at through that lens, Western society seems ripe for this disorder. Now is a time when diagnosis can lead to action -- not only are there more medications to treat A.D.D., but Americans are arguably more willing to take pills to change their temperament. Also, other eras provided more jobs for people who needed to move and do rather than sit and think -- more jobs in factories, on farms, in door-to-door sales. Go even further back, and there were adventurers and pioneers. Today we sit at desks, in cubicles, staring at screens.
Add to this the fact that the support systems that disguised disorganization for some people at work have eroded. ''People wouldn't suffer the effects of A.D.D. if they could have the classic executive secretary who would proof their expense accounts and keep their calendars and get them to meetings,'' Ratey said. ''If I were to create an environment that is bad for A.D.D., it would be today's typical office.''
Ratey is the first to agree with what he sees as the ''general public's belief'' that A.D.D. is probably overdiagnosed, in children and in adults. But, like most in his field, he also says that it is simultaneously underdiagnosed. ''Yes, there are people who will throw this label at behavior that does not fit the criteria'' of the condition, he said. ''But there's no doubt that the condition is real. And the much bigger number is those who have it but have not been diagnosed.''
A.D.D. looks different in adults than it does in children. There are two general categories of the disorder -- with and without hyperactivity -- and adults tend to exhibit the kind without. That may explain another difference as well. It was long thought that A.D.D. was primarily a disorder of boys (twice as many boys receive the diagnosis as girls), but psychiatrists like Adler are finding that the ratio of men to women in his adult clinic is a fairly even split.
The most logical explanation for the discrepancy is that boys are much more likely to have the hyperactive form of A.D.D., and it is the children who are bouncing out of their seats in class who are most likely to be given the diagnosis. The subtler inattentive form is more common in girls, who may well appear spacey or disorganized through their school years but who underachieve quietly and don't disrupt the class. They hit the wall only when they reach adulthood and need to juggle the demands of life and work.
Today's children -- or at least the ones who call enough attention to themselves -- may prove to be fortunate. Those whose condition is diagnosed early are armed with a modern arsenal of weapons, chemical and otherwise, and ''have spent their school years learning how to manage their A.D.D.,'' said Wilma Fellman, author of numerous books about A.D.D. and work. ''They have had the chance to become quite prepared.''
Those whose conditions are diagnosed when they are adults, however, like Vivienne Sales, have no such preparation. They have to undo decades of damage, and do so while somehow holding on to a job.
Carl Mandiola is 37, and he can list more than 50 jobs that he has run through in his working life. He has tended bar, served in the Air Force and been an E.M.Y. He has sold Amway products, waterbeds, cookies, shoes and long-distance phone service. He has worked security at a supermarket, been a janitor in a medical lab, made pizza at a fast-food joint and assembled butyl rubber innards for compression tanks on a factory line. In all, he has been fired from a dozen jobs for poor performance and from a half-dozen more because he was downsized, and he left the rest because he became antsy and bored.
For most of these years he had no label for this restlessness. But he called himself quite a number of names: lazy, loser, stupid. In his late 20's, however, he found a niche in the world of graphic design. He taught himself to do artwork on the computer in a style that is whimsical and bold. He landed a position at a small publishing house in Boston, creating invitations, advertisements and brochures. It was one of the few jobs he had ever had in which he was closely supervised (an advantage for most workers with A.D.D.) but also free to set his own hours (another advantage). ''I turned on at night,'' he said. ''That's when I got things done. All I needed was a good cup of coffee. All the distractions were gone.''
Mandiola had been working at the publishing house for more than two years -- a personal record -- when he moved to New York to marry in early 2001. By then his field was changing rapidly, and cost-cutting meant that fewer people were expected to do more work with less direction. He found, and lost, several jobs that had neither the structure nor the flexibility he needed. ''I'm not a multitasker,'' he said, words that could be a slogan for A.D.D. ''I was used to one or two projects at a time, and they were working seven or eight projects, and they wanted it all done in a day.'' It was this crisis that led him to a psychiatrist and a diagnosis of A.D.D. Now unemployed and with a newborn son, he is thinking of leaving the design field entirely. He says he wants to become a real-estate investor. Or a television writer.
A.D.D. shows many faces in the workplace, but Mandiola's story includes the features prominent in most of them -- the choppy résumé, the tendency to rise to a challenge in the beginning but to unravel as the work devolves from interesting to routine. True, changes in the world of work mean that a peripatetic work history has become more acceptable to potential employers, and while that does make it somewhat easier than it might otherwise be for workers with A.D.D. to get a job (at least in a good economy), it does not make it easier for them to keep one. A recent Roper poll of adults who identified themselves as having a.d.h.d. found that they held 5.4 jobs over the past 10 years, compared with 3.4 jobs for adults without the disorder. The same poll found that only 52 percent of adults with A.D.D. are currently employed, compared with 72 percent of unaffected adults.
Vivienne Sales had an equally checkered work history. After graduating from Indiana University in 1986, she earned a master's degree in international studies from Ohio University. She then worked as a building inspector with the Indiana Department of Labor, did data entry for the Long-Term Credit Bank of Japan, waited on tables at a Japanese restaurant and taught English in Korea. Few jobs lasted for more than a year. In 1999, she was fired from two technical-writing jobs within three months, then went on to leave seven part-time jobs and fail a four-week teacher-training course.
Near the end of 1999, she entered graduate school again, for a degree in library science. ''I'm good at finding information,'' she reasoned. She was also better at being a student than being an employee. She said she thinks the discipline of the classroom kept her on track. While she maintained a B average in the program, concern over her fractured career path led her to see a job counselor in July 2000.
The trip to the counselor led to testing, which led to a diagnosis of A.D.D. (Like many others with the condition, Sales has other issues as well. As many as 50 percent of A.D.D. patients have another syndrome during their lifetime, most commonly depression, anxiety disorder, learning disabilities or bipolar disorder, Adler said. For Sales, the co-travelers were narcolepsy and dyslexia.) It was a diagnosis that brought both relief and regret. ''It explains so much,'' she said. ''Most people cannot believe that someone with three university degrees could be such a washout in the real world.''
The first step after diagnosis is often medication. Drugs tend not to work without monitoring and therapy, Adler said, but he also finds that counseling alone is not enough. Psychiatrists like Adler compare A.D.D. medications to driving a car. It's easier than walking, but only if you know how to drive. Robert Tudisco (the lawyer with the amusement park in his brain) describes the role of medication this way: ''Before the drugs, I could walk through a room and I wouldn't even see it was a mess. With the drugs, I see it's a mess. It bothers me that it's a mess. I want to do something about it. So now I'm ready to learn how to clean it up.''
Unlike nearly every other medicine on the market, A.D.D. treatments were first tested in children, because for decades it was not thought that they were needed for adults. Until very recently all these drugs were officially approved for A.D.D. only in those under 18 and were prescribed off-label for that purpose to anyone else.
These drugs were stimulants, like Ritalin, and they were dispensed in dosages meant to get a child through a school day. Recently the pharmaceutical world began to develop new formulations designed to last longer -- particularly helpful in the workplace. At the end of 2002, the Food and Drug Administration approved the first medication specifically for use in adults. Atomoxetine, which is sold under the name Strattera, is not a stimulant, but a norepinephrine reuptake inhibitor, and it can last for a full day. Strattera has an additional advantage because it allows workers to do jobs -- machine or truck operator, for instance, or airplane pilot -- that could be dangerous under the influence of such stimulants.
Even when drugs mitigate the symptoms of A.D.D., however, they rarely eliminate the complications of workplace interactions. At 50, Sealani Weiner has the typical wandering A.D.D. résumé -- jobs in office administration, followed by jobs in sales, followed by her current profession, social work. In fact, she has struggled so much in her work life that she changed her name along the way. She became Sealani in 2002, in order to leave the failures of Cheryl Lani behind.
Weiner also battles depression and suffers from thyroid disease and diabetes. ''I think it's hysterical,'' she said, laughing (remarkably, she is often laughing), ''that it takes eight medications every day to make me feel normal.''
A longtime New Yorker, she moved to New Mexico seven years ago and went through five jobs there in the next six years. Since 2003, she has worked as a social worker for an area hospice and part time at a psychiatric hospital. Both jobs were at risk shortly after she began.
Her supervisor at the hospice found her difficult to work with and worried about her effect on families. ''It was hard for Sealani to focus,'' said Karen Newcom, who became Weiner's boss last summer. ''She'd come in and tell me she wanted to talk to me. She'd end up going in five or six directions. She couldn't decide what was the most important thing to talk about. She was just taking so much of my time. More so than any other employee.''
It didn't take Newcom long to decide that Weiner was creating other problems at work. ''She's in hospice,'' Newcom said. ''She's dealing with families in crisis. She was supposed to calm them down. I know the effect she was having on me, and I can't see how she would be very helpful.''
One of the myriad wrinkles of A.D.D. is impulsivity. In Weiner's case this shows up in her tendency to speak before stopping to think. In one staff meeting at a previous job, for instance, she voiced the opinion that a patient about to be released from the hospital ''won't pay attention to anything anyone says, and we should just let him drink himself to death.'' In another meeting: ''I said a patient was a bitch. It was true, and everyone knew it was true, but I was fired for it.''
The fallout from similar behavior in her current job sent her in tears to the therapist who had diagnosed her disorder. She met with a psychopharmacologist the next day and left that appointment with a prescription for Strattera. She had resisted taking medication until then, she said, feeling that she was already taking so much for her other medical conditions. But she started on this newest pill, she said, ''to save my job.''
She did not immediately mention that choice to anyone at work, but Newcom said she noticed a change within days. ''Out of nowhere she started coming into my office and was more focused,'' Newcom told me. ''I commented to her that I had seen a change, and that's when she told me about the A.D.D. and the medication.''
As Weiner described it, Strattera slows her frenetic brain. ''I've gone from 100 miles per hour to 80 miles per hour, which is still way faster than anyone I know,'' she said. ''I feel calmer inside. Instead of darting from one thing to the next and never finishing anything, I can take on one thing at a time.'' Which does not mean that she has become a shy and circumspect employee: medication addresses A.D.D. symptoms; it does not transform personality. In the year since she began taking medication, Weiner has been written up for ''inappropriate comments.'' But she said she feels victorious nonetheless, knowing what her bosses don't -- that many times she followed the advice of her therapist and did not ''fly off the handle.'' Instead, she waited 24 hours and used that time to role-play a more measured response with her husband.
So far she has managed to save her hospice job. ''If she had not gone on medication, she would have put her job in jeopardy,'' Newcom said. But she acted too late to keep her part-time position at the psychiatric hospital, where both patients and staff members have complained about her rudeness. ''I think before I went on meds, I burned my bridges there,'' Weiner said. When the time came for her annual review this spring, she said, she was taken aside by a supervisor and told that it would be best if she resigned. So she quit before she could be fired.
In this litigious age, where suits are brought over the temperature of a cup of coffee, you would expect a flood of employees with A.D.D. seeking job protection under the law. Yet, at best, there is barely a trickle.
''There's no landmark case,'' said Patricia Latham, who, with her husband, Peter Latham, is the author of a series of seminal books on disabilities and the law. The message sent by the scattered cases that do exist, she said, is not encouraging to others who might think of bringing more.
A.D.D. can be covered under the Americans With Disabilities Act, as well as state antidiscrimination laws. But those who try to prove they have been discriminated against because of their A.D.D. must show that they are highly debilitated by their disorder yet still capable of doing their jobs if their employer would provide ''reasonable accommodations.'' In short, plaintiffs must walk the tightrope of all disability employment law. ''You have to be substantially impaired,'' Latham said, ''but not so impaired that you do not qualify for your job in the first place.''
That narrow line is why more than 90 percent of cases brought by employees under the A.D.A. ''are not won,'' Latham estimated. That statistic includes all disabilities, she added, and does not account for the additional, intangible hurdles faced by workers with hidden syndromes like A.D.D.
Ours is a society in which excuses are inexcusable. Over the generations we have learned tolerance for some disabilities, but mostly those that we can see. Quirks in the wiring of the mind still generate very little sympathy. If you are missing a limb, I understand that you can't do the same job as I can without help. If you are chronically late for work, however, I am much less likely to understand why you can't try harder to be on time. It doesn't feel wrong to dismiss someone for disorganization, or laziness, or a brusque manner with customers. In fact, it feels right.
Taking A.D.D. to court, therefore, is often an uphill battle. Unless there is some clear evidence of discrimination -- glowing reviews that turn negative immediately after the boss is told a worker has A.D.D., for instance -- there isn't much chance of prevailing under the A.D.A., said John Beranbaum, a plaintiff's attorney who specializes in disability law. Employees who are not given reasonable accommodations have some recourse, but the definition of reasonable is limited under the law and does not involve changing the essential job description. Those who counsel A.D.D. employees, therefore, often advise them not to bother with the courts. ''I get calls saying, 'I need to come in late, and my boss won't let me, can I sue?''' said Harold Meyer, who, in addition to advising companies and employees on A.D.D.-friendly workplace strategies, is chairman of the New York City chapter of Children and Adults With Attention-Deficit/Hyperactivity Disorder, known as Chadd. ''I tell them, 'You can sue, but you won't win.'''
In short, the realm of work is a universe away from the realm of education for those with A.D.D. In the public-school system, a child's diagnosis is like an admission ticket; districts are obligated to help students whose learning is impaired by their A.D.D. In the world of work, the burden is on the A.D.D. employee to help himself.
That did not stop Vivienne Sales from asking her employer for help. The day after her argument over the interlibrary-loan request, she sent a memo to her supervisor. It read, ''I have the following documented disabilities that require accommodation,'' then listed her A.D.D., followed by her accompanying diagnoses. ''I am requesting a 504 accommodation plan,'' the memo continued, using the language of disability law, which she had looked up on the Internet.
That first memo was followed by a second one, two weeks later, addressed to Cheryl Moreno, the manager of human resources, whose book request had been lost.
''I need an accommodation to be able to perform my job duties because of a disability,'' Sales wrote, and she went on to explain what steps she had already taken on her own:
''Using two different day planners. One is left at work; the other is always with me. Each day at work, I compare the entries in both day planners to make sure I do not have any scheduling conflicts.
''Create tracking charts for projects. I use tracking charts to keep track of the . . . seminars that I present for the semester.
''Using a small microcassette recorder, I record items that need to be done for the next day. Then I play back the tape and write down what I have said into my day planners.
''Using flex-scheduling to go to counseling and doctor appointments. I make up my time by working late.''
But these strategies alone were not enough, she wrote in her memo, and she told Moreno what else she would need:
''Educating my co-workers about my condition so they will get a better understanding of it.
''Having set deadlines on when projects should be completed.
''Giving weekly progress reports to my supervisor. In turn my supervisor checks on my progress on a weekly or biweekly basis.''
She sent the memo via interoffice mail. Then she waited to be fired.
Ayana Kee did not walk into Jennifer Koretsky's office on a recent spring day, so much as she swept in, radiating exuberance and energy. Kee is a second-grade teacher -- by all accounts the kind you would want your child to have. Koretsky is her A.D.D. coach. Their twice-weekly sessions are rivets in the infrastructure that is rising within the world of adults suffering from A.D.D.
Kee settled herself on the couch across from Koretsky and started to explain that she loves her job, loves teaching children. But while all the other teachers are gone by 4:30, after an eight-hour workday, Kee is sometimes there until 7. ''The custodian tells me I have to leave because he has to mop the floors,'' she said. Then she brings a satchel of materials home and works until bedtime.
The two women spent the rest of the session mapping out a time-management plan for Kee. ''Let's look at some things you can take off your plate,'' Koretsky said. ''It's not like you have an assistant you can delegate to, but what you do have are kids in the classroom. How much of the classroom management can go to them?''
Kee's eyes widened. She had never thought of this.
''Everything in your class is already clearly labeled, right?'' Koretsky asked.
''It is, it is,'' Kee answered.
''And the children like to help, right?''
''Oh, yes, they do,'' Kee said, and she was off and running. ''The books in the classroom library are labeled on the back to show what baskets they go in. They can put the books away. They can put away the crayons and pencils and things that I am forever cleaning up after they are gone. I can make a list of all the possible jobs within the classroom. We already have a daily job board. I can also make an afternoon job board, and each afternoon we could stop and take just a few minutes to do those. I have 19 students. If we spent 10 minutes. . . . I just thought of a job! Museum curator! They could help me set up the boards where their work is displayed.''
''So this idea sounds like it would work?'' Koretsky asked.
''It's a plan,'' Kee said.
Coaches are not therapists. They are either self-taught or, like Koretsky, they are graduates of places like the A.D.D. Coach Academy, which charges $3,695 for a nine-month curriculum taught over the phone and online. ''Coaches concentrate on what, how and when, never why,'' said Nancy Ratey, a nonstop whirlwind who helped create this field from scratch as a roundabout way of managing her own A.D.H.D.. Married to John Ratey, co-author of ''Driven to Distraction,'' she coaches from her home, which is covered, bedrooms to boiler room, with notes reminding her to close this door, leave that one open, plan a vacation, fix the garage door.
Unlike Koretsky, who meets with Kee in person once a week (and again by telephone or e-mail that same week), Ratey does nearly all of her coaching by phone. She has coached clients as far away as Moscow and as close as across town without ever seeing them, charging up to $400 an hour for her services. Ratey takes 15 clients at a time, and she describes them as a mix of executives, professors, lawyers, doctors and authors. One attorney called her because his secretary threatened to quit unless he found himself a coach. One chronically late advertising executive asked Ratey to train his administrative assistant to check on his preparation progress every 15 minutes. Ratey has instructed assistants to ask the boss to empty his pockets of all accumulated business cards when he returns from meetings and to take the boss's car keys until important reports are finished.
(Permit me a detour here, since detours are certainly fitting for this story. My favorite adaptive strategy was used by Robert Tudisco. His son was enrolled in a preschool directly across the street from his law office. Yet every afternoon, Tudisco arrived late for pickup. Tudisco tried everything he could think of to get himself out the door on time -- reminders on his watch, his computer, his Palm Pilot, his alarm clock -- and then he noticed that his paralegal, whose workday stopped at 5, always left precisely on time. So he told her ''that she wasn't allowed to walk out the door without me,'' even if she needed to physically yank him from his chair.)
Most often, though, it is the A.D.D.-afflicted individual, not the support staff, who signs up for coaching. While the coach's role is technically to help with the day-to-day mechanics of work, most coaches find themselves advising clients on less concrete problems, like whether their particular job, and even their entire profession, is a good fit. It is accepted wisdom in A.D.D. circles that certain types of work are a nightmare for those with A.D.D. (accounting comes to mind) and that others are virtual magnets for those with the condition: sales, contracting, waitressing, hairdressing -- any job that involves chatting and moving around. Stock trading, acting, law enforcement, emergency medicine -- any job that runs on adrenaline and deadline. Journalism is thought to be full of people with A.D.D., doctors and coaches tell me. (Yes, I took the screening test. I have many of the tendencies, but not the disorder.) Entrepreneurs with A.D.D. often thrive as well, but only if they have a partner who is good at paperwork.
Unfortunately for Vivienne Sales, librarian is not on the list. And yet, it is what she most wants to be.
Sales was not dismissed after her argument in the library last summer. Instead, she found an unexpected advocate in Cheryl Moreno. The h.r. manager said she believed that the rules would have permitted the library to dismiss Sales until the moment Sales declared that she had a disability. At that point the rules change. ''The median cost of accommodations for impaired employees is $240,'' Moreno said, quoting a statistic in vogue at human-resource conferences. ''So we tried to help.''
In Sales's case, the help cost more than $240 and came in the form of a job coach whose $100-per-hour services were paid for by the university. Finding such a coach in Prescott, Ariz., took most of last autumn, and it was not until the end of last year that Sales began working with Evelyn Larriba, a vocational specialist from the West Yavapai Guidance Clinic who was not specifically trained to work with adults with A.D.D. but who brought up a grandson who has the condition.
During January and February, Larriba met with Sales at the library. Their work started with her desk, which took two hours to straighten up. Then they tackled her time management, dividing Sales's workload into sections and creating interim timetables. That worked when it came to ordering her quota of graphic novels, which she finished on time, but was not quite as successful when it came to reviewing periodicals for the library's collection. Despite a detailed template, the first batch of reviews that Sales turned in were handwritten, and her boss had to advise her to type them up on the computer. Larriba said she has never seen a client work harder. ''You couldn't ask for anyone who is more dedicated to doing a good job,'' Larriba said of Sales. ''She tried desperately hard.''
Once a month, Sales met with her supervisor, Evelyn Harris, to discuss her progress. The portrait painted in Harris's memos is one of incredible determination and effort but only incremental change. Harris said that both she and Sales were determined to make it work. ''I approached Vivienne's training as I would with a brand-new person,'' Harris said. ''We agreed we would start from ground zero and build.''
In the January report, Sales was chided for missing a deadline for a student newspaper because of a computer problem; missing a meeting because she forgot, despite three e-mail reminders; and missing a day of work because she forgot to take her medication. She failed to straighten the library bulletin board where students post ''for sale'' and ''for rent'' notices. She yawned through an entire meeting, without covering her mouth, leading Harris to reprimand her for ''unprofessional behavior.''
''From our discussion today and the list of things that are not getting done, I feel that you are not multitasking,'' Harris wrote. ''You focus on one or two projects and ignore the other daily/weekly tasks that need to be done on an ongoing basis. You will work with Evelyn Larriba during the next two weeks on time-management skills and prioritizing techniques.''
A startling fact about the world of A.D.D. is the number of people who are grateful for the disorder, who consider it the best part of themselves. David Neeleman, for instance, the founder of JetBlue Airways, has said that he will not take medication for his A.D.D., fearing that it would make him just like everybody else.
''It's the source of my creativity and my drive,'' echoed Thomas Apple, who was given a diagnosis about seven years ago, when he was in his early 40's, and went on to create the world's largest video display for stock market quotations. ''You can think outside the box because you're not in a box.''
''A.D.D. is the greatest thing that happened to me,'' said Sam Grossman, who became a partner in the Albert Corporation, a real-estate company based in Brookline, Mass., two years ago, when he was 22. ''I wish I could hire four or five people like me with A.D.D.,'' he said. ''The impulsivity that comes with this means I can walk into a building, see things an ordinary person wouldn't see and act on my gut right away.''
Even the slim chance that such success is possible kept Sales going. ''I see things in ways that other people don't,'' she said. As an example, she told me about how another librarian happened to mention that a copy of the ''Seabiscuit'' dvd was missing. That same morning, Sales happened to pass the interlibrary-loan shelf and was distracted by a glimpse of something out of place. It was the wayward dvd.
At about the same time, Sales was training students to enter information in a database of aviation-themed periodicals. It was boring, repetitive work -- year, month, volume number, titles, features, keywords -- and Sales hated it. While trying to find new books for the collection, Sales accidentally found herself not in her library's database but in a commercial one that included almost exactly the same information. ''Our project was reinventing the wheel,'' she said. ''Other companies were already doing this work.'' So she wrote a memo (on the computer, not by hand) and presented it to her boss, practically giddy at her efficiency.
She told her coach these two stories over and over, certain they would save her job. Success, however, is a matter of perspective, and what Sales saw as victory, Larriba saw merely as what others do effortlessly every day. She did not share that with Sales, however, letting her client savor the feeling of accomplishment.
''That memo was my best work,'' Sales remembered. ''It only had one typo.''
Sales's determination to do the job right was certainly noticed. There was praise in her next evaluation.
''Your presentation was well organized, your PowerPoint slides were effective and your personal demeanor was professional,'' Harris wrote in March. (Larriba had advised Sales on her outfit, double-checking that it was pressed.) ''That was very good.''
But there was criticism too -- and a tone that sounded like a boss building a paper trail. Sales was cited for lapses that she says she suspected would not be held against any of her co-workers. It gave her the feeling that she couldn't win, no matter how hard she might try. By April, it was clear that the fight was over. Sales was told that she had taken too much time with too little result preparing a display for Black History Month and too little time updating the library's emergency and disaster manuals. She had introduced items in meetings that were not on the agenda. She had recommended the purchase of books without realizing that the library had already ordered them. She had recommended the purchase of electronic devices without first conferring with the electronic-services librarian. (''Your response when I questioned your recommendation was, 'Whoops!''')
This final evaluation came with an attached list of available positions elsewhere in the university. Of those, seven required advanced training or degrees that Sales did not have, one was a part-time slot in the copying center and one was interlibrary-loan specialist, the job that started all the trouble in the first place. After reading the list, Sales went home and lay in bed with an ice pack on her head.
As a part of Sales's severance package, she received 16 hours with her vocational coach, and Larriba spent much of that time discouraging Sales from applying for jobs that involved too much multitasking or would require her to relocate. Sales said she thinks a move to another state, or even another country, might provide a clean slate and a new start; Larriba said she thinks a move would be nothing but overwhelming.
''You have to ask yourself, Are you running to something or are you running away from something?'' the coach told her client. ''You can't run away from A.D.D.''
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