Executive Dysfunction: Could a CEO have ADHD?

by John Fleming, Ph.D., C.Psych.

For many professionals and lay people alike, the idea of a highly successful person with attention deficit hyperactivity disorder (ADHD) is contradiction. ADHD is a neurological disorder that creates an inner restlessness, impairs the ability to organize, makes it hard to maintain focus and remember things, and interferes with the ability to maintain motivation for mundane but important tasks.  How can a person struggle with these types of difficulties and still manage a successful business or function effectively as a doctor, lawyer or accountant?  It is both possible and probably more common than you think.

To untangle this contradiction let’s begin with an example. Jack is a highly successful president of a rapidly growing advertising firm. Most people would be very surprised to learn that Jack has ADHD. But watch Jack carefully. First you’ll notice that Jack does not sit down at his desk. Unless you catch him in a meeting, he is constantly on the move. You will not find an agenda at that vacant but messy desk. His agenda is set by whomever and whatever comes through his door (or phone). He has people assigned to projects and has established a working pattern that ensures that his senior people come to him often to discuss projects and keep him in the loop. When Jack’s help or expertise is required, his assistant or other staff members come to him, often in the 11th hour, where he jumps to a frenzied but typically brilliant finish. Meetings are often a problem, but staff have gotten used to Jack physically drifting out of meetings with a “can you finish this up from here?” Unfortunately, the days usually end up being rather long because of the inefficiency of this scattered approach. Jack has also learned to decreases his distractibility by maintaining an almost relentless stress level; like many others with ADHD, he works better in crisis mode.

At home, Jack is much like a caged tiger. He does not know how to relax. He finds himself a stimulating project that he will attach himself to with nearly religious zeal until it is completed or it loses its sparkle. There is a very long list of incomplete projects around the house. Overall, Jack can be a bit difficult to be around unless you’re participating in his obsession of the moment. He has a difficult time playing with his young children. He is impatient and always thinking about getting to the next thing; he is seldom able to savor the moment. Alternatively, you might find him exhausted, the other side of the frenzy and tension. His marriage is a testimony to the deep affection his wife holds for him. She has managed the thankless role of being the counterbalance to his moment-to-moment enthusiastic turns. Like the majority of ADHD adults, Jack also suffers from a concurrent psychological disorder.  For Jack, it has been a low level depression that made him doubt himself and limit his ejoyment. Until recently his depression never really responded to medication or psychotherapy since his ADHD was never diagnosed or treated. His sleep is also chronically inadequate because he can’t regulate his intense drive and his chronic sense of insecurity. It is very hard to sleep when you are chronically revved up and worried about what you might have forgotten to do. Jack is a success, but he seldom enjoys it.

Now you see it, now you don’t

Interestingly, most people with ADHD have at least one area of functioning where they don't appear to struggle at all with the core symptoms of the disorder  (distractibility, disorganization, chronic restlessness, short-term memory lapses, or priority setting). Having ADHD does not mean that you cannot concentrate but rather that you have poor control over your ability to concentrate. The loss of focus happens much less often if the person is working on something of intrinsic interest. For people without ADHD, it is like the difference between reading a mystery novel before bedtime and reading a dry textbook; most people can stay focused on the novel despite being very tired, yet they would find it nearly impossible to concentrate on the textbook. ADHD is kind of like that except that it runs 24 hours a day. Typically, the amount of distractibility varies inversely with the amount of stimulation that the situation provides.   Many doctors overlook the possible contribution of ADHD to a patient’s problems because the patient can perform superbly some of the time. This oversight is the result of an overly simplistic understanding that if a problem has a neurological cause, it will be consistent in its presentation. This is simply untrue.

This substantial variation in performance contributes to the misunderstanding that people with ADHD are simply lazy.  Because they seem to be able to perform some of the time their failure to perform most of the time is perceived as a matter of choice. The critical difference is that for someone with ADHD, this capacity to perform is dependent upon external circumstances and is not simply a matter of choice or will power.

What distinguishes the situations where such an individual performs well versus poorly?  One important factor is that the activity is usually an area of strong interest.  It is also very much tied to level of structure in the situation, the clarity of goals, short rather than long deadlines, or alternatively, whether or not the person can successfully complete the task while staying in a fairly reactive mode. Things tend to go smoothly as long as the challenges and demands come in a steady and interesting stream. Those with ADHD tend to do well when they can keep slaying the dragons while someone else cleans up the mess, does all the paperwork, and orders new dragons.

Because ADHD is a lifelong condition, people who suffer with it never know that life can be different. In fact, most have no idea that the average person does not share their struggle to stay focused and organized. For most people finishing a long but dull task doesn’t require getting up 15 times, checking their email every 10 minutes, and constantly having to reread a paragraph because none of it sank in. But luckily, life can be vastly improved for most people with ADHD.

Diagnosis and Treatment

The first step in rewriting Jack’s life started with a diagnosis. Not an easy proposition for someone who clearly seemed to suffer from depression and was always a high achiever. After a lengthy and thorough psychological history, Jack was given not only a new diagnosis but also a completely new way to understand himself. It wasn’t a shameful flaw, but a complex aspect of the functioning of his brain. The diagnosis began the process of gaining control of his life through understanding the reasons for the problems and then finding ways to create change.

Treatment for ADHD is multidimensional. It typically begins with a trial of medication. For some this makes an extraordinary difference, like putting glasses on a terribly nearsighted person. Suddenly, things are much clearer. For others, the effect of medication is minimal, only slightly reducing the mental spin. Most adults also benefit from some counseling to help them better understand how their brain works and how to modify their life to minimize the negative impact of their neurological makeup. This typically involves a process of building external structures to help keep them on track. Such things as learning to use a calendar, how to effectively create and use to-do lists, establishing creative reminders to keep track of time and activities, and successfully using others to help stay focused.

For Jack, the issue was not about improving his performance at work but rather to increase his efficiency while reducing his stress. It included the creation of a visual system for tracking projects, controlling people’s access to him, creating fixed strategic meetings which were short enough for him to sit thorough. These meetings provided him with the key information to organize his day allowing him to set priorities and minimize the distraction of his worries about other projects.

This wide variation of performance in successful people with ADHD often results in their feeling fraudulent; that others will eventually see that they are not really as skilled as they appear to be.  Without the understanding that a diagnosis and treatment can bring, most of these high functioning individuals are left baffled by the mystery of why they sometimes think with such incredible clarity while at other times they feel completely befuddled.  Key here is the lack of personal control. It is not a matter of the person being able to turn the clarity on and off but rather being at the mercy of external circumstances which they don't have any clear algorithm for understanding. Many high functioning adults with ADHD are plagued by a chronic worry that their good luck is going to fail them and they are going to be exposed as the fuzzy headed thinker they know they can be.

On at work, off at home

Many individuals with ADHD have had the good instincts, direction, or pure luck to place themselves in a career that provides the stimulation and structure necessary to succeed and even excel. If this were the whole picture, an ADHD diagnosis would not be warranted.  To qualify for a diagnosis, the condition must significantly impair functioning in at least two areas of life (hence the term “disorder”).  People with ADHD and a successful career tend to suffer the most in their personal life and in areas of self-care. While work situations will often provide that perfect mix of stimulation and structure that they need, these external supports don't typically extend themselves as well into their personal life where self regulation is so much more difficult. 

For Jack it was getting his personal life back on track that proved most difficult. It involved getting him and his family to understand that it was best to socialize with Jack around an activity. That they needed planning sessions before a weekend so that expectations could be tabled and a plan established before Jack got swept away.  By having a better plan for his leisure time Jack found it easier to enjoy blocks of time with his children since he knew that he had other time set aside to finish the other things. Jack was allowed to move in and out of “family time” and find activities that he could enjoy with his children.

By expanding our awareness of how varied ADHD can be we create the opportunity for people like Jack to understand their struggles and begin to find solutions. Today, Jack is no more successful than he was before. But today, he feels much more in control of his life and is finally getting a chance to enjoy his success.