Attention Deficit Disorder & ADHD

New York Times July 18, 2004 | 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.t. 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 resume,
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. resume -- 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
disibility. 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.''

  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.''