Living and working with ADHD

A raw essay on what ADHD is and isn't, the costs it imposes, how it can be managed, and how we can best help the struggling.

Cranes at work above Barcelona’s Sagrada Familia, the enduring symbol of unfinished projects. Photo by iam_os on Unsplash

I wanted to tell her it was getting better, because that was supposed to be the narrative of illness: it was a hurdle you jumped over or a battle you won. Illness is a story told in the past tense. - John Green

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Being fully real about mental illness in the past tense is hard enough. Few ever quite get there. It’s just too personal, too shameful, too risky. Vulnerability sucks. 

This post is even less fun for me, in that it’s about mental illness in the present tense. This isn’t a story about victory. It’s a story about failure, and lifelong vigilance.

Why bother to write it? Because many millions of people share my condition, most of whom struggle to (a) understand their illness, (b) set the right self-expectations, and (c) educate their employers, partners, and loved ones on how they can help. 

My goal is to cover three things: 

1. What it’s really like having an executive function impairment, both as a high-level professional and just as a human being. 

2. What can be overcome, what can’t, how to ask for help, and how to restructure your life so you need the least help possible.

3. How to help the afflicted.

Some parts will get personal. I don’t include those details in a bid for sympathy, but only because I think most accounts gloss over the true reality. Improving our collective lot can only come with real transparency. There is no easier way.

Though I do ask you to read gently. Not for my sake. But for those who might forward this on looking to initiate a dialogue that will likely be very hard for them.

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Subscriber note

I promised a while ago that I’d only use this newsletter for journalism-related content. I'm half breaking that promise here, mostly because I want to give subscribers a window into why content delivery here has been so uneven.

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But there is an on-mission angle: writers with severe ADHD can make exceptional journalists, given the right support structures.

Making newsrooms more neurodivergent can be a real advantage if done well—and it can be done well. I hope this helps that end in some small way.

That said, I’ll be publishing future essays like this in a companion substack. It’s free.

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ADHD at 10,000 feet

While I’ll get into what ADHD is as the post goes on, a single thought experiment gets to the heart of it. 

Imagine you’re tasking someone with daily action items, but where:

1. If you give them one thing, anywhere between one and four get done

2. If you give them two things, no more than two get done

3. If you give them three, none get done

4. If you give them four, you’ll soon find them in fetal position medicating their anxiety by hyperfocusing on something wholly unrelated

Now consider that folks in scenarios 2-4 are all incurring a running deficit. And every day is like this, which makes any backlog compound quickly—and brutally. 

Folks with a backlog live in Bad Time, within which they struggle to: (a) enjoy anything without feeling guilty, (b) make good health decisions, (c) clear said backlog. 

One poorly understood thing about ADHD is that it’s functionally a recursive disability: it’s as informed by our coping mechanisms as it is by our miswiring. Which is to say that how and how long we live in Bad Time can make things much worse. 

But there’s one truth to every case: living in Bad Time erodes people. And avoiding this requires a lot of awareness and intentionally on both sides.

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Labeling issues

The history of ADHD terminology (brief summary) is both horrific and instructive. 

A taste:

In 1902, Sir George Frederic Still, the so-called father of British pediatrics, published a paper in The Lancet about children unable to act “in conformity with moral consciousness”—a group he subdivided into those with obvious brain deformities, those with run-of-the-mill “idiocy and imbecility”, and those who seemed to have some “finer physical abnormality” he couldn’t detect.

As one imagines, treatment followed the terminology. There was little in the way of compassion, accommodations, or safety nets. It was long seen as a moral issue.

While the latest label, Attention Deficit Hyperactive Disorder, is less prejudicial than the older more abusive alternatives, it still fails in being incredibly misleading:

1. Hyperactivity is mostly seen in child cases, and even then isn’t a cornerstone symptom. Also, hyperactivity can be outgrown (to a point). ADHD can’t.

2. The issue very much isn’t a deficit of attention. (We’ll get to that in a bit.) 

Many have thus pushed for Attention Regulation Disorder. While that’s better, I prefer the more direct Executive Function Impairment (EFI), which I use here. 

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Assessing for EFI

Self-diagnosis is a dangerous thing. I was diagnosed at 27 or so by an accredited psychiatrist. I’ve also studied the topic deeply, and had dozens of conversations with specialists and other diagnosed folks. But I’m not competent to judge who has it. 

That said, those who feel strongly that they might have EFI can read this short post about ADHD in students.

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If it resonates in an overwhelming way, go see a qualified clinician—not to confirm your assumption, but for their independent judgment. 

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Understanding EFI

I like to think about it in Marie Kondo terms:

When we select which thoughts to follow and which things to do, each option promises a different level of joy—a different cocktail of reward chemicals.

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Healthy people largely make healthy choices, focusing on commitments, body maintenance, balanced calendars, quality time with loved ones, etc. 

But now imagine two tweaks:

1. A lower baseline of these happy chemicals floating around while deciding (think grocery shopping while hungry). 

2. A bombardment of less healthy choices that offer immediate and sustained payment for as long as you keep thinking about them.

(Note that EFI folks following the “wrong” trains of thought here don’t have a deficit of attention. They’re usually hyperfocusing—just on the wrong thing. It’s a question of what they’re paying attention to, not their ability to sustain attention.)

Anyway, this is living with EFI. 

Now, you might argue that everyone faces this kind of choice. And that’s true! We live in a whole global arcade of attention-hacking distractions. But it’s a difference of degrees, and even seemingly modest differences compound over time.

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Imagine for example that Challenge A is of medium difficulty to one person, and high to another. Assuming the world is dominated by A-type challenges, would you expect this disparity to produce overly similar people?

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A theoretical but powerful example

Though I make no judgment about whether he actually has EFI, consider a case like George RR Martin’s. From the POV of most fans, he has just one thing to do: finish The Winds of Winter. But imagine that he’s already fully mined said project for neuro-rewards, and that every offered side project is absolutely dripping with them.

You could stack up the real-world rewards for finishing the book as high as you want, and it wouldn’t matter. Already-mined things are just tremendously hard to focus on. The activation cost of picking them up again increases in a sort of inverse proportion.

One might further imagine that our theoretical Martin would feel very guilty about this, and that living in Bad Time would reduce his baseline happiness even further— making it increasingly more difficult to pass up quick-hit side-quest rewards.

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How my EFI manifests

When I go down a new rabbithole, the rewards stay bountiful and constant until I’ve really exhausted the subject. Though it’s usually just a few hours, I can go as long as 24-36 hours without a meaningful break, often without getting all that tired.

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When it comes to client work (and this substack): 

• I now only work with clients whose work I find interesting, where there’s a high chance that I get to research / write about new things where I’m able to hyperfocus. (And for substack I obviously just choose on interest.)

• But I routinely take 2-5x more notes than I’ll ever pass on. I’ve learned to trim my billing to what was useful to my client, to steer myself back on course, and to edit my notes to be less hypomanic. But I have zero ability to prevent or restrict that hypomanic rush of parallel thoughts.

• The upside to my clients/readers is that my work is often incredibly detailed and rounded. The downside is that it all takes longer than it should, and much of that detail needs to get scalpeled anyway. 

It’s not uncommon that I’ll do 200-250 hours of productive work in a month, but where two-thirds of that is on random deep dives that never cross the finish line. This means that I always work far more hours than I can rightfully bill for. This means I bill for a part-time number of hours. This means less money. 

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Monetizing EFI

My economic salvation has been that I’ve been able to just bill more per hour. But few people with EFI have this privilege. Most exist in a constant anxiety: they know that they produce excellent work when their hyperfocus overlaps with the job to be done, but they also know that this happens less than 40 hours a week.

The people I know who’ve really escaped Bad Time permanently have used their creative output to drive a successful substack, publish a book or piece of software, make a killer album, etc. Once they no longer need to worry about monthly bills, they can get away with fully leaning in on monetizing their hyperfocus. 

But many are stuck in a rut. They’re living in Bad Time for most of their waking hours, and can’t easily break out. They could go back to school for a more appropriate certification, but most schooling is EFI hell. So they often try entrepreneurial routes, most of which get abandoned once the reward in fleshing out the idea runs dry. 

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The costs of EFI

In writing this section, it was hard to balance: (1) limiting length, (2) limiting “woe is me”-ism, (3) still making the point here in a raw and full way. 

So I settled on just a few bullets to give the sense: 

• Though I’ve been unreasonably lucky in love and friendship, roughly 100% of the people who love me have at some point effectively told me “you’re one of the most infuriating people I know”. I always agree. It always wounds.

• I allowed myself to live in Bad Time so long that I lost myself for several consecutive years. I was generous friends away from homelessness.

• I struggled so much with dental hygiene that I had to replace all my teeth at 32. (Most people with EFI turn a corner on hygiene in their teens, as I did. But combined with a Bad Time sugary diet, the damage was done.)

• Though I manage a pretty good professional career now, in years past I left multiple startups and very large sums of money on the table, and built a long chain of former collaborators whom I profoundly disappointed.

• I’ve lost thousands of dollars from late paperwork. I even hired an assistant this year to send me a daily reminder to migrate my hours from my notebook into my invoicing trackers. I ended up just falling behind on a new invoice.

I don’t live in Bad Time nearly as often these days. But I was back in there just a few months ago. The safety margins are thin. And I can only manage as well as I do because of privilege. My bill-rate allows me to work less than full-time (ie., fewer to-dos to fall behind on). And even so, I have to stay so, so vigilant.

Whenever another sufferer trusts me enough to tell me their true accounting, I weep. Not figuratively. The details are almost always gory, and deeply sad. When they talk about it publicly, assume that they’re vastly under-exaggerating out of shame.

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How to help the afflicted

The first step is awareness. Most people I know with EFI didn’t get diagnosed until deep into their adult years. While they knew something was wrong, it never occurred to them that it was ADHD, largely because of how widely it’s seen as (1) a disability that primarily affects children, (2) something to do with hyperactivity. 

So if this rings awfully true to your experiences with a loved one, please forward this. (Or forward whatever other resources you can find that spark a gentle discussion! I don’t care about views here. But I have tried to make this useful for this use case.) 

As for helping those with a credible diagnosis: 

• Help them declare frequent bankruptcy. If they promised you something and it’s clear that they’re in Bad Time now, set them free.

• Help them under-commit. If you know a backlog is forming (or even just likely), try to reason them into saying no to new things.

• When they start a new hobby (especially a new business / venture), be supportive of their ingenuity, but also try to help them gauge realism.

• Make smart bargains about household chores. Eg. if they struggle with cleaning, can they pay a college student to come by once a week? Don’t just take on their half, but be creative about how to minimize their to-do lists.

• (You can nudge them towards healthy eating, exercise, good sleep, etc. All that will theoretically help. But they’ll struggle to stick with any of those things for as long as they’re in Bad Time. Bankruptcy has to come first.)

Note that doing any of these things is 10x easier if they’re at a place of acceptance. If they aren’t yet, expect fierce resistance.

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And that’s not your burden. If they’re say 25 or older, it’s reasonable to insist that they pursue diagnosis and counselling.

Loving people with EFI is hard. Very hard. Sugarcoating that only creates false expectations. But that doesn’t mean that the benefits can’t be wonderful. People with EFI who primarily live in Good Time are a delight. But most aren’t there yet.

To give your person their best shot, be gentle, be gracious, but also stick to your guns: they need to take their disability seriously. Even severe EFI doesn’t absolve anyone of bad self-management. Help them in smart, sustainable ways. But never take on the burden of them choosing to make a home in Bad Time.

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How to help others help you

In a way, all I have to say here is a mirror of the above. Most of all, just make it easy for people to work with you—and to love you.

More concretely:

• Get a therapist.

• Talk to your employers. If you do project-based work, they’re usually already aware. Being clearer will rarely hurt.

• Communicate early and often when you fall behind. Ask for help.

• Declare bankruptcy where appropriate, as often as once a week. Avoid slipping into Bad Time like it was quicksand. Because it is. Except more threatening.

• Limit saying yes to new things the day you’re asked. Learn to sleep on it. See how you feel as other things pile up, as you return to Bad Time, etc.

• Regularly interrogate yourself on why you want to say yes. Is it just the juicy prospect of reward chemicals? If so, what’s going to happen when those run out? And if it’s a deeper desire (say EFI atonement), will that ever work?

• Prioritize hobbies and commitments that don’t depend on you. Joining a rec team with a half-dozen substitutes might be safe. Joining one with only two isn’t.

• Embrace minimalism. Force yourself to sell things you bought for abandoned hobbies. Be slow in buying new things. Reduce what you need to manage.

• Shift your career in the direction of your oldest and stablest interests.

• Don’t start a business unless you’ve been in Good Time for a year or more. And even then, be slow, cautious, and thoughtful. Bring in second opinions.

• As directed by a competent professional, experiment with medication. None are silver bullets, or even close. All have tradeoffs. Some do help a bit. 

But really just learn to be gentle with yourself without excusing yourself. You don’t need to beat yourself up for having EFI. But your sense that you often make things harder for those around you is indeed real. Mind you, most are happy to bear those burdens in love. But their love is much, much easier to keep alive when you do your part. 

You can’t un-have EFI. No self-work or pill or magical cure will free you. I’m sorry. I wish it weren’t so. But with the right pluck, luck and loved ones, you can adjust such that you live mostly in Good Time, where your gifts will shine with the fewest clouds.

I’ll be cheering for you. 

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(This subscription button is for supporting my journalism work. For the free substack where I’ll be posting future essays like this, go here.)

1. Taken from John’s novel Turtles All the Way Down, in which he provides a very raw look at the realities of living with severe OCD—and how it can’t just be overcome, and what it means to manage it successfully.

2. Physical health concerns have also played a huge part this year. But there were output problems before, most of which boiled down to “I still have day work that needs to get done as a first priority, and some days that’s just all I can manage”.

3. As a related point about students: many with EFI perform well in lower grades, up until the advantages of quick-twitch lateral thinking fall second to the need for focused study. I personally suspect this explains some/much of the “gifted kid burnout” phenomenon.

4. This is reductive. Our brains are horribly complex! But various actions trigger staggered waves of neurological rewards—eg. dopamine, oxytocin, serotonin, endorphins. And how we earn those rewards deeply informs our base behaviors.

5. Many suggest that this is fundamentally an instant gratification problem. And it is! But hungrier people are going to be less patient about waiting, and are going to be more susceptible to vastly more satisfying alternatives. When it’s easier to do a good thing, we do more of it. When it’s harder, we either do less of it or spend more energy on it. 

6. This is extra true if I’m currently in Bad Time, as losing myself in hyperfocus makes me temporarily insensible to the stress of being in there.

7. One common EFI coping mechanism is developing extreme creativity at self-deception: we learn to justify our current area of hyperfocus on the level “ah but this will actually unlock some future good!”, largely in the same way that hoarders justify new purchases. You can’t reason with people in this state until they’re ready to see it.