The hidden struggle of high-IQ, high-achieving people with ADHD
“You can’t have ADHD—you have a PhD.”
“You graduated from medical school.”
“You’re a successful lawyer.”
“You run a company.”
I’ve heard versions of these statements throughout my career. In fact, a psychiatrist who knew me well once exclaimed, “Kathleen, you don’t have ADHD!” Apparently, my accomplishments were evidence enough. Therein lies one of the great paradoxes of ADHD: high intelligence can help compensate for ADHD so successfully that the ADHD itself becomes difficult to see.
When “doing well” hides the struggle
Research increasingly confirms what I and many others have seen clinically for years. High-IQ people with ADHD may perform perfectly well in school—and may achieve at very high levels academically and professionally—while struggling considerably in everyday life. And because retrieval memory can be inconsistent, requests for extended time on standardized tests may be very reasonable, despite high grades. I have experienced the “tip of the tongue” phenomenon countless times. In fact, when I’m writing, I just leave a _____________ mark and move on, knowing that in a minute or five I’ll recall the name, the term, or the phrase and can fill in the blank.
Thomas Brown, PhD – who devoted much of his career explaining the nuances of ADHD, especially among high IQ people, studied adults with ADHD whose IQs were 120 or above. Nearly three-quarters showed significant impairment on at least five of eight measures of executive functioning. Tom was one of the first to look at intellectually gifted individuals with ADHD through his ADHD clinic on the Yale Campus.
Unfortunately, the typical behavioral health provider, whether prescriber or psychotherapist, isn’t aware of this ADHD/High IQ paradox. Sadly, many gifted people with ADHD have sought treatment or accommodations over the years and were turned down because when highly intelligent people with ADHD are compared with the general population, their performance may still fall comfortably within the “average” range.
Imagine someone with intellectual abilities at the 98th percentile performing at the 50th percentile on a task requiring executive functioning. We may look at the score and say, “Nothing wrong here.” But we’re asking the wrong question. Average compared to whom?
The brilliant child who won’t write a page of A’s
Years ago, I worked with a remarkably bright six-year-old girl. On her own, she had already figured out that the pitch produced by a string was related to the string’s length. Then her first-grade teacher instructed the class to fill a page with capital A’s. She could already read and write. So, she wrote one perfectly good capital A at the top of the page and signed her name at the bottom. Instead of seeing an advanced student in need of challenge, her teacher misinterpreted her behavior as defiance.
I saw a very bright little girl saying, as politely as she knew how, I already know how to do this. Why am I doing it again? She became so unhappy that her mother came to me saying she never imagined she would be worried about depression in her six-year-old. This is what can happen when high ability, ADHD, boredom, and an inflexible environment collide.
My advice was not to change the child, but to change the environment. Her mother transferred her to a private school better suited to accommodate the needs of a very bright child with ADHD. She might leave her jacket at school, or forget to return the permission slip for the school field trip, but meanwhile, she could compete academically with students two grades ahead of her.
A Highly Accomplished Physician Who Paid a High Price for his Achievements
Another client comes to mind, a physician who had attained national recognition in his specialization. He conducted research at a teaching hospital and remarked, “No one would guess that I have ADHD.” And yet he and his family paid an incredible price for his achievements. He told me a brief story that summed up his work life. One sunny spring Saturday, he was driving along the parkway into the city to the hospital, as usual, when he noted a man heading out of the city in the opposite direction with a kayak on top of his car. He ruefully remarked, “That will never be me!” While his colleagues were at their child’s soccer game, on the tennis court, or sailing on the Chesapeake Bay, he was heading into the hospital for a weekend of “catch up,” a never-ending process.
Giftedness doesn’t protect against ADHD Research on gifted children tells much the same story. High-IQ children with ADHD show the familial patterns, co-occurring conditions, and functional difficulties associated with ADHD in other children. One particularly revealing study found that high-IQ children with ADHD often performed about as well as average-IQ children without ADHD.
Think about the implications. They look “average” because two powerful forces are pulling in opposite directions. Their intelligence may be compensating for their ADHD resulting in average range performance, so that we conclude there is no impairment.
Achievement doesn’t tell us what achievement costs A bright student may earn A’s—but start every paper at midnight. A physician may be superb with patients—but chronically behind on charts. An attorney may be brilliant in court—but unable to keep track of paperwork. A successful executive may run an organization—but depend heavily on an assistant, spouse, adrenaline, deadline pressure, or sheer exhaustion to keep everything together.
Educational and professional achievement tells us what someone accomplished. It doesn’t tell us how difficult it was, how inefficiently they had to work, or what it cost them to accomplish it.
Research finds that high-IQ adults with ADHD generally achieve more educationally and occupationally than average-IQ adults with ADHD. But compare them with equally intelligent people who don’t have ADHD, and their difficulties become much more apparent—including poorer occupational and family functioning and lower quality of life.
When compensation stops working
Highly intelligent people can become extraordinarily good at solving around their ADHD. Sometimes they do it for decades. Then life changes. College is less structured than high school. A first job requires self-management. A promotion brings administrative responsibilities. Parenthood overwhelms carefully constructed routines. Menopause changes functioning. Retirement removes external structure. Aging may make compensatory strategies harder to sustain. Suddenly the person who has “always managed” isn’t managing nearly as well.
We need much more longitudinal research on this phenomenon, but clinically it raises an important question: What happens when intelligence has been compensating for ADHD—and the compensatory system finally becomes overloaded?
We need to ask a different question
When evaluating a highly intelligent child or adult for ADHD, perhaps we should stop asking:
“Is this person performing below average?”
Instead, ask:
“Is this person functioning substantially below what we would expect given their abilities?”
And then ask something else just as important:
How hard are they working to look this successful?
Because a person’s transcript, diploma, job title, or IQ score may tell only half the story. High intelligence doesn’t cancel ADHD. It only camouflages it. And only for so long. If we want to recognize ADHD in high achievers, we need to look beyond what they’ve accomplished—and understand what it has taken for them to accomplish it.
When executive functioning challenges finally stop a high achiever in their tracks
I recall a very intelligent PhD and political consultant that told me that he had left his Ivy League doctoral program because he was unable to complete his dissertation. Only with the intense support of a girlfriend was he able to return and complete his dissertation while she played the roles of coach and body double.
Dr. Lisa Joy Tuttle recently completed a study of high IQ individuals with ADHD in doctoral programs, interviewing those that succeeded in completing their doctoral dissertations and those that continued to struggle. This study, the first of its kind, will be presented at the ILAT Global ADHD Summit on Oct. 29 and 30th.
These are exactly the kinds of experiences and challenges we need to understand better and are rarely addressed at standard ADHD conferences. Lisa Joy Tuttle, PhD will be joined by Dr. Russell Ramsay and Nancy Doyle PhD who will explore issues related to ADHD, Career Success, and High Achievement: Understanding and supporting adults across the career lifespan.
I’d love for you to join us.
Learn more about the ILAT Global ADHD Summit: www.ilatglobal.org