Undiagnosed ADHD: Jay's Story

Jay described having trouble focusing on his work, being increasingly distracted, and feeling like his brain wasn’t working properly.

His outbursts followed a series of major life events for this talented executive that had taken place over the past five years; he lost both of his parents, his youngest daughter had gone off to college, and his foundation was facing unique challenges that demanded greater organizational leadership and executive function demands than ever before. With the continuing sizable growth that had resulted from his successful stewardship, Jay felt increasingly overwhelmed and out of control which was eroding his confidence and making him feel less effective.

Deep feelings of inadequacy began to surface, and he began to feel like a bit of a fraud and feared his employees would find out that he had no idea what he was doing much of the time. At the conclusion of our first session, mindful of other powerful men who I had treated who had “hit a wall” at work having previously functioned quite well, I said to Jay, “Over the course of your adult life you have been accruing increasing levels of power and prestige, yet perhaps have been feeling more and more helpless. Therein lies a paradox that might be worthy of exploring together. Clearly you have achieved great outward success yet have also sustained a series of losses in recent years. As well there may be something biological going on that is adding to your distress. If you choose to work with me, we will explore all of these issues over time. What do you think of this approach?” Jay agreed that he would like to work with me, and so we began.

During the course of evaluating the underlying causes of his anger outbursts, it became apparent that he had a history of some childhood learning difficulties, which had been largely overcome by his innate intelligence and hard work but had left within him a legacy of humiliation given his growing up in a family of high achievers. His father in particular was an extremely driven and highly accomplished businessman and had expected and demanded “great things” from his son, getting furious with Jay as a child when he’d mistakenly interpreted Jay’s learning problems as “laziness and willfulness,” and “not respecting the value of hard work.”

Jay’s learning difficulties included

• trouble sustaining attention
• being easily distracted
• clowning around in class
• messiness with his backpack, desk and bedroom
• procrastinating around homework assignments that were “boring”

Completing these assignments took him much longer than his peers, which deepened feelings of humiliation. When called upon to answer a question by a teacher, Jay would be unable to answer as he hadn’t heard the question in the first place. His mind had been wandering elsewhere or he had been daydreaming. His teachers not infrequently commented that Jay “didn’t work up to his ability.”

As a teenager he had joined a gang of older boys that actively vandalized local schools and merchants, and, given his charismatic personality and innate leadership skills, Jay eventually became the gang’s leader. He recalled that for several years he felt angry at the whole world and got a kick out of destroying property that belonged to others. Despite his angry lawbreaking behaviors, deficits in attention and executive function, and a mediocre school performance; through hard work and persistence he had completed college and “just squeaked by” in graduate school where he attained an MBA.

Jay’s lackluster academic career was more than made up for by a strong passion for his work, an intense drive to help make the world a better place, a warm and charming leadership style, and a keen ability to motivate and inspire others. As a result, he had risen to the pinnacle of his profession in the world of not-for-profit organizations and his foundation had tripled in size and was nationally renowned for its work at the time he began to see me.

After reviewing his history, and performing a standardized screening questionnaire, I said to him, “Jay, you are suffering from ADHD, a condition with which you were born. It helps to explain much of what you struggled with as a child, which resulted in your feeling humiliated in class, and at home in confrontations with your father. He had expected so much more from you than you could possibly deliver given the constraints that this condition had placed upon your functioning in class, in completing homework assignments, and with respect to your chores at home. In spite of your ADHD you have achieved remarkable success, which is a tribute to your character, resilience, and work ethic.

“However, the increasing demands of your position in recent years have overwhelmed your ability to process information, serving to recreate those feelings of humiliation and helplessness that you experienced long ago. We can treat this condition with medication, analyze your workflow to help you develop better routines to manage workplace demands, and also help you come to terms with the intense feelings that are undermining your relationships at home and at work.”

We initiated psychotherapy and medication treatment, and I recommended changes to his work environment to improve his focus and organization. The first medication prescribed was Adderall XR, which assisted him in significantly improving his focus and being free from distractibility. Unfortunately, it would wear off sooner than he desired, as Jay would frequently need to work into the evenings and he desired medication coverage through this period of time. As a result, we substituted Vyvanse for the Adderall to achieve a longer duration of action. Neither the Adderall nor the Vyvanse helped him with his difficulties in planning, organizing, working memory, and following through (all executive function deficits), and an ongoing tendency to misplace important items. Strattera (atomoxetine) was added to further boost activity in the norepinephrine circuits, which then had a major positive impact in improving his executive functioning abilities to organize his life, and in reducing some of his anxiety.

Jay then replaced his executive assistant with one who was more talented and better able to assist him in organizing his daily routine. He was encouraged to use a smart phone calendar and its alarm function, and to create a digital to-do list on the phone, all of which synced with his laptop and his assistant’s PC. He adopted these tools which helped to make him a more effective executive. His wife was invited in for several sessions along with him – first to explain the diagnosis and treatment plan and then to engage her help in developing routines for Jay at home to make their life together less stressful. She had become increasingly troubled by his anger outbursts, frequent interruptions while she was speaking, and his impulsivity when driving the car.

During the course of his therapy Jay was able to grieve his parents’ deaths. On one such occasion I said to him, “Jay, as a business executive you are accustomed to taking rapid action to solve thorny problems and have always strived to find a solution that enables your organization and you to move on successfully. While this driven ‘can do’ style works well in the business world, it does not work so well with the human heart. You never took the necessary time out to grieve the deaths of your parents, and perhaps now is the time.”

Reluctantly, and against the grain of his action-oriented personality, Jay began to express his feelings of sadness and anger over helplessly watching his parents grow old and enfeebled. He had just felt so powerless and bereft at the time yet had buried these feelings by throwing himself ever more forcefully into his work.

He also expressed his sadness and anger over his younger daughter moving on to college, and the emotional consequences of the empty nest syndrome in him and his wife, and its effect on their marriage now that his favorite era in their lives together had come to an end. Jay was able to grieve another huge disappointment in his life, when his older daughter first repudiated his religious background, and later became engaged to a young man of a different faith, and converted to his religion.

Then his daughter and future son-in-law decided that they would be married on a beach in Bermuda, instead of the storied hotel that he and his wife had dreamed of for her ever since she was a young girl. He had celebrated many holidays with his family there, and he had long wished to walk her down the aisle at this special place.

His heart was broken, and I thought about how best to help it heal. I recalled how it had felt when our oldest daughter attended graduate school here in D.C., and when her college sweetheart moved here to be with her I got really excited, and was convinced that they would settle here for the remainder of their adult lives. Then, her boyfriend decided to pursue a once-in-a-lifetime entrepreneurial opportunity, and the two of them moved to New York City. I felt sad, yet it was an easy train ride to go and visit with them. Then the little startup that her boyfriend had joined was acquired by a Bay area behemoth, and they got engaged, moved to San Francisco, and then got married. My heart was broken, and yet I felt so happy for them as they launched their life together.

Feeling like Jay was a kindred spirit I said to him, “Jay, I am reminded of how Steve Martin felt in ‘Father of the Bride.’ The wedding itself was the easy part, but coming to terms emotionally with his daughter getting married was the hard part. It raises so many issues that are important for us to discuss – how you feel about your little girl growing up and moving on with her fiancé; what it feels like for you to be growing older and facing mortality, while the two of them are just launching their life together; seeing them so happy and deeply in love, with you being married to Karen for all of these years and how that relationship can feel troubled or stale at times; what it means for your daughter to assert herself and be different from you, and to shatter your longstanding dreams regarding where she would be married. You likely have deep feelings about all of these issues. Let’s explore them.”

And so, while Jay was initially furious with his daughter over these choices in her life, through talking about the issues that I raised, and others that emerged, he was able to eventually let go of his anger toward her and the attendant feelings of betrayal, express his sadness and other feelings about this momentous life stage event, and move on to begin to love his new son-in-law.

Jay eventually became aware of his anger toward his father as well, who had been a demanding perfectionist – and in many ways was the opposite of his son – meticulous in organization and focus, but lacking Jay’s passion and creativity. Through the process of grieving and letting go in the context of a supportive and empathetic psychotherapy Jay felt less burdened, and the substantial resolution of his ADHD symptoms provided by the medications had increased his confidence, and helped him to feel more in control of his life, reducing his feelings of being constantly overwhelmed.

Over time Jay became significantly more satisfied with his life, and more effective as a leader. He began to grow his senior leadership team by hiring in some extremely talented individuals with strong organizational skills, and was able to take the activities of his foundation to other countries to work toward ending hunger there. He began to be able to laugh at situations that used to provoke his angry outbursts, and experienced more joy. While he was able to give up most of his road rage, the challenging traffic patterns and fierce roadway congestion in the Washington, D.C. region prevented him from fully letting go of his anger outbursts at other motorists. At least now he kept the windows of his car closed when he shouted at them!