Professionally successful adults with attention-deficit/hyperactivity disorder (ADHD): Compensation strategies and subjective effects of pharmacological treatment.

Although as a group, adult patients with ADHD have difficulties in social functioning due to inattention and executive dysfunction, some strive and succeed in living a productive, independent life.
PURPOSE: To report on professionally successful adults with ADHD and analyze their main symptoms, compensation strategies and the subjective effect of methylphenidate on their functioning.
METHODS: The main symptoms of five patients with ADHD who are University educated and financially independent are reported. These patients were selected from a personally followed cohort of adults with ADHD. All were diagnosed according to DSM-IV adapted criteria (K-SADS E, version 6.0) and completed the Portuguese translated version of the ADHD adult self-reporting scale (ASRS).
RESULTS: Main reported symptoms included difficulties with attention, tendency to procrastinate and to 'shuffle' priorities, excessive daytime somnolence, memory difficulties and impulsiveness. Compensation strategies revolve around conscious, 'energy demanding' and time consuming efforts to control and circumvent symptomatic behavioral tendencies. They feel methylphenidate helps by alleviating the need to constantly apply compensation strategies for socially disabling symptoms. In sum, they achieve the same results in a more natural, less effortful fashion.
CONCLUSIONS: Adults with ADHD may succeed professionally despite significant symptoms of inattention and executive dysfunction. They do so by appropriately using effortful strategies of compensation, the need for which is alleviated by the use of methylphenidate. These subjective reports require confirmation in prospective studies on larger series of patients.

Around two-thirds of children with ADHD carry over symptoms and disability into adolescence and adulthood,[1,2] with an increased risk for complicated outcomes in a number of psychosocial issues, including low academic and professional achievements, problematic social, familial and marital relationships, and involvement in traffic accidents, alcohol and drug abuse.[2-5]

The impact of ADHD, ranging from a childhood problem affecting performance at school and early parent and peer relationships to a disorder interfering with adult functioning, mirrors the development and engagement of frontal lobe structures in the regulation of social behavior in adults.[6,7] Recent data have shown a delay in the maturation of cortical structures in children and adolescents with ADHD, most notably in the frontal lobes,[8] supporting the notion that ADHD adults were at a disadvantage to deal with the massive increases in social pressures characteristic of adolescence and early adulthood.

Interestingly, although as a group adult patients with ADHD suffer the consequences of problematic social functioning, some individuals succeed and function very well academically, professionally and at a family level. Therefore, adults with ADHD are distributed along a functional continuum, with some pertaining to the extremes of this spectrum and many functioning somewhere in between. The author has recently focused studies on ADHD people pertaining to the high functioning end of this spectrum, and particularly how such individuals compensate for their ADHD symptoms. This study presents the case histories of some of these patients, including their experience with stimulant medication. Perhaps these illustrative case reports can serve to kindle the interest in future studies comparing ADHD patients able to be professionally successful with those who are not.

Patients and methods

From a pool of 63 patients with ADHD diagnosed according to DSM-IV adapted criteria (K-SADS E, version 6.0)[9] five were selected five who (i) have graduated from university; (ii) are actively working in the field they graduated in; and (iii) are financially independent. Patients were aged between 21 and 55 years of age, and were seen in private practices or at the Behavioral Neurology Clinic of the Hospital São Lucas da PUCRS. Their scores on the Adult ADHD Self-Report Scale (ASRS-18), version 1,[11] adapted to Portuguese[12] are shown in Table 1. In addition to probing for ADHD-related symptoms, history taking focused on practical difficulties and on the effortful, time-consuming and other types of behavior used to circumvent these difficulties. The latter were conceptualized as compensatory strategies. In addition, the presence of symptoms of inattention, hyperactivity and impulsiveness during childhood and adolescence, according to the DSM-IV,[10] were specifically investigated through the K-SADS for childhood symptoms.[9]

Table 1

ASRS-18 scores in the Portuguese translation of the scale. Part A refers to 9 symptoms in the domain of inattention, disorganization, difficulties to get activated to start and to conclude tasks. Part B refers to 9 symptoms of hyperactivity and impulsiveness. Symptoms are scored between 0 and 4 points, from absent to very frequently present.[12]

Patient	Part A	Part B	Total
1	34 / 36	26 / 36	60 / 72
2	30 / 36	28 / 36	58 / 72
3	28 / 36	29 / 36	57 / 72
4	22 / 36	20 / 36	42 / 72
5	26 / 36	27 / 36	53 / 36

All patients were taking doses of methylphenidate ranging from 0.7 to 0.85 mg/kg/day. Their subjective views regarding the effect of this medication on their difficulties and impact on their daily life were questioned in an open, unstructured fashion. The latter was seen as relevant because it is not clear what to expect from stimulant medication in high functioning adults with ADHD. In addition, all patients were seen by a psychiatrist, who managed psychiatric co-morbidities, when manifesting. All patients agreed to having their cases reported and published.

Summary of the case reports

The ADHD-related symptoms reported by these five patients, the strategies they employ in a bid to compensate for their symptoms along with subjective accounts of the effect of methylphenidate on their daily lives are briefly summarized below and in Tables 2 and 3. Complete case reports are contained in the Appendix.

Table 2

Main symptoms reported by five successful adult patients with ADHD and the strategies they use to compensate or circumvent these difficulties.

Symptom	Strategy to compensate / circumvent
Difficulties with focusing and persevering on tasks	Active, effortful vigilance to persevere and conclude tasks
Difficulties with reading - do not read or take a long time reading	Development of abilities to grasp the key aspects based upon only partial reading of relevant texts
Taking longer to conclude tasks	Active, effortful vigilance
Tendency to procrastinate	Development of abilities for ‘last minute pushes'
Underestimation of time
Accelerated forgetfulness	Taking notes all the time / Multiple diaries, alarm clocks, etc
Excessive somnolence
"Shuffling" priorities	Active, effortful, vigilance to keep priorities
Feeling that could have done better if only...

Table 3

Main subjective effects of methylphenidate reported by successful adults with ADHD.

Reduced need for effortful self-control to attend to the tasks at hand

Increased ability to get started on tasks and activities, thus keeping on schedule

Improvement in the ability to remember meetings and other commitments

Decreased impulsivity, irritability and impatience

Greater clarity to define goals and make decisions

ADHD- related symptoms

Difficulties with attention and concentration, interfering in a number of activities ranging from reading to attending meetings and even following conversations, were reported by all patients. The group is easily distracted by less relevant stimuli that they encounter. During childhood and adolescence, they all had difficulties concentrating in class and doing homework. As depicted in the case histories (see Appendix) these difficulties either led to their parents being summoned to school or were artificially minimized by either low levels of school demand or high levels of strict discipline at home.

In addition, they constantly struggle with a tendency to procrastinate and ‘shuffle priorities around’. Unless they actively refrain and redirect their efforts, they tend to spend a significant amount of time doing less important, less urgent, and usually more immediately rewarding activities, disregarding deadlines for priority tasks. A related symptom, described in detail by one of the patients, is the need for ‘last minute pushes’ in order to finalize really important assignments that could be done in a much better, more organized fashion should procrastination and postponement not systematically occur. In essence this is ‘running to catch up on lost time’, a term used by many of the patients. At least one patient mentioned she had excessive daytime somnolence, which compounds her difficulties to pay attention and concentrate during the day.

Two other potentially interfering symptoms were reported, namely, memory difficulties and impulsiveness. Forgetfulness was common, but had a peculiar characteristic in which the patients described that they not only tend to forget current appointments, duties and materials, but also tend to forget facts, events and details at a faster rate than their peers. Thus, when discussing what happened or was dealt with during a meeting or a trip, or what somebody said or wrote in a film, a report, a newspaper or a book, they feel embarrassed because they cannot retrieve information that easily comes to mind for other people.

Difficulties with impulse control appeared in different forms. One patient got easily irritated and impatient, and tended to openly argue or got into complicated situations with their clients. Another said things ‘before thinking’ and later regretted that a series of events (in this case, at a building plant) evolved from the decision taken impulsively.

Compensatory strategies

These five patients have become professionally successful and the strategies they used in a bid to compensate for their ADHD-related symptoms are summarized in Table 2. These strategies could be divided into effort-related and practical strategies. To circumvent the constant drive to distraction, the difficulties focusing for long enough on a given task and the tendency for impulsive attitudes, all mentioned they had to dedicate an enormous amount of energy and control / refrain themselves at a conscious level. As one patient put it, he ‘cannot allow things to ensue naturally’ or else they would not move in the right direction. Others developed the ability – and dispend the energy required – for last minute pushes. These effort-related strategies are felt as tiresome and some patients feel exhausted after struggling to manage their days. Practical strategies of symptom compensation indicated by the patients included taking notes copiously, building complex warning or alarm systems so as not to miss appointments, and reading only parts of texts and then developing the ability to grasp the main meanings from these excerpts. In a sense, these are also energy-consuming.

Medication effects

A common line in the subjective reports of these patients when questioned in an open, unstructured fashion, was that they felt methylphenidate reduces their need for constant self-vigilance to accomplish daily goals. Participants believed they wasted less time and did not need to invest the constant extra-effort to get things done. The feedback they got from friends, relatives and colleagues is that their impatience, irritability and impulsiveness diminished. In addition, some patients had the impression that their forgetfulness was less marked.

Discussion

For ontogenetic reasons, the social challenges faced by a child and by an adult are very different and relate to the level of brain development. Thus, the child deals mostly with school and family, whereas the multi-layered universe of the adult includes issues related to academic and professional achievements, a much more complex social network, access to substances such as alcohol and drugs of abuse and, above all, the concept of future. As the prefrontal cortex and its circuitry with other cortical and sub-cortical structures mature, the idea of a future and its links with decision-making in the present becomes a major issue.[6,7]

One of the neurobiological perspectives of ADHD is that of a disorder associated with a delay in cortical maturation, particularly marked in the prefrontal regions.[8] Therefore, it is understandable that symptoms should reach beyond the constructs of inattention and hyperactivity,[14] and include elements of a ‘developmental’ executive dysfunction.[14] This is confirmed by longitudinal studies probing the natural history of ADHD[1-4] which show that difficulties with school and relationships seen in childhood frequently translate into a high risk adulthood, marked by academic, professional, financial and psychological difficulties. However, population analyses sometimes eclipse the fact that some individuals may eventually evolve into a professionally successful adulthood, in spite of their symptoms. The five patients presented in the present work illustrate this point. Symptoms of these patients, along with their strategies to compensate or circumvent them, and in which ways they feel pharmacological treatment with methylphenidate impacts their daily life shall be discussed below.

Symptoms of ADHD in adults and possible strategies to compensate

The main symptoms reported by these patients along with the strategies they believe may help to compensate or circumvent difficulties are summarized in Table 2.

All these patients reported a lifelong history of difficulties concentrating, focusing and persevering on tasks and with reading texts. These individuals take much longer to conclude tasks, unless they actively make an extra effort to concentrate for longer periods. They cannot ‘allow things to ensue naturally’ else they will fail. This demands significant dedication and energy. In addition, one patient said she developed the ability to grasp the meaning or the most relevant information of a text from reading just parts of it.

Another set of symptoms concerns activation of behavior and the idea of time, core aspects of the executive functions toward achieving favorable results in the future.[6,7] The main practical symptom is a tendency to procrastinate, that is, to systematically postpone what the patient knows is his or her priority. A realistic perspective of the passage of time prompts the person to commit only to what he or she will be able to honor, thus avoiding the tension caused by an excess of obligations and the disappointments of missing deadlines. This tendency to procrastinate is a reluctance to engage in activities which (i) are not pleasurable and (ii) demand effort and concentration. Furthermore, it is closely related to the ‘shuffling’ of priorities, in which less important or less urgent (usually also less demanding) matters are taken care of first, relegating more urgent matters for later – often ‘dangerously’ close to deadlines.

One interesting aspect of the executive dysfunction in ADHD is that patients have a reasonably clear idea of their duties and of arrangements with others. However, their acts suggest otherwise, as if they were not ‘anchored’ in the future consequences of such acts. This concept of ‘anchoring’ is relevant: normally, committing to something or someone generates an automatic feeling of obligation and responsibility with the need to honor that commitment. In a sense, the moment we commit, our brain ‘launches an anchor’ to the future and this helps to guide our acts, until we reach the future point where we are anchored, that is, we comply with the obligation we have committed to. In the lack of anchoring, that is, of a brain representation of future scenarios, it is easy to deviate from the trajectory that would lead to the desired consequence.

It should also be stressed that the tendency to procrastinate shown by adolescents and adults with ADHD is not related with the intellectual abilities to actually perform the task. There is, indeed, a very ‘painful’ discrepancy in which on the one hand the person is capable of performing the task, but on the other simply cannot engage to do what has to be done. Other symptoms stem from these difficulties, including the understandable feeling that the task or work could have been done better with higher quality, if only… an adequate amount of time had been allocated to the task. As exemplified in these case histories, some patients try to compensate for this tendency to procrastinate by developing the ability for highly productive ‘last minute pushes’. Even though the latter are often inefficient to avoid the feeling that the final output could have been better, through these pushes at least some documents, texts or presentations are produced, which would not have happened if it were not for this capacity to become focused in the last few hours before deadlines.

Other symptoms depicted in the case histories concern excessive daytime somnolence and memory difficulties. Excessive somnolence is one of the key symptoms of the ADHD-related entity provisionally called sluggish cognitive tempo[15] and adds to the difficulties in concentrating and getting up top speed, being an easy path to procrastination.

The author has made the (unpublished) observation that a significant percentage of adults complaining of memory difficulties have ADHD, particularly after overt mood or anxiety disorders are excluded. Memory difficulties in patients with ADHD are usually attributed to the pervasive deficit in attention, and as anyone who has attended a lecture or read a paper can attest, retrieving information is indeed more difficult when acquired and stored without the benefit of full attention. However, poor attention may not tell the whole story, and ADHD patients have difficulties keeping information on hold while attending to something else, suggesting a role for impaired working memory. Finally, a mechanism of accelerated forgetfulness may be at work. This has been described in patients with epilepsy[16] and refers to a reduced capacity to access stored information after some period of time. Patients with accelerated forgetfulness have difficulties in recalling facts, experiences and combinations much sooner than their peers, and this has been specifically mentioned by some of the patients. The way to compensate is again labor-intensive: they took notes all the time, keeping multiple diaries, alarm clocks, and often recruiting a network of colleagues and family members to remind them of important meetings and other obligations.

Finally, difficulties with impulse control are a major source of problems for patients with ADHD and reflect poor behavioral inhibition.[3,6] Impulsiveness crafts a style of decision-making which does not benefit from the use of executive functions. Because of this, socially embarrassing situations commonly derive from precipitated statements or attitudes and also from commitments or promises not anchored in the future – that is, on the real capability of being honored. When a given behavior is no longer adequate, acceptable or useful for the person, it should be inhibited, allowing real time to consider other options and act accordingly. Impulsiveness has to be actively fought and such constant vigilance is indeed exercised by some of the patients as a means of compensation.

Because financial independence is a major social goal, and granting that these patients could be considered professionally successful, they might be regarded as not being functionally impaired, thus challenging the diagnosis of ADHD (10). However, the subjective reports suggest that these patients suffer a great deal to manage their days, and often feel exhausted with and overwhelmed by the extra levels of effort and preoccupation needed to circumvent a tendency for distraction, disorganization and procrastination. Thus, the author proposes that this effortful functioning together with the fact that these patients’ minds are constantly occupied with how to get things done ought to be conceived as a functional impairment. This understanding is also important to interpret their subjective reports on the effects of methylphenidate, as further discussed below.

In a recently published, comprehensive, longitudinal study of a cohort of patients with ADHD, Barkley and colleagues analyzed a large number of symptoms related to executive dysfunction to single out those that best differentiated adults with ADHD from those with other psychiatric disorders and from a healthy control group.[3] After a series of sophisticated statistical analyses, these authors arrived at nine symptoms including being easily distracted, deciding impulsively, having difficulties to withhold an activity or behavior when this is the most appropriate attitude, beginning projects without adequate planning, not following through on promises or commitments, disrespecting priorities, having a tendency to drive vehicles much faster than other people, having difficulties to sustain attention in demanding tasks, and having difficulties to organize tasks or activities. This evidence provides strong support for the notion that symptoms of executive dysfunction are key features of ADHD in adults. This has significant therapeutic implications, as will be discussed next.

Therapeutic considerations

Because none of the patients were actively engaged in cognitive behavioral therapy, therapeutic strategy will not be dealt with in the present work. On the other hand, all were taking methylphenidate, four of these for long enough to report on the effects of the medication.

There is a pressing issue concerning stimulant treatment in adults with ADHD because it is not clear how much the medication impacts executive dysfunction which is central to the difficulties of these patients. Well-designed studies on stimulants in adults with ADHD have measured efficacy on the basis of improvement of the core symptoms of inattention and hyperactivity/impulsiveness[17] while the efficacy for symptoms of executive dysfunction can only be extrapolated. Even more significantly, it is not at all clear to what degree and through what kind of symptom alleviation might stimulants help patients who are functioning well professionally. Thus, it was deemed important to describe the subjective impressions of these patients with the use of methylphenidate (Table 3).

Taken from the spontaneous reports, these patients felt that when using methylphenidate, they were not so overwhelmed while the level of physical and mental effort needed to manage their days was reduced. In other words, they suggested that the medication reduced the need to be ‘en guard’ all the time, which constituted their main effort-related compensatory strategy. In addition, they reported that other people had remarked that medication made them less impatient. Generalizations such as these can only be suggested through case reports, such as those presented here. Of course, these are not scientifically valid conclusions, but are clinical impressions that may help to formulate testable hypothesis. In particular, the different perspective of functional impairment suggested by these reports should encourage the development of instruments to measure quality of life in adult patients with ADHD,[18,19] which will then allow a more solid view of the impact of medical treatment in these patients to be formed.