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The Flying and The Thud: Mental Health Issues on Agile Teams

About this Publication

Over my ten plus years of working in Agile, I’ve seen a preponderance of ADHD, OCD, anxiety, Asperger's Syndrome, autism, Bipolar Disorder I and II, etc. Additionally, since Agile encourages teams to work together, these issues can be a stumbling block—and sometimes a 50-foot wall—that keeps the team from growing, and even from simply functioning. While supervisors have supported ridding the teams of these "difficult" team members, I have advocated maintaining the members and tweaking our approach to be more inclusive.

1.     INTRODUCTION

I’m writing this in the middle of a tornado of emotion, information, and desire to know more. By the time this is published – a few months from now – I expect even more will have changed.

Earlier this year, very prominent people – Kate Spade and Anthony Bourdain – killed themselves, and their family members attribute those deaths to the mental issues both people experienced. Ms. Spade’s family recounted how she was afraid to seek treatment for fear of how she would be viewed, resulting in a potential financial loss for her company. Mr. Bourdain’s family described how he sought treatment, but then promptly ignored it.

In our own software development community, we hear stories similar to Joseph Thomas’ [1]; a man who excelled prior to working in Uber’s “intense work culture,” committing suicide a mere 6 months into his employment. Prior to Uber, “…this (was) a man who didn’t have a history of crumbling under stress,” Richard Richardson, the family’s lawyer, said.

The windows are slowly opening, whispers of darkened smoke eek under the doors. The conversations, much needed and important, are beginning.

With these events in mind, I move forward with what I already believe to be an extremely important topic – mental health issues on Agile teams.

2.     It’s Not Them, It’s Me

I come to this topic with more knowledge than I’d care to have, having lived the majority of my life without vital information. From the time I was old enough to remember, life with my mother was either a whirlwind of thought and extreme activity or it was completely devoid of movement and motion – The Flying and the Thud, I called it.

The Flying was at times magical, filled with creativity and excitement, a whirl of pixie dust surrounding everyone near it. My mother’s trip to Wal-Mart when we were young involved us watching her load the cart with everything she could remember from an imagined shopping list. She’d picked up a hammer, nails, a vent cover, paint, then she’d see a sewing kit out of the corner of her eye. Her mind flitted to all the holes and buttons in our clothes that needed repairing. She began grabbing needles, thread, seam rippers from the display walls; snatch pre-cut fabric, start talking about the quilts she would make us from the scraps, then remember she had wood leftovers in the house that needed to be used and wouldn’t a new wood burning stove be perfect, resulting in another aisle grab of more nails, a book on building your own fireplace.

As we circled the store, sometimes for hours on end, our cart would quickly fill and eventually, she would begin to tire. The Thud was coming on, her eventual fall to the ground that made her forget this world ever existed.

By the time we’d finally reached the checkout counter, she’d either rid the cart of everything except contact paper, unripened bananas, and hair clips, or she’d buy everything, barely having the energy to remove anything from the cart, and even less to bring it all into the house. She’d limp into her bedroom, closing the door, sleeping in her dark room for a solid 10 hours. The small piles of her purchases collected dust for months on end, until finally, mercifully, they were put out in the front yard for a garage sale.

Having grown up in that environment, I did not know anyone lived differently. This was the normal I expected everyone experienced.

It was not the first time I was wrong.

I had my own flying and thud. In my own head, waves came crashing at me hard for a random block of three days. I would feel an exceptional rise in my creative thoughts. I would spin from one topic to the next, interrupting anyone speaking because I could think through at least five possible endings to what they were about to say, and had already concocted a response. I would forego sleep so that I could play piano until 2 am, or, trance-like, write a 200-page story, or design an entire set piece for an imagined play, complete with working lights. These waves resulted in orchestral symphonies, complete plays, paintings, drawings – all of them done while, what I referred to as my secondary brain, was occupied by books on tape or PBS documentaries. When I returned to look at the drawings, in particular, I could recall every detail of the documentaries I had listened to as though they were in front of me again. This was my flying.

These bright spinning colored days were always followed my own thud, the ungraceful drop to the ground that would break my emotional bones. While they could be triggered by a horrific news story, a gut-wrenchingly miserable song, or an emotionally encompassing film, usually the thud stumbled in on its own, pulling me down and dyeing everything with a wash of dark grey. It was rare that the thud resulted in tears; instead, I continued on, feeling as though the string had been cut from the balloon that kept me tethered to this world. I felt no connection to it and no desire to continue it.

School allowed me to hide my issues, my inability some days to put full focus to anything, to flit around the room with thoughts and tangents. I easily finished full assignments the period before it was due, all the while absorbing the current class’s lesson.

As grown-up, work was harder. Unlike others who suffered as I did, I did not subconsciously self-medicate. I had no taste for alcohol or drugs. I suffered the flying and thud at full force, no buffer.

Unlike school, co-workers and supervisors were annoyed by my fits of creativity as they came packaged with my irritation, bluntness, and ego. My sick days flittered away easily when I could not force myself to function. After an unexpected breakup in my personal life, I spiraled into a thud that left a deep imprint on the Earth. For days, I sat crying even though I was holding perfectly normal conversations. A concerned co-worker/friend drove me to the hospital, having to explain to me that how I was reacting wasn’t typical.

The majority of the time, it felt as though I had been secretly stuck with a needle of potent drugs, over and over, with no control over what would happen.

At one of my previous employers, my then-boss wrote me up for those same indicators. My inability to focus during meetings, my interrupting, my absences, my tardiness, my distractibility – had infuriated and baffled him. His requirements for my continued employment were strict: I had to forego my cell phone completely, control my interruptions, only be absent for pre-approved vacations, not miss nor be late for any meetings, and be completely focused during hour+ long meetings. I would have to continue this under his watchful eye for six months, if I was to remain at the company.

The first week of these requirements I felt as if heavy chains had been attached to me as I moved. I was without improvised tools that kept me focused during droning meetings. There was a real possibility to me failing spectacularly, and I knew this company had no problem ridding themselves of difficult people.

The prior year, Carl (not his real name) was my co-worker who I saw struggle with similar issues but on a grander scale. I had coached him several times prior to the restrictions and after to help him find ways to be successful. I watched him struggle as if in physical agony while trying to meet his boss’s expectations.  It was not the way he worked, Carl told me. He felt as if he were being put into a box, then forced to walk five miles while twisted inside. When he was given similar restrictions and failed to meet them within the sprint, his boss fired him.

Another team member, Jack (not his real name,) struggled later the same year when he was written up for the third time for the same infractions. As a Scrum Master, I experienced Jack’s lack of focus, watching him follow many rabbits down several holes simultaneously, and distracted by people simply walking by his desk.

Jack heard every conversation within a five pod radius, and desperately wanting to be folded into an accepting group, would interject himself into discussions, interrupting and correcting, and easily irritating others. After being written up the first two times, he questioned not only the individual items that had been listed in his downfall, but escalated the issue, causing even more contentiousness. The third time was the charm, however, and they let him go before the end of the last restrictions expired.

My determination was simple: I would not fail – and, I did not. However, in doing so, it meant opening myself up to the possibility of causes, causes I did not want to admit. It meant possibly being labeled what I had for years what I had denied.

I finally decided to have myself tested.

Prior to this point, even though I had a grandmother and mother with undiagnosed Bipolar II Disorder, one child with an officially diagnosis of the same, a sister who exhibits Bipolar II traits, I still had convinced myself that it had skipped a generation.

The test took over 6 hours and, before I even left, the doctor told me what he suspected – a fact that I have been hesitant to talk about for the same reason anyone reading this might be hesitant if they have experienced the same diagnosis; a fact I struggled with even as a child, but had no name, no medicine, no exercises, no way to anticipate or to control the way my mind twisted and turned. Like an internal roller coaster, it jotted, stopped, skipped ahead, interrupted itself, curved, and left behind any original thought just to chase a new one that appear like a red balloon.

So, now, I was this thing.

I was Bipolar II.

3.     Let’s Talk Some Facts

As a whole, we’d like to think mental health issues aren’t overwhelming prevalent, but according to The Center for Workplace Mental Health, 1 in 5 adults will experience a diagnosable mental illness in any given year [2]. Twenty percent of us. And that's across all sorts of fields, not just software development.

Half of those, though, will go untreated. They will suffer in silence, but they will still suffer. On top of that, many workers feel they cannot be away from work to treat their mental health issues. So, while they are physically present at work, their depression and/or other symptoms keep them from being able to function fully – a term coined "presenteeism."

According to the U.S. Surgeon General's Report on Mental Health from 1999, the costs of untreated mental health disorders results in $79 billion annual loss to businesses due to lose of productivity and absenteeism [3]. That was nearly 20 years ago.

According to Kessler et al., 2006, mood disorders are estimated to cost more than $50 billion dollars a year in lost productivity and result in 321.2 million lost work days [4].

In 2008, an abstract presented by de Graaf, et al., screened over 7000 workers in 10 countries for attention deficit/hyperactivity disorder (ADHD) symptoms [5]. Out of all these workers in a multitude of industries, 3.5% of workers showed symptoms of ADHD. In spite of this, only a "small minority" ever received treatment.

Compounding this situation, these workers were:

  • Less likely to graduate from high school or college
  • On average made 20 to 40% less than coworkers with no symptoms but equal education and training
  • However, when employees, specifically with ADHD symptoms, DID seek treatment, 80% reported improvements in job satisfaction and productivity, an astounding result

4.     I Don’t See the Relation

Over my ten plus years of working in Agile, I’ve seen a preponderance of ADHD, OCD, anxiety, etc. issues on Agile teams. Instead of receiving adjustments that might help us flourish, we are met with admonishments and whispers behind our backs. Managers write us up for infractions that are more symptoms than real problems. People around us pick at what they can understand and discard what they can’t.

When Carl was promoted because of extensive creative project work he completed, his once-teammates-now-subordinates reacted with passive-aggressive behavior: ignoring work directions, excluding him from important meetings, imitating him when he was out of the room. They struggled to work with his approach as a teammate. As a supervisor, they collectively decided it would be impossible.

On one particular occasion, Carl arranged a Blue Sky meeting so that the team could investigate new ways to improve the team overall (as in, if all things are possible in the blue sky, what would you do?) As they all sat in the room, the silence from the team was thunderous. No one would speak or contribute. They didn’t understand him, and he didn’t understand why.

Within a week, Carl was demoted.

As I mentioned earlier, Jack struggled in his relationships with co-workers and his boss, wherein his symptoms worsened when they rejected him. When this occurred, his boss’s and teammates’ negative reactions intensified. Because of their lack of understanding and Jack’s inability to inherently “be like them,” he was ostracized.

From that point, subjective confirmation came into play, where anything positive he did was discarded but anything negative was given double weight.

Funnily enough, by rejecting people like me with mental issues, others miss the incredible caverns of hidden surprises that come from inside our brains.

Years prior while working for a college with a registering class of 24,000+, I was put in charge of collating and distributing all the semester’s transcripts. Because the mailing labels were printed in a different facility than the transcripts, they arrived unmatched and in varying order. On top of that, we employed 190 volunteers to complete the work. As a result, it was common each semester to have approximately 3,900 transcripts that were mismatched and returned.

The years I supervised the process and volunteers, I understood instinctively how to match the labels to transcripts and how to translate enough information to the volunteers to make it easy to understand. My mind bent around the problems, flexing itself against the edges, and discovering the worm holes that caused issues. My first semester, the number of returned and mismatched transcripts: 4.

Because we are not typical, does not mean we are not worth the effort.

4.1       An aside

I’ll stop here for a moment to clarify something: Having Bipolar II Disorder, and having raised several children: two with ADD, one of those with social anxiety; another who is bi-polar; another who has Asperger’s Syndrome, I avoid using the word “normal.” Instead, in our house, we use the word “typical.”

Normal refers more to a state of being, as though there is only one form of human being we should all be. Anything outside those boundaries is abnormal, including over-performing people. Typical refers to what we are as a median. It captures the overall sense of a thing. For instance, in school you might say, “Typically, at this age, six-year-olds can read most Dr. Seuss books.”

Typical is important because we all are not identical – none of us. Therefore, those of us who do not match what is typically observed are not misfit toys, ready to be discarded at the first indication that we do not mimic everyone else’s behavior.

Though we may see patterns that typically occur in each other, we are not standard, as though created from a machine. We do not move in identical ways. We do not voice ourselves as duplications of each other. We do not think the same way. And, this is to our ever-evolving advantage.

5.     But why Agile?

On an Agile team of 5 or more people, research shows that frequently at least one (1) person is currently experiencing mental illness. The majority of those are dealing with depression, whether brought on by genetics or a situation (PTSD, trauma, etc.). So, if we had three (3) hypothetical teams of five (5) people (total of 15 people,) the likelihood would be that three (3) of them would be experiencing a mental health issue. Only one (1) of them would seek help [6].

Software development employs Agile. In turn, software developers show a preponderance of ADHD, OCD, Asperger's Syndrome, autism, Bipolar Disorders, etc.

Additionally, since Agile encourages teams to work together, these issues can create stumbling blocks (and sometimes a 50-foot walls) that keep teams from growing, and even from simply functioning.

Two years ago during a conference in Nashville, I participated in a Kanban workshop. From the back of the room, a hand shot up during the Q & A portion. The gentleman rose and spoke of a team member with whom he and others struggled. He described how the team member acted: distrustful (his word,) interrupting, single-focused, balked at last minute changes. The list went on and on. He heaved a great, frustrated sigh as he finished.

The presenter did not. He simply said, “Get rid of him.”

Get rid of him.

A harsh, but likely, typical response; those of us who have these conditions face a hostile/difficult environment. Getting rid of someone shouldn’t be our first solution.

I am not a doctor. I don’t even play one on TV, so I can’t pretend that I have the medical background to be able to diagnose a person simply from hearing their story as told by yet another person. In my opinion (based on my personal experiences,) the team member likely needed some adjustments or modifications, even if he didn’t realize it.

I told this story later to my colleagues, trying to elicit their ideas about what they would suggest as a solution. Interestingly enough, many people responded that it would depend on how good of a worker she or he was as to whether or not it was worth the effort.

Let me put this into another context: if you had someone who was born needing a wheelchair, would you only adjust or make modifications for this person in the office if she or he were exceptional? If so, where do you draw the line where they would no longer be worth it?

Many people with mental issues generally are born with them, while some people have issues as the result combat, abuse, and other trauma. Many suffer from something that they were simply born with and likely might not know they have. If we only make adjustments for those of us who are exceptional, then we’re helping to perpetuate life-long issues with under-employment, ongoing stigma, lack of proper care, and loss of emotional support.

Remember, you hired this person for a reason. Likely, that reason is a good enough one to make an effort.

6.     Why I Discussed My Mental Health Issues at Work

For me, hiding my diagnosis – even before it was official – was a huge burden. Every moment, I was afraid I would be discovered. I spent an enormous amount of time worried I’d be found out, and then doubly worried what the consequences would be.

Deciding to finally talk about it with my colleagues was a very personal decision. Because of the stigma that still attaches itself to mental health issues, you have to judge for yourself what your true risks are.

In many ways, discussing my mental health issues at work benefitted both me and my teams. My teammates acknowledged that there was a greater sense of relief in understanding the reasons behind some of my actions. In some cases, co-workers have acted as “bumpers” for me, in that they are able to see symptoms before I can. Additionally, because we’re having these important conversations, there are more adjustments that are easily made, rather than begrudgingly. When adjustments are made, for me, it can help shorten a cycle because I’m not simultaneously trying to process through a cycle, complete my work, and navigate unrealistic emotional expectations.

Having people I work with understand that there are times I don’t choose to act the way I do or that I need some support is a tremendous burden lift. Additionally, there were times I wasn’t unaware of my behavior. Because I had eventually elected to self-manage my mental health issues with exercises, meditation, and other natural remedies, being able to identify a tipping point helped thwart episodes immensely.

Additionally, being open about my condition makes it easier for others to discuss issues they may experience, too.

7.     So, I Want to Tell My Coworkers I Have a Mental Health Issue

Pick Your Time Before It Picks You. Many times, crisis causes you to feel forced into a conversation. If you have an opportunity, then choose when and where you want to talk about this topic. Find some place quiet to have your conversation where you can feel composed and relaxed.

Practice Makes Perfect. Running your conversation through your head prior to actually having it can help you work out your kinks, but also, it might calm you because you’ve taken away some of the sting of the topic itself. Better still, if you have a friend who already knows your situation or you’re working with a therapist, try practicing with them to make you feel more comfortable.

Teachable Moment. Likely, whomever you’re revealing your diagnosis to doesn’t know much about your mental health issue. Be prepared to answer some basic questions about what it is. In some cases, it might be helpful to have a few websites handy to fill in the holes.

If Sorry is Needed, Say It. One of the most difficult things for me to do was to go back and apologize for my behavior – not because it wasn’t warranted. I had hurt some feelings and made some people feel uncomfortable, but once I found out my diagnosis, there was a part of me that felt like, “Hey, that wasn’t my fault. It was the disease.”

For me, I learned to adjust to the idea that while this disease wasn’t me, I was still responsible for my actions that were a direct correlation from it. Throwing my hands up and saying, “hey, it’s not my fault,” was not an acceptable answer. While I did not chose this disease, I was not going to become a victim of it and let it lead me around.

And, with that, I needed to accept responsibility even if I couldn’t always have control.

Adjustments You May Need but Not Know About. Reponses to your revelation will differ, but funnily enough, the ones I had the hardest time with were “What can I do to help?”

The first time I was asked that, I wasn’t exactly sure how to respond. I knew some superficial things I had done to help self-regulate, but those were more instinctual. I didn’t know for sure.

As I talked about it, I began to read more about adjustments at home and at work that would help regulate my cycling. If asked, I would recommend talking about experimenting with a few things to see how you respond. Just because it worked for someone else, doesn’t mean it’ll work for you. Alternatively, just because it didn’t work for someone else doesn’t mean it won’t work for you.

8.     What Are Typical Symptoms? (And How Can I Adjust for a Coworker?)

NOTE: Symptoms varying even within patients with the same diagnosis.

A few symptoms you may see in others that may indicate they made need adjustments:

8.1       Impulsiveness

Issue: Adults with ADHD, Asperger’s Syndrome, autism, etc. may struggle with impulsivity and temper outbursts in the workplace. Many with these mental issues may interrupt, talk out of turn, abruptly end a conversation, walk out of a room unexpectedly, for instance. During a presentation by a Marine, my then-teenager with Asperger’s Syndrome rose up, walked across the room in front of the speaker, and went out the door. When the teacher came to check on him, he told he that he simply didn’t like that the speech had turn to a recruitment pitch and he didn’t see the point in staying since he couldn’t join the military anyway.

Possible Adjustments:

  • Create a team building around role playing, especially if your team member needs to be prepare for a difficult conversation.
  • Embolden team members to try relaxation and meditation techniques.
  • Encourage your team member to write down triggers. Consider ways – together – to diffuse these situations.
  • Try recognizing when you feel compelled to interrupt. Tap your knee with one finger three (3) times slowly to help regulate the compulsion.
  • Keep a pad and pen handy to write down things you want to talk about, but would disrupt the flow of the current conversation. This will keep you focused on the current conversation without constantly reminding yourself what you want to talk about without listening to what is being said.

8.2       Hyperactivity

Issue: Adults with the hyperactive presentation of ADHD often do better in jobs that allow a great deal of movement, such as sales. For sedentary jobs, they may fidget, rock, tap, or do other activities that allow them to remain partially active. In most cases, they will not be aware of these activities, though others in the room may be very aware and annoyed by the actions. Many team members demonstrate this symptom in particular. Fidgeting, tapping, drawing may appear in multiple sit-down meetings. A bipolar disorder team member once described it as though she had two brains: one she would occupy with drawing while the other listened intently to the demonstration.

Possible Adjustments:

  • Remind team members to take breaks, even simple ones, like standing up at their desks, or walking around the office for a few moments. This activity encourages oxygen back into the body and helps regulate hyperactivity.
  • Prompt team members to bring ADD or fidget toys to meetings, or take notes in meetings to prevent restlessness.

8.3       Distractibility

Issue: Problems with external distractibility (noises and movement in the surrounding environment) and internal distractibility (daydreams) can be the biggest challenge for adults with ADHD. In fact, many workers with mental health issues complain of being overloaded with incoming information to the point that it can aggravate or generate an episode.

Possible Adjustments:

  • Notably, distractibility can be one of the most difficult issues to deal with – both at the team member’s desk and in meetings.
    • A private office, a quiet cubicle, or an unused conference rooms offers a chance away from the distractions that may acerbate the situation, causing frustration for everyone.
    • Additionally, consider allowing him/her to work from home.
    • A sporadic, planned calendar of when the team member can have uninterrupted time may help with anxiety and distractions that cause the work to go on longer or go unfinished.
  • Another consideration, create a flexible schedule so your team member can have a few undistracted hours in the morning or afternoon.
  • Encourage noise-cancelling headphones. Consider soft music or other white noise that may cover distracting noises from a nearby conference room, printer, call center, etc.
  • As a team member, consider forwarding your calls directly to voicemail. Then, set aside a specific scheduled time to listen and respond.
  • When writing, turn off the grammar and spell checker. Often when writing, these features can become disruptions, too. You can always turn them on after you’ve finished your first draft.
  • Carry a small notebook to write down quick ideas so you can quickly return to the original task without contact switching.
  • Avoid contact switching/multi-tasking.
  • While in a meeting, consider ADHD-specific fidget gadgets that keep your hands busy, but your mind focused.

8.4       Poor Memory

Issue: Failing to remember deadlines and other responsibilities can antagonize coworkers, especially when working on a team. Because many of these workers struggle with processing every ounce of information that comes into view or earshot with little way to filter out unnecessary information, some information may get lost in the shuffle. Short-term memory is bombarded with so much metaphorical and literal noise; it struggles to determine what is worth retaining. Much like overloading yourself while carrying books, if you stumble, you likely won’t have much finesse in keeping the most important books in your grasp.

Possible Adjustments:

  • Use tape recording devices or take copious notes at meetings.
  • Write checklists for complicated tasks.
  • Use a bulletin board or computer reminder list for announcements and other memory triggers.
  • Rather than use a cell phone (which can cause issues with impulsivity and distractions,) consider wearing a watch and using a printed or written day planner.
  • Write notes on sticky pads and put them in a highly visible place.

8.5       Boredom

Issue: Because of their strong need for stimulation, some adults with ADHD become easily bored at work, especially with detailed paperwork and routine tasks. Many find it easy to create new ideas or designs, but have difficulty completing the seemingly mundane tasks to actually finish the work.

Possible Adjustments:

  • Give yourself a time limit – either in duration or an alarm set to a specific time. This may help you stay on task.
  • As we know in Agile, breaking up long task into shorter ones can help make the task seem more manageable, and help with feelings of progression.
  • Take breaks, drink water, get up and walk around.

 

8.6       Time management

Issue: Managing time can be a big challenge for adults with ADHD.

Possible Adjustments:

  • Like we do with epics and stories, break large projects into smaller pieces, with self-imposed due dates.
  • Every time you reach a due date, reward
  • Consider how much time you need to get to your meetings and then set your computer to beep beforehand. For instance, someone people prefer a 15-minute warning before a meeting so they have a chance to change their mindset and then travel to the meeting with a fresh and open mind.
  • Think about setting all the meetings you create to end early, leaving you time to refocus before going into another meeting. For instance, I set my hour-long meetings to end at 50 minutes after they start. For meetings of 30 minutes, I only schedule them for 20 minutes.

9.     The Flying and The Thud

What is magical in my head, what keeps me awake nights under stars that disappear into the sun’s light, would annoy and discombobulate others. But, as my friend who is color-blind says when people ask him does he miss not seeing all the colors in the spectrum, “This is the color I’ve always seen the world.”

And that’s me.

From the start, I’ve not had a day on this planet that wasn’t washed in either the gorgeous Flying or the acidic Thud. The tectonic movements I feel as I walk, I’ve adjusted to their movements; others would stumble, maybe falling into the crevices created.

As I grow older and my body’s chemicals naturally shift, so do the shape of the Flying and Thud. The dust devils that spiraled me from earthbound to an inner heaven revolve more leisurely. The decaying migration of depression crumbles like hardening lava, eking out acrid sulfur to remind me that I can avoid parts of my inner volcano, but it exists.

I will still hesitate to open an email with new edits on an essay. I will still avoid phone calls from friends who enjoy drama’s vortex. I will still spin and spin and spin internally at the mere thought of joy.

I’ve learned ways to anticipate the shifts in the earth. I’ve learned to avoid things that open my inner crevices. I’ve learned to not look over the precipice.

I’ve learned - more importantly – what I have is not who I am.

What I do about it, is.

 

REFERENCES

[1] https://www.usatoday.com/story/tech/news/2017/04/27/is-uber-culture-to-blame-for-an-employees-suicide/100938330/
[2] SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, http://www.samhsa.gov/data/population-data-nsduh/reports?tab=38

[3] https://profiles.nlm.nih.gov/ps/retrieve/ResourceMetadata/NNBBHS

[4] Kessler RC1, Adler L, Barkley R, Biederman J, Conners CK, Demler O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T, Ustun TB, Walters EE, Zaslavsky. “The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication.” AM, Am J Psychiatry. 2006 Apr;163(4):716-23.

[5] de Graaf R1, Kessler RC, Fayyad J, ten Have M, Alonso J, Angermeyer M, Borges G, Demyttenaere K, Gasquet I, de Girolamo G, Haro JM, Jin R, Karam EG, Ormel J, Posada-Villa. “The prevalence and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative.” J. Occup Environ Med. 2008 Dec;65(12):835-42. Epub 2008 May 27.

[6] Shoji M, Satoh S, Oda S, Kubota H, Imai Y. “Mental health in software engineers. II. Classification of occupational stressors, and relationship between occupational stressors and psychiatric disorders.” Sangyo Igaku. 1990 Jul;32(4):258-64.

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