E75 - What is it like to have ADHD? (with Dr. Russell Ramsay)

Dr. Russell Ramsay is a co-founder of the Penn Adult ADHD Treatment and Research Program, and served as professor of clinical psychology in the department of psychiatry of the Perelman School of Medicine at the University of Pennsylvania.

He is author of Nonmedication Treatments for Adult ADHD (2010); Cognitive Behavioral Therapy for Adult ADHD (with Dr. Anthony Rostain, 2015) and The Adult ADHD Tool Kit (also with Dr. Anthony Rostain, 2015).

His most recent book is Rethinking Adult ADHD: Helping Clients Turn Intentions into Actions (2020). In addition he has a popular blog on psychology today, rethinking adult ADHD.

In today’s episode we discuss:

 - Misconceptions people have about ADHD
 - What it is like to have ADHD
 - What kind of impairments it can cause
 - Medication based treatments for ADHD, their effectiveness and safety
 - And how you can approach ADHD treatment psychologically

Interviewed by Dr. Alex Curmi - Give feedback here - thinkingmindpodcast@gmail.com Follow us here: Twitter @thinkingmindpod Instagram @thinkingmindpodcast

If you would like to enquire about an online psychotherapy appointment with Dr. Alex, you can email - alexcurmitherapy@gmail.com

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Transcript

 Welcome back to the Thinking Mind podcast. My name is Alex. I'm a consultant psychiatrist. Today I'm in conversation with Doctor Russell Ramsey. Doctor Ramsey is a co-founder of the Pen adult ADHD Treatment and Research Program, and served as Professor of Clinical Psychology of the Perelman School of Medicine at the University of Pennsylvania. He's the author of several books about ADHD, including Non Medication Treatments for adult ADHD, and he's a co-author of the book CBT for adult ADHD and the adult ADHD toolkit. His most recent book is called Rethinking Adult ADHD Helping Clients Turn Intentions into actions, which came out in 2020. In addition, he has a popular blog on Psychology today, Rethinking Adult ADHD. In today's episode, we discuss common misconceptions people have about attention deficit hyperactivity disorder, what it's like to have this condition, what kind of impairments it can cause, medication based treatments for ADHD, their effectiveness and their safety, and also how you can approach ADHD psychologically. This is a huge topic and there's lots left to discuss, but I hope this podcast can at least be a good introduction. For those unfamiliar with ADHD or those who know a little bit about it, but want to have a more in-depth understanding. This is the Thinking Mind podcast all about psychiatry, psychology, psychotherapy, and related topics. If you like it, there are a few ways you can support it. You can share it with a friend. Follow us on social media, give us a rating wherever you happen to listen or if you want to support us further, you can check out the Buy Me a Coffee link in the description. In addition, if you have any feedback, you can email us at Thinking Minds podcast at gmail.com. Thank you so much for listening. And here's today's conversation with Doctor Russell Ramsey. 12s Russell Ramsey, thank you so much for coming on the podcast. Alex, thanks for having me. I'm excited for a couple of reasons. Firstly, we haven't really made an episode about ADHD yet and it's an important topic. A lot of people are talking about ADHD. And then the second reason I'm excited to speak to you is because of course. Non medication treatments are your specialty. You've literally written the book about them. And I've recently started working with ADHD patients. And I've noticed as clinicians, we can often feel a bit hamstrung when patients, for one reason or another, aren't suitable for medications for ADHD or they don't respond well. And there's clearly a desire in this space for different treatments, psychological treatments, ones which don't have side effects. So I'm really excited to dive into all that. Firstly, how did ADHD become your specialty? Was that something you always had an interest in, or was it more serendipitous than that? Much more serendipitous. It found me. I did not even go looking for it. So I'll try to keep it brief. But, um, I went to the University of Pennsylvania. I'm a clinical psych clinical psychologist. Um. And I went to the center, or I was. Glad to be accepted to the center for Cognitive Therapy at the University of Pennsylvania as a postdoctoral fellow. Way back in 1995. Um, you know, Doctor Aaron Beck, one of the fathers of cognitive therapy, his his program, even though he had moved on to the Beck Institute by then, just getting good training in basic cognitive behavioral therapy for depression, anxiety, a host of other things. And it was. I was fortunate enough to have a second year of the postdoc. Uh. I guess you could say I failed the first year, but it was just. I think they were thankful to just keep me on. Um, but then I ended up being like, uh, getting on the faculty track as an instructor. So I was just doing my basic cognitive behavioral therapy. And tracked it down in my planner. March 8th, 1999. So we're coming up on 25 years. Doctor Tony Rothstein, a psychiatrist at Penn. 1s And my line about Tony is there are two types of people in the world, those who know Tony and those who are about to know Tony. He's a very gregarious person, a big personality, and he was also a and still is an expert in ADHD. And he started off with an expertise in child as a child psychiatry. And then over time, he specialized in adult psychiatry and was the head of the adult residency program in the medical students psychiatry medical students at Penn. So I knew of him before, but figured, oh, this is a good chance to meet him. Brought me in, had a discussion. He said, you know what? And this is 95. The book, Driven to Distraction by Ned Hallowell and John Brady, was published in 1994. I'm sorry, this is 1999. I arrived at Penn in 95. 1s There's a little more attention to adult ADHD. He was telling me, he said, I'm thinking about it might be good to start a specialty program focused on that. And he said, I can handle the medications, Tony. And he said, it seems like cognitive behavioral therapy might be a way, a useful approach for adults with ADHD. And I was at the center. And my line about us is everything interests both of us, and we can't say no to work. So at that moment I said, yeah, sure. Why not? I'll give it a try. And so that was my entry into ADHD. 1s And, um, sometimes want to say tongue in cheek. I'm disposition lazy. So it was fortunate that there was very little literature, relatively little literature at the time. So it was pretty easy to catch up on. And just, you know, starting there. In some ways, I am not qualified to do anything that I've done with my career. I would not be able to do it in the same way today anyway. But, um, you know, from there, work together on, you know, Tony with medications. Um, me with his he's very familiar with cognitive behavioral therapy and respects it to, um, developing a, you know, and we and other people independently. Susan Young in the UK, who I greatly respect, Alexandra Phillips in in Germany, um Mary Suunto at in New York, uh, Steve Safran and Harvard. I'm sure there's other others. Oh, Marie Verita in Finland. I don't like, uh, Margaret Margaret Weiss in Canada at the time. Anyway, all working on similar things and pretty much arriving around the same points about this. Modifying cognitive behavioral therapy, which is an evidence supported treatment for depression, anxiety, other things. And after, you know, lo and behold, these years later is also reached the status of an evidence supported treatment, psychosocial treatment for adults with ADHD. So that's sort of how not sort of exactly how I got into it with no training, no background might have even argued that I had maybe some of the same misconceptions that people had back then. And maybe, you know, unfortunately, some people still have. 2s What are some of the misconceptions people have about ADHD and what? How would you address those misconceptions? Some of the historic ones, um, are adults can't have ADHD. And early on in the official diagnostic criteria, the Diagnostic and Statistical Manual of the American Psychiatric Association, at least, um, the first presentation and I'm blanking on the year, I think it was 1968 and DSM two. It was about a 22 word description of, um, hyperactive kinetic disorder of children explicitly said generally, uh, you know, older children, uh, and you grow out of it by the end of adolescence. Now. Serendipitously the same year. There were actually some early studies looking at, hey, there's a few young adults who were hyperactive as children who didn't grow out of it. So we now realize that and ADHD is categorized as a neurodevelopmental syndrome. What does that mean? That means it's not an episodic condition. Like somebody gets the flu and then they get over the flu. And for some people, depression might be episodic. There's a period of depression treated to remission. Or they work through it and then they go, okay, I'm over it. 1s Um, chronic medical conditions like chronic fatigue syndrome or other. Um, I'm blanking on the term, but, um, immune system autoimmune disorders might be more chronic. And so neurodevelopmental would mean it's there in some form, showing up in childhood, even if it's not identified then, or necessarily causing problems necessitating or resulting in the seeking of an evaluation or treatment. 1s Um. There are many children identified with ADHD in childhood, and then treatment into adulthood or other supports are part of continuity of care. But with our program and other adult ADHD programs, very often we'll see people who are late identified. It doesn't mean late onset. There was some studies about that a few years back ago that has generally quieted individuals without ADHD in childhood, who all of a sudden blew up with ADHD in adulthood. But generally there were some definitions they used of childhood ADHD just not meeting full criteria, but that is not required. So the neurodevelopmental as part of our adult ADHD evaluation, and others, even if somebody coming to us as an adult, we are asking about childhood. Different levels of school, getting symptom rating scales whenever we can. Somebody else who know them like a sibling or a parent. Yeah. What were they like in childhood? Did you see those things? You don't have to retrospectively meet the full diagnosis, but there just has had to be not and not just one thing. Oh yeah. There were late, um, they were late with this homework assignment in sixth grade. Oh, that's. They might have ADHD now. No, there's a cluster of symptoms that people go, yeah, they were always late. They struggle with these things. We had to sit with them to make sure they got their homework done. Yeah. Loving parents, just trying to support. There were usually some other compensations or protections. And then maybe when the person goes away to university or other things, then it's becoming more of a problem. Like I'm failing my classes, even though I'm I feel like I'm spending a lot of time on work, and I quit the rowing team, and and I'm still not able to get my head around it where, you know, as part of a comprehensive evaluation, we can pretty reliably identify ADHD in adulthood when there wasn't ADHD when there, um, when it wasn't, I diagnosed younger. And on the other side, this is also other people's concerns. There are ways with that same rubric to say. Yeah. You're having some attention problems, some organizational problems today, but we don't see it fitting into this trajectory. And so those are valid. And you endorse them on the ADHD rating scale. But we don't think this is ADHD. But here's what we think can be helpful including sometimes the cognitive behavioral therapy. Yeah you procrastinate. We can still use the same cognitive behavioral therapy principles we use for adults with ADHD to help with your procrastination from anxiety or stress. And I tell you what, I use them, and I found myself being a lot more efficient over the years, having, uh, worked with adults with ADHD and working on many of the coping strategies. So maybe we can dive in a little bit to into what ADHD is, and maybe we can start with the client's perspective. So based on your experience, what is it like to have ADHD? What is someone's day to day experience like? Some quotes I've heard and I've written on these. I know what I need to do. I know how to do it, but I just don't do it. So one or the other. It's not exactly you mentioned before. My first and my first very lengthy answer was about some of the same misconceptions. 1s Well, you know what? And even the notion of attention deficit hyperactivity disorder. 2s Um, Russell Barkley, uh, one of the leading researchers and figures in in ADHD, both for children and adults. And I'm happy to have gotten to know him over the years. Um, he has this line I always use where he said calling ADHD an attention problem is like calling autism eye gaze disorder. It's an element of it, but it doesn't capture the essence. So it's not wrong, but it's incomplete. So I know what I need to do, but I just don't do it. And that leads into one of the facets of ADHD is it's not a knowledge problem, it's a performance problem. It's not that somebody's like, I'll tell my clients, hey, if we're working on procrastination and all I tell you is, you know what? You really need to start earlier. Please pay on the way out. Sue me for malpractice, please. You know that. I know you know that. But it's using this as an example. Somebody says, I know I have to do this assignment for school or work. I know the benefits of doing it. I want to get it out of the way before the weekend. But when I sit down to do it, then I think about something else that I could do that I could probably get done quicker and let me do that now and then. I'll be in the mood to do this task. Then I'll do it. And if you do, that's fine. But generally what happens then? It's like, oh, now I'm not in the mood to do that. I'm distracted. I don't have enough time. I'll do it tomorrow. So that is one of the manifestations. And also from the cognitive behavioral therapy part. 1s Yeah. What do we have to offer other than oh, next time try harder not to procrastinate. Part of it is. All right. Did you have a realistic. Did you have a plan for doing the task or are you waiting to. I'll wait to fit. When I feel like doing it, I'll get around to it. No, it's pretty good. You know, one strategy is let's make an appointment. If you're in your planner, when is a good time for you to do it where you have some protected time? And let's not say I'm going to work on it all day. Give yourself half an hour. An hour again, I know what I need to do, but I just don't do it. It's a performance problem, not a knowledge problem. Then you sit down to it. Oh, I could do this other thing. Well, that's. That's a thought. It's not a negative thought about the person. It's like, I could do this other thing, which is accurate, but is that the wisest choice here? And what is your thought about doing the task? It's going to be hard. It takes me longer than other people to do. Um, I have a hard time organizing my thoughts. Each of these could be true to a degree, but still manageable. So that's part of factoring in the manifestation of ADHD and day to day life and day to day roles. Things that we want to do. That, you know, somebody with ADHD has demonstrated the capacity to do. When I sit down and work on it, I get positive feedback on it. But I can't always get myself to sit down and work on it. Or other times I wait till the last minute and what I hand in isn't as good. So that consistent inconsistency. I know I can do it, but will I get myself to do it when I have to do it? And also one of the features and. 1s It is a misunderstanding about ADHD. When you look at the official list of 18 symptoms, at least in the DSM and I think the ICD, the International Classification System. 2s Emotions aren't listed anywhere. Now ADHD. 1s A facet of it is emotional dysregulation or difficulties managing emotions. 1s Um, both downregulation being overly overly excited or easily frustrated, quickly quick to anger and being able to soothe that before saying the wrong thing or acting impulsively. Also up regulating emotions. How do I make myself feel enough? Like studying for the the university exam start three days before the exam rather than the night before. When there's motivation all over the place, it's panic and nobody in their right mind is going to be in the mood to study or do work. But that is part of the emotional regulation that we all have. How do I think through? I don't want to walk into the exam unprepared. I'll feel better once I get started. If I can get a little bit done, then I can enjoy the rest of my day rather than waiting till the evening. All these things that we know. But again, not a knowledge problem, performance problem, but also how that's part of the the cognitive behavioral therapy for adults with ADHD. How do we bring these to bear and have external reminders or set things up for success, um, in personalized ways for you? That may not be the way you know, other other people do it. So, um, so that, that, that some of the manifestations. So procrastination is one also time management, which is really organizing behavior across time, how we pace ourselves. Um, how do I start with this? Disengage and switch to that. There's something in the ADHD universe called hyperfocus. Oh, I can get hyper focused on this and work on it for four hours. And if somebody is trying to get something done the night before, I'm not going to begrudge them that. But if somebody gets locked into one homework assignment but also has two others that are due tomorrow, spending the four hours may not be the best allocation of time that let me get it done after two hours where I can submit it, rather than making it perfect so I can disengage and get the other, get the other assignments done and that sort. You know, several colleagues have said talking about like ADHD not, you know, not intentional or it's, um, calling it ADHD and attention problems like calling autism disorder. I've also heard like, well, it's not an attention deficit, it's an attention allocation problem. How can I stay focused on where I want to direct my focus without getting distracted, but also being able to disengage when I have to appropriately to switch and spend time and listen to my child or my partner. Um, rather than going, I can't talk right now. I have to stay focused on this. So it's it's it comes up in a lot of different ways. And even that what I touched on. 1s It comes up a lot in relationships. And these could be, um, relationships of belonging or affection, like dating partners, spouses, children, friends. Also places like school and work where other students, teachers, other employees working together on work teams. This can get both at the performance problem. Oh, you didn't contribute to the work group, but also the interpersonal like eye contact when talking with people. Little things that are taken for granted. Like I told you about this before, why don't you ever remember the name of my supervisor? And this is where the misunderstanding about what ADHD is by other people might set up an unrealistic standard. Um, it's not done intentionally or not from not caring. Pardon the double negative. It's from some of the working memory deficits which are core for ADHD, being able to hold on and manipulate information into long term working memory, or being able to remember to remember something you just promised somebody. Yes, I will pick up milk on the way home from the store and then it goes away. Now, another thing misunderstanding about ADHD. Oh, everybody has it a little bit. No they don't. Another one of these lines is ADHD is a matter of degree, not of kind. So. This self-regulation that I'm referring to, which is pretty much boils down to one factor how efficiently do we do what we set out to do? Not some. 1s Expectation for like robots, or that we're always going to do the same thing perfectly, efficiently, no, within reason. And the self regulation bundles down like what I said, how efficiently do we do what we set out to do that can break apart into semi distinct factors? Um, and there's various measures out there for it which can be part of an evaluation for ADHD. But in case it's not clear now the suite of skills, the self-regulation skills, um, the phrases out there in the in a society more the executive functions, you hear more about them. These days. The term has been around in neuropsychology for decades. Um, with many different, you know, definitions. Um, one a couple I like put forth by Russ Berkeley, who I mentioned before, these are behaviors that we do to our self to manage ourselves. And in a more extended description. These are how we set out and enact plans and goals and follow through on them step by step. Maybe working with others, like in a group project or in a classroom, or using social and cultural means like school, work, other things. Towards a delayed goal, a long term goal for which we know our life will be will be better. We have skin in the game, but for which there's not immediate enough payoff. 1s Um, putting money away for retirement, working a little bit on the paper for a while. Um, exercise, things like that. And using that definition with a gentleman who's adult ADHD evaluation I had just completed, he slapped his knee and he said, that's it. My boss always tells me if he needs it from me in ten minutes, I deliver it in five. But if I have a week, it takes me three weeks. Because 5 minutes or 10 minutes, it's defusing a bomb. It's right there in front of you. 1s Uh, but a week. Well, I don't have to do it today. I have the weekend or I can do it later. And then it's putting it off. Putting it off until the panic of the last minute. Now, going back to the executive functions, they break down into things like time management. Uh. 1s Disorganization or organization. Emotional regulation. Um, impulse control, um, motivation, task switching, initiation, a whole host of things. It can get divided up a bunch of different ways. So. 1s The things I'm talking about here will sound familiar. Yeah. I have a hard time getting started sometimes. Or. Oh, yeah, I forget to pick up the milk on the way home sometimes, but. With individuals with ADHD and this will be a little clumsy. But for the illustration, it's like, uh, the executive functioning skills fall on a bell shaped curve. Where, like most human traits do, like height, you have extreme, you know, maybe little people or shorter than average people. There's this range in the middle. That might go from about five six, five, seven to about six foot six foot one. I'm about five, six, five, seven. If I stand next to somebody six one, you'll tell a difference. But we're not going to turn heads. And then you have taller than average individuals like NBA players and things like that. So for illustrations now I'm lumping a little bit here for the purposes of our discussion. Individuals with ADHD probably fall at that upper end of difficulties. They'd be like the NBA players in terms of ADHD, many more difficulties, uh, greater severity. And what is part of the official diagnostic criteria and life problems? Directly stemming from those difficulties. So, you know, ADHD. So not everybody has ADHD. The feelings are familiar. The difficulties may be familiar because we all have them at some times sometimes. And I use the example if you have the bout of a flu your executive functioning will go down. If you have sleep problems, your executive function goes down. If you're an episode of depression, your executive functioning will go down. But for all these episodic situations, when the episode is passed or you get treatment treated to remission, your executive functioning should go back up to your typical baseline. But this goes back to the neurodevelopmental definition with individuals with ADHD. The baseline is a moving target. It's the consistent inconsistency and it's very context sensitive. So there might be some situations like hands on learning, like an internship where you actually get to do things and learn by hands on learning and seeing it and then doing it. That might be a better fit for somebody with ADHD. And just like sports can be, but not always, because sometimes even in some sports, like in American football, a player might have ADHD and there were a really good player, but they forget the play when they get to the line of scrimmage or they miss practice or things like that. So, um, ADHD is a matter of degree, not of kind. And people will ask, um, what's the difference of kind? 1s One episode. It might be somebody like with bipolar disorder who has a manic episode, extreme energy, uncomfortable energy, where uncharacteristic for them. When they're in the midst of the episode, they're getting by on very little sleep, highly energized, and often doing risky or unwise things that, again, are out of character for them. Maybe gambling, risky sexual relations, or doing things unusual like in the middle of the night outside painting their house at 2 a.m. or something like that because they feel like doing it and they have the energy and they go do it, something out of character for them. So that would be the difference of kind. But ADHD is a matter of degree. Right. I think that's very important for people to understand that we can all struggle with these difficulties to a degree, but when it gets particularly intense, it just it's going to become a problem that's pervasive, that's going to really hold you back in different areas of your life. And something I've noticed again, with individuals who have ADHD is the the these difficulties are just much harder to have voluntary control over. So like you said, with attention, it's not an inability to pay attention merely so much as a lack of volition over your attention. Your attention is constantly being pulled in different directions, particularly by short term, immediately rewarding stimuli or tasks. And then sometimes people with ADHD hyper focus. But interestingly, even if they hyper focus, say they play video games for 12 hours or they manage to study or work for 12 hours, they feel a kind of lack of control in that space, and they often lose track of time, forget to eat completely, can't hear their partner talking to them or their children talking to them. So even when they're hyper focusing, there's a lack of control there. And one thing I'm curious about is, do we have any sense why these problems with attention and impulsivity are also linked to hyperactivity like problem sitting still, always feeling restless, talking excessively? Do we have any idea? Perhaps this could be explained by what's going on in the brain, but do we have a strong sense of that in the ADHD community? 2s I think we have as good of an understanding as we ever have now. It's more complex and as we learn more about the brain and differences and things like that. So and other examples of neurodivergent, we're always expanding. 1s But a lot of it goes back to some of the control mechanisms, the self-regulatory mechanisms, if you will. Um, so running through some of the work put forth and I'm just standing on the shoulders of Russ Barkley, Tom Brown, some other people at the, at the front end of, you know, the executive functioning approach. But looking at a developmental model, the first executive function to actually emerge. Well, actually, the first one is a sense of self that we are a distinct entity. And this comes in, you know, infancy, childhood. We're a distinct entity. Entity from all these other beings were around. Like, if I'm hungry, that doesn't mean the cat's hungry or and I'm worried about my hunger. Uh, so that's first that there is a self to regulate. Then the next one is behavioral inhibition. Being able to stop and pause rather than responding to the environment. Now, things you mentioned before about, um, drawing attention away or getting locked into a video game, which is highly reinforcing and game developers know what they're doing. 1s Um it's called the pre potent response. There are things we're not going to naturally gravitate to. Uh it trivializes it a bit but I'll use it as an example. There's there's, you know the a wealth of those t shirts that say I think I have ADHD. Oops, a squirrel. But we're going to be gravitate. It's going to be hard to ignore motion in our field of vision, because we're sort of hardwired to catch that unless we know, okay, there's going to be squirrels and birds outside. I want to stay focused on like this, this, um, podcast or typing a paper. So there are ways, you know, as we get older, we can override that. And with the behavioral inhibition, rather than just doing and responding and with the pause even in childhood. In that pause. Now we can act with intention. Okay. If I keep doing this, what's going to happen? And also learning from the past. The last time I grabbed the cat's tail, I got bit. Maybe this time I'll try scratching its head. Now that draws on some other executive functions. But there's this quote in a book and I'm going to forget the citation right now. And I love this quote. And it says when you press a pause button on machines, they stop. But when you press pause buttons on human beings, we start. And I think in that pause that opens up that ability to say, rather than doing what's most appealing now. Oh, eat the dessert. I'm going to think about later. Oh, I'm trying to. Whatever. Watch my sugar, watch my calories. Um, train for the triathlon. And how will I feel later if I eat this sweet treat which, like I tell my clients, it's not a legal and moral or an ethical. And many of us will succumb to that periodically. But at least now you have a fighter's chance of you know what? I'll feel better later if I can at least delay right now. Now that's putting it into adulthood. But that's like one of those first ones where children can stop and pause. That opens up for. 1s Visual working memory that's being able to imagine or picture things run simulations in our head. The video replay, if you will. Now, some people say I don't see in clear movies or pictures, but we can get impressions that are sufficient. That example I used where I jumped a little ahead, where I said the last time I pulled the cat's tail, it bit me. Let me try scratching its head. Or we can think about, you know, the last time I canceled with my friend, they were upset. I better not cancel this time. And we can do problem solving in our head rather than trial and error learning even things we haven't encountered that maybe we've witnessed other people do, or we've learned from them just through the pictures that we run in our mind. That sets the stage for verbal working memory. And this is our talking to our self, our internalization of language, how we can have thoughts and beliefs about things and values and aspirations. Oh, I want to get in shape. So I'm not going to eat this, this pie right now. And I can think through of either something healthier I can order or how good I'll feel later for not having eaten it. And when I when, you know, rather than feeling guilty about it. Um, the next one is the emotional management. Be like, I talked about this a little bit before being able to down regulate upset emotions so that we don't overdo it and up regulate it or, um, rev up our emotions when we need to get started doing things. This is not saying that we don't feel. We don't have opinions, that we're not excited, that we're not angry. These are all very healthy emotions, but usually the rapid onset or the strength of the onset and the behaviors. And this is where impulsivity and the emotions overlap a lot because. You know, impulsivity, I think, is an underappreciated factor that does persist a lot for adults in terms of impulsive spending, impulsive statements, saying the wrong thing, or saying something out of anger that you can't take back, even though later on you go, I don't know why I got so upset. Impulsivity is a core feature of procrastination. I know I should do this, and I know I'll I'll be ahead of the game in class or with taxes if I do this now. But I want to do this just for a little bit, and then I'll get back and do it. And if we do, that's fine, but often we don't. Then the last one, at least in a model Berkeley put out there, is reconstitution, which comes from the childhood capacity to play, which is often taking things apart, putting them back together, seeing what's in the inside, how things work, maybe role playing games, uh, playing like you're your favorite actor or athlete or superhero, things like that. It's a way to practice how things work, and that's what we use for creativity and problem solving. Innovation and all these things when we put them together, especially. 1s Acting towards long range payoffs. My boss needs this from me in a week. Saving for retirement, getting in shape. Um, not waiting till the last minute on the deadline. Remembering the promises, uh, and following through on them that we promise to our loved ones. And this is the other thing with. Totally valid 100% intentions to do it. But that's where the working memory difficulties they they're not calibrated to that or you know, other you know other such matters. That's how you know, some of the facets of ADHD and all these things can play a role on intentional attention as well, because they're inhibitory for some of the distractions. And with the, the restlessness, which can go into, um, even that behavioral inhibition, the first one and it's not always anything. Like what? I'll hear a lot of my clients when they talk about their childhood. They said teachers like me and I wasn't getting in trouble for criminal activities or hurting other people, but I would call out in class or I would talk to my friends or, you know, maybe impulsively say a joke in the middle of class or do something else. And it. It wasn't sociopathic by any stretch, but it was just disruptive for other students because it was breaking their concentration. So this is also and there's also what's known as the default mode network in the brain. That is our everybody's brains resting state. Where, you know, we're driving down a long, straight road, not a lot of other traffic. And there's part of us paying attention, but also part of us is in this resting state where we may daydream a little bit. Not in a dangerous way for driving, at least for somebody without ADHD. Or we're mowing the lawn and we're thinking about other things at the same time, and it might be where we figure out problems. Um, but then if something happens, like there is a car that cuts in front of us, or we notice a rock on the lawn that we're mowing, then our attention goes back to the here and now. But with ADHD. Part of the thought about the attention problem is the gear shifting with that is inefficient, where there might be spending too long in that, that unfocused or that other focus network, and maybe not getting pulled out efficiently into the here and now, um, and things like things like that. That's why there's sometimes a proneness to daydreaming, getting lost in their head, or even something like getting engrossed in reading. You know, in class. But then the teachers moved on to the next lesson. But the student with ADHD got lost in reading and didn't pick up on the cues that everybody else could pick up on, because it was almost like they were in this, um, vacuum is not the right way, this tunnel vision in a way, and not hearing it, but that that can happen in adults too, where missing things and, um, being lost in one's thoughts as a distraction. 3s Yeah, I think those are all really important symptoms for being aware of, particularly the impulsivity, which as you said, really isn't talked about enough and can lead to some of the most overt dysfunction in people's lives. And because we don't necessarily associate the impulsivity with ADHD, it can be overlooked. But. You know. And this this also ties in with one of the other diagnostic criteria, which is impairment. So for someone to be diagnosed with ADHD, there has to be evidence of significant impairment and at least a couple of areas of an individual's life. Maybe you can give people a sense if there aren't familiar with how serious can this get if you have severe undiagnosed ADHD? What kind of impairments might they display? Right, right. You know what? It's a range. And even within the impairments, a couple things. Yes, for children and adolescents, at least in the DSM. Just to make sure it's not just. Maybe a particular teacher in school, or maybe the parents are divorcing and they're stressed at home. That might be causing the difficulties. There have to be at least two areas of impairment. Um, school, family, uh, friendships or out in the community. And it could be during doctor visits or whatever. I would make the case that for adults, impairment in any one area. And and this is how I practice is sufficient because if somebody is getting fired from their job, they might get along with their family and with their friends. But if ADHD is directly relating to unemployment, that has ripple effects on the family and other things, that is sufficient. Um, or other things like relationship problems, things like that. So that's my humble opinion. Um, and the range of well, one other thing with DSM, with other and this is just pointed out to me, I should have known it, but. Like with depression, anxiety, some some of the other diagnoses. 1s Um. 1s Distress. It's causing the person distress. So even if they're doing okay and their job, but they're having inordinate stress about it or, you know, maybe taking extra time to keep up with it or worried about like, okay, I'm taking too many days off, things like that or other distress. 1s That that is deemed impairment, but that that is not listed in for ADHD. Maybe because what I said before, emotions aren't listed in there. So if we think about distress as emotional, it's considered an emotion free zone. But we now know from that executive functioning conceptualization that's not the case in terms of the impairment. 1s I mean, think about it. Where do we not use self-regulation? Now, that said, not everybody has it. But there's virtually no area of adult life that is protected from it now. It doesn't mean everybody has everything. So it could range from very complex. 1s Uh, multiple problem cases where somebody has a clear case of ADHD. They also have coexisting depression and or anxiety or other things. Um, maybe problems at work and in their home life and with friends and whatnot. Um, bankruptcy. Oh, let's layer on. If somebody also has a medical condition on top of that or other family circumstances like and these these are not impairments, but also part of their regulation difficulties and challenges is they have aging parents who require them to get them to appointments and schedule appointments on top of scheduling. So I'm painting a very. 2s Complex picture, but it happens. 1s Um, 1s and, you know, we can go down, like, sort of the middle of the continuum. There might be people who maybe it's like one area of main impairment, like work or school or in relationship, and maybe other things are I'm okay at work, but it takes me twice as long to complete half as much. But everybody likes me. My performance reviews are fine. I'm not losing my job, but it's taking up a lot of time and that's also contributing to my relationship difficulties. And maybe they are starting to become more anxious and maybe drinking too much or whatever. So there's I mean, that's a degree of complexity, maybe at the milder end or the and I think some people would claim, well, are there any straightforward cases where somebody goes. 2s I'm generally getting out. I'm good with my family. They like me at work, but I'm spending too much time keeping up with work or school on the weekends. It's getting in the way of personal time a little bit with my fitness, because I'm sacrificing my time to the gym. Um, and my cholesterol is up. Um, even though I'm not going to get divorced, my spouse is telling me, you know what? I need you around more. You're not helping out around the house, and friends are a little upset where we go generally mild, and it doesn't sound like things are falling apart, but it is enough and it is getting at health. And that's another one of the things that we're only now in the past couple of years, getting more data on is the direct correlation of ADHD and self-regulation. With health problems from studies tracking children. At least with the study I'm thinking of, it was hyperactivity disorder in childhood, but ADHD into their mid to late 20s, about 27, and they were tracking some health variables. And at 27. 1s Um. And their their health variables were put into some algorithm, like an insurance company would use for a risk calculation. 1s Um. Individuals with persistent ADHD into adulthood were. I'm forgetting the exact number, but. So this. But this isn't an exaggeration. Their health status at age 27 predicted probably about 12 years reduced estimated life expectancy. At 27. Now the encouraging factor and going back to. I know Russ Barkley would always get I'd hear people talk about his talks like it's such a downer. I know this is a downer. Um, one of the encouraging things about this study and related studies, most of the health related variables are changeable and can be targets of treatment being medication treatment, the non medication treatments. Um, but as anybody knows. Keeping up good health, watching your diet, that is like a big self-regulation challenge. How do I say no to the dessert or whatever? And how do I keep going to the gym? Enough so. And keeping up with the preventative appointments within busy schedules, I'm fine. I can do without that colonoscopy for another year. And until you're not and managing, you know, individuals with ADHD who might have chronic health conditions like diabetes or other things that require consistent management, there's a lot of different, um. Yo yo challenges there. So the health is a domain and but people can have milder straightforward. And maybe it's like a college student getting through university. And maybe they get into a job that is a better fit for them and they don't notice the symptoms as much now related to this discussion. So persistence of ADHD, 1s um, for those diagnosed in childhood for whom it persists into adulthood. There were some other studies done by Margaret Sibley in the US. A masterful she has my utmost respect. And to top it off, she's a really cool person. Um, they had a study of children with ADHD that were part of a treatment study. The MTA study, the largest, um, combination of behavioral treatment and medication study, um, and doing one without the other as well. Well, they actually follow those kids into the mid 20s. And every other year they would have a comprehensive diagnostic evaluation. 3s And, you know, some of the persistence studies before would say, well, probably about 3,040% of kids with ADHD still have adult ADHD, and that could be upwards of 70 or 80% if we go. Yeah, but in adulthood they might have a few fewer symptoms, but they still have impairments. So it's residual. This study was doing full on. Did they meet criteria or not. And what they found is about 91% of kids with ADHD at follow up had some degree of persistence. Now when they looked at the study every other year. So maybe the kid at age eight and ten had ADHD met full criteria, but at age 12 or 13, that follow up study, they fell just below. And maybe because they start had a sport or they found a strength, or they had went to a small school that had a lot of attention. But maybe 2 or 4 years later in high school or university, it was back up because the context now, it didn't go away to zero, but it was almost like this up and down course, a little bit above, a little bit below, but that over time it would end up being persistence. And that's generally what we see a lot. And people might have certain life circumstances I mentioned before, very context specific. And at the end of it all, there was only, um, 9% that had sustained, um, remission from ADHD, if you will, might have, you know, quote unquote grown out of it, which some people do, at least being subthreshold in terms of not meeting the full diagnostic criteria, but people might still be dealing with some inefficiencies or still in some sort of follow up treatment. Um, you know, to manage so that persistence over time, but also how the difficulties can come and go like a certain class or year in school, um, workplace, you know, talking about areas of impairment, pretty much any domain of life. Not that everybody has everything. Like Tom Brown says, ADHD comes in small, medium and larger, you know, tall, grande and venti. Um, but it can be like one area that's really big. A lot of things that are, uh. 1s You know, a little bit, but still notable and stressful. So it takes on it takes on a lot of colors and flavors and you know, it's just in terms I mentioned, you know, colors there in terms of cross-culturally and different racial and ethnic identity groups. Um, there are cultural differences and community differences in what gets characterized as a symptom or a problem that can lead people to seek help. But make no mistake about it, wherever there's a human brain, there is a risk for ADHD. 1s Um, you know, uh, to some degree in the population and the adult persistence rates, depending on how they're calculated, can go from about two, 2.53% upwards to, um, you know, 6 or 7%, again, depending how it's defined and whether it's like subthreshold but still seeking treatment for difficulties. Yeah. So are you saying between 3 to 7% of of children diagnosed with ADHD may still have ADHD in adulthood, or 3 to 7% of the total population may have ADHD? In terms of like of the whole adult population. I mentioned the persistence before, but this would be a cross-section, including the children who continue to have it were diagnosed in childhood and continue to have persistent symptoms, including those late identified adults who had some symptoms in in childhood that are validated by, or at least assessed for and identified through a comprehensive evaluation and now have the diagnostic diagnosis in adulthood. So the whole picture of adults with ADHD as a cross section 18 and above, how many people have ADHD? And one of the previous studies from uh, 2004 2005, in the US, it was 4.4%. But that was like a screening, uh, screening study, a population study. And actually based on that study, another point here, and this also goes back to professional services medical, medical or non-medical. And again, this got pointed out to me before, um, part of that National Comorbidity study in the US, where they did a lot of phone surveys and screening measures and just trying to get a sense of how many people have what now I'm going to forget the exact number. But depression emerged, at least in the the emotional the psychiatric diagnoses as number one. And let's just say it was about like 8%. My number might be off a little bit. Anxiety was about three point something percent and everything went down for there. 1s You're going to get this answer right. But you know what came up as number two? ADHD. And this was adult ADHD number two. 1s Now how how many of my colleagues psychologists, social workers, psychiatrists, you know, other stakeholders, you'll hear us talk about it. Like I said, I developed an ADHD program. I had no business doing that. 1s Um, yeah, I was very, uh. I did read the research. I did it the right way. I had great background training in that. But I really, I think in graduate school, maybe childhood ADHD and a child development course was about and maybe autism as well. But it's woefully underrepresented in medical schools graduate schools like and I, you know, with the ADHD program at Penn, I also kept like a half a day a week at the center for Cognitive Therapy. So I would see clients without ADHD and also some people who came through the ADHD program, and it made sense why they're over there. They're having attention and organizational problems. Who we said, you know what, this doesn't sound like ADHD. Your your the issues you have are valid and they are true, but it doesn't hit their trajectory. But I would see them to say, hey, our behavioral approach might be helpful. Um, but so many, so many people just don't get trained in it. Now. Depression and anxiety in my field, the mental health field, that's like in family medical practice, the common cold, everybody gets trained in it. Um, even if it's not your specialty, you could, you know, you you're probably competent in it. Um, it's not like, especially, like, obsessive compulsive disorder with the exposure response prevention where, you know, people, you know, get trained, you know, get exposed to it. But maybe they go, yeah, I didn't get trained in the actual delivery of the system. And ADHD is not even that. So what is number two, at least in the US is woefully underrepresented. So in terms of access and finding people who are qualified to treat it now. The US, Europe, the UK and Susie Young Susan. That should be more formal. Doctor Susan Young um in the UK has been at the forefront of many um, guideline developments within the UK and there, Europe and elsewhere and many other people. But the US, for the first time, the American Professional Society for ADHD and Related Disorders is coming up with the empirically based guidelines for the assessment, the diagnosis and treatment of ADHD. So a little humble bragging, but I'm also involved in a group, uh, a companion group to that, um, organized by Chad, children and adults with ADHD. Um, and headed up by Peter Jensen, who was actually the lead researcher in that MTA study I mentioned for children. Uh, but he's seeing, like, a group of us from different professions, and I'm representing psychologists where we're going to take those guidelines and then come up with clinician toolkits. Um, and this will be for, you know, helping, you know, with people coming together for psychologists, there'll be one for psychologists, psychiatrists, neurologists, nurse practitioners. Now, people are going to be disappointed because there's no way we're going to be going, oh yeah, just do these 20 steps like, like. Like, I don't know, like a recipe for cooking. Yeah. Even if you can't cook, follow these steps and you can boil water and cook spaghetti or something like that. It's not going to be that granular, but at least in scope or what should be. And we're hoping that it also affects effects and influences training programs and continuing education and people seeking more specialized training in how do we provide services and support for adults with with ADHD. And we know that ADHD is hugely genetically, uh, influenced, heritable, I think around 70 to 80% heritable. We can see when we're assessing these patients. It runs in families that often have cousins, parents, aunts, uncles who even if they don't have a formal diagnosis, they resemble the patients difficulties a lot. Is there any strength to the argument that, uh, our environment, as particularly as in, in modernity, with all the technological advances we've made that our environment is. Increasing the prevalence of ADHD. Or maybe it's more subtle that it's making us all at baseline somewhat more ADHD like, but not increasing the population of people with ADHD as such. Is there any validity to that argument? 1s You know what? There's validity to the questions and what I say. These are empirical questions. So no you raise a lot of good points. And please, if I leave any one of them out, remind me. So yes, ADHD does rank among the more one of the more heritable conditions in psychiatry, generally on par with height and schizophrenia, things like that that are. Now it's also what's important. It is a complex genetic trait. What that means is there are multiple factors, multiple candidate genes. And with all respect to any of these genetic testing things, um. I don't, I'll just be cautious because I'm not familiar with how they work just to go. I would imagine it might have a hard time mapping even somebody with a genetic profile. That's the other thing with the brain scans, looking at locations of the brain that might be a little more smaller or not as efficient. We cannot use that as a diagnostic tool, because there could be somebody that said, you know, you look at it and say from the research standpoint, oh, that's not an ADHD brain. Oh, here is one. But the non ADHD brain picture is somebody with ADHD. And the one that looks like ADHD isn't similarly with genetics. Um, there could be somebody with a profile that we go, oh, this is consistent with some of the research. They have a high D4 allele or whatever, but it's not. It's not like Mendelian genetics, like it's eye color. Oh, you have two brown eyed parents with a blue eyed child who's who's fooling around? No, they could both have the recessive trait that shows up as blue eyes. And it's not that it is not that clear cut. So it's complex. The interaction with the environment on two fronts is interesting. One, there is the field of epigenetics, the interaction of environment and gene expression. I think this hasn't been supported, but let's not let facts get in the way of a good example. There were some things about early um. 2s Uh, prenatal risk factors like cigarette smoking and genetic profiles. That said, if you have these risk factors and the genetic ADHD was a lot more prevalent now, again, I think some of the replications did not support that. But that's that's the notion of environment. Um, and. You know, there's more literature on adverse childhood experiences, aces, life stressors that could create, uh, contribute to the expression of ADHD. Um, another thing common, you know, even at birth, is low birth weight. Also premature. But the premature babies, the the the shared factor is low birth weight. And that's the risk factor. Not 100%. What? Why? And don't worry, if your child was a low birth weight, that doesn't it's not a 100% guarantee. So there are these other sorts of interactions. Where it could contribute to the risk for ADHD. Um, even if there's not the and and the breakthrough in a family where everybody say we're all Type-A personalities and we get everything done yesterday and now we have this one child who doesn't seem like they belong to us or something like that. 1s Um. 2s The the other interactions with environment. 1s Um, things like somebody gets a head injury at some point and that affects brain functioning. Now, children and adults with ADHD are more prone to variety of accidents across the board, all parts of the body. Uh, probably from impulsivity or inattention, whatever the case may be. And it could be. And let's just say a child had a lot of concussions that really active, hyperactive, whatever. Um, but or we could say just very active. And it was questioned. Well, how much activity? Whatever. 1s Is the later difficulties. Post-concussion syndrome. Is it from ADHD? Um, did they have ADHD and post-concussion syndrome? And if this person. Yeah, they they played a lot of sports, but if they never had the concussions, they were, for lack of a better phrase, typically developing. Those are hard questions to answer. And also even for individuals in adulthood who did not have a history of ADHD, but then all of a sudden are having executive functioning and attention problems as the result of a head injury. And some people will call that acquired ADHD. Well, that is not an official category and I wouldn't count that as ADHD. It's not dismissing the difficulties. Um, and I heard from a colleague that even for people with like head injuries and things like that, you know, sometimes the medications for ADHD can be helpful. But I would also wonder, we just don't have studies on the cognitive behavioral therapy treatments for ADHD with that population. And there might be more cognitive rehabilitation problems. Programs that might be a better fit. But those are empirical questions about how these difficulties can unfold. And now, with many senior adults either growing up and living with adult ADHD and now reaching the senior years, or people coming in in the senior years going, you know what? I always had these problems. Um, and now I'm reading about it and I think it might be it, but also, I don't know if this is any cognitive decline or early dementia and they can coexist. And this is an area of much more research. Lastly, and another empirical question. 1s We have generations of individuals who have been on gadgets. Pretty much from childhood, or at least the very young years. And I know there are cautions against this for brain development. And also there's I think actually some studies on this, having parents with ADHD and on their phone, everybody's on their same phones and we know one of the one of the facets. And please don't take this as anybody going, oh my gosh, I broke my couch with my child. Um, but eye contact. And if we're on our phones and children and having the eye contact with parents and, um, for focus and attention and learning how to do stuff and, and all the other good things, um, that getting impaired, it may be having some, some effects. To my knowledge, I'm citing some studies I've read about second hand. Um, but at the same time, are we saying that? Oh, so we're saying like 40% of the world is going to be ADHD because of our phones and all that? I'm a Gen Xer so I can put my phone aside and things like that. So I didn't have it all that all the time. But like I said, we have these generations to do. It seems to be from the research I'm aware of, it's more of the social side of things, and especially for young women, the comparisons and, you know, some of the social comparisons and not fitting in and things like that. And I just think that. Are there differences in attention and and executive functions coming from this? Because at the same time, there are many things that can draw us away and get in the way of things. It's it also can be a very helpful tool in terms of digital planners and having things not having to carry around a lot. Um, being able to get immediate feedback, write down the thing, remember to get milk on the store on the way home and set a reminder. Um, there are many ways, and for many people it's at both. And I go to use it for the coping skills, but I stay for the distractions. So that's still an open that's still an open question, but certainly more of the adults with ADHD, we see and we ask about it and as do my colleagues. It's the relationship with technology and many people. I think most people are saying I overuse it. Uh, checking it however many times. Um, but again, it's that question of impairment, how much overuse is actually getting in the way of things. And this is something that can get bundled in to the treatment. So it is certainly a variable to be considered in all forms of treatment. Uh, there direct question about how much of this might be creating a generation, but also with people with intact executive functioning that might be challenged by this phone. Generally, most people fall into something where we go, yeah, if we're waiting for the train or something, or are we on our phone? Yeah, but what are we going to do, stand there staring at the brick wall? Um, so it can be something for those empty spots. Now we can make the argument as just to give a call out William Kitchen at Cambridge or Oxford. And I'm sure those institutions don't mind me mixing them up. Um, who's, uh. He was he was at the. He was at a postdoc at the center for Cognitive Therapy. Uh, when I was there and had a good point. And he's an expert in mindfulness, so he would probably say, well, do mindfulness exercises while you're there. Um, but just to give a call out to them. Um. 2s But you know, so there might be overuse, but it might be filling in the gaps where we didn't have things before to to bide our time as we're waiting for things. So it's an open, empirical question, but a lot of people are able to balance it and know they're on their phone a lot, but still predominantly use it for okay. My child texted me that they arrived. Okay. Um, I'm checking my emails on my phone, but I'm still eating a healthy dinner, getting to the gym, tracking my gym workout, tracking my sleep, and using it quite well. Even if we say, yeah, I'm using it more than I have before, more than I like, but generally doing well in their job, well in relationships, um, well in their personal health and other matters. 1s But it's a great question and, you know, to be continued. Yeah. So I think it's safe to say that. If you're a person who didn't grow up with smartphone technology and you don't really if you don't have ADHD, if you use your smartphone a lot, it's may induce a ADHD like state of mind. But the key difference is if you were then to put in some healthy habits, change which apps you use, regulate your phone usage more. Those problems, with all likelihood, quickly reverse, and you can actually increase your focus and increase your attention. And there's a reversibility, whereas if you have ADHD then you're susceptible all the time. You're going to be susceptible to your phone. And if you're not using your phone, you're going to be susceptible to other things. Phone usage may make it worse, but removing your phone from the equation isn't going to make everything better. And now the open question you talked about, which I think is really important, is, is exposure to these devices when the brain is still developing. Could that, uh, induce a set of symptoms that's very similar to, if not indistinguishable from ADHD? So I think that's definitely important topic for research in the future. Um. Moving on to treatment now. I'd like to mostly talk about non-medical, non-medical treatment, but briefly, what's your experience with medications for ADHD being what proportion of people can get a satisfying treatment outcome with medications and your experience? You know, it's an interesting question. It can get sliced a lot of different ways. So I'm a psychologist, not a psychiatrist, so I cannot prescribe. But I work very closely with the psychiatrist and and many others. And so I've been around it and familiar with them. Um. 2s They can be there among the most highly effective and safest that we have, at the very least psychiatry and in the treatment of mental health issues, psychiatric diagnoses. And I think I'm writing this in addition to probably in all of medicine, taking that taken as prescribed, which is always the caution. And, you know, one of the concerns is about misuse and diversion, which are certainly valid, especially among college age students. Um, and there's been. You know, voice concerns about addiction. But all the studies, especially more recent ones, would suggest that one, they're highly effective for individuals with ADHD and taken as prescribed. Um, individuals with ADHD are at no greater risk for stimulant or. And I think I'm writing this one overall. Uh, substance use or addiction. Then the general population that's important. It's not like it's totally protective, but that you're at no greater risk. And the clinical realities working one on one with individual cases is you might run across people who start a medication for ADHD, then abuse it or divert it or, or people without ADHD who misuse it or, you know, take it when they shouldn't. It happens, but generally not to the degree, not outside what we would expect, um, in the general population, population risk. So yeah, this would be something like, okay, there's some new thing in an automobile and that people are worried it's going to distract them. But people go, no, it's actually very helpful. And there's no greater risk for an accident than anybody else. So people will still have accidents with this new device in their car, whatever it is. But it's not at a greater rate than people without it. So it's, you know, it's it's a draw, if you will. Now, the other questions, um, in terms of improvements based on the research, generally people will get better and I think like upwards probably about. And this is where it gets fuzzy a little bit. Let's just say, you know, two thirds, 80% will get better. It doesn't mean asymptomatic. Um, and it doesn't mean it's perfect. Um, and there can be side effects. There can be people who are non-responders, um, who they try different preparations and nothing seems to work. Every brain is different. Or like I said, the intolerable side effects. Not liking how it makes them feel. Maybe ramping up feelings of anxiety because they are stimulants. There are also non stimulants, so there's a range of options even though it's generally around a certain corridor of options anymore. So they can be highly effective. 1s Um. But also partially effective, where just because somebody says, hey, I'm focusing better, it doesn't mean if they're a student, they're going to magically write essays in one draft or read Beowulf in one sitting, or whatever the case may be. They're still might be the behavioral struggles. So the medications can be very helpful. And for some people at the upper ends, they say it's a game changer. I can now focus. And what I've heard clients say when medications are working, I'm aware of the distractions or I hear the noise over there, but I'm not pulled away by it. I'm aware it's there. Um, but I can stay focused longer. Uh, for many people, it's like getting the right prescription eyeglasses. You know, I now I can stay focused on the reading, the writing longer. It's not magic. It's not a academic pill. Like, oh, you're going to graduate first in your class, and everybody on stimulants will go and graduate law school, med school, or any other aspirational thing. No, it's still hard work, but at least now it levels the playing field. Um, so they can be, um, a range of effectiveness. And for many people, even partial effectiveness, and for individuals who might have coexisting mood or anxiety, especially with the anxiety. Some people say once I get on the right medication, I'm even though it's a stimulant. Maybe I'm not as anxious because now I feel more on top of things. I'm not rushing at the last minute. Uh, I'm getting along better with people because I'm following through better things like that, even though it's not a medication designed for anxiety. Now, somebody else that's a similar person. That person's twin might go, yeah, it's helping with my focus, but my heart's racing. My blood pressure is up, which should be monitored and and ah, as part of the guidelines. Um, but so they go, oh yeah, I can't take this anymore. Even though it was helping my focus because, you know, I just didn't feel comfortable in my skin. So they can be they're among the most effective. But we don't want to oversell it, like, you know, active coping. Uh, maybe without seeing a therapist or a coach or somebody else, um, is required. It's not like, oh, I don't have the right things in my planner anymore, or I don't have to set my alarm to wake up, or I can write essays in one draft. Yeah. Stuff is still hard work, but at least. And what most people will say, at least it's a fair fight. And what most people will say is. You know what? I don't have to be head of the class. I don't, I just I just want to know if I put in, even if it takes me an hour longer, if I put in the effort to read, write the paper, I just want to know that my grades are going to reflect my effort and my preparation. And if that's a B-plus, I'm fine with that. I just don't want to have to retake the class or get to late in the semester because I fell behind and have to drop the class, but still pay tuition for it and retake it and take an extra year to graduate. And sometimes that can be a reason. Decision. You know what? If I take whatever it is 15 credits a semester? That's overwhelming. But if I can reduce that by a class or two, it might take me the extra year, year and a half, but I'll be more likely to finish and and be less stressed each semester and get more out of my class and the whole university experience. And that's the personalization. And some people without ADHD might make that question. I need to go home because my, uh, my parents are ill and or they need me, or, uh, maybe they serve in the military or something. So sometimes there are extended graduation rates, but for various other, various other reasons. So it's not a shameful thing. It can be a very personalized and excellent decision that helps you get more out of college, as it were. So medications can be very helpful. But but they're not the end all be all in them. Yeah that makes a lot of sense. And what I find when speaking to patients with ADHD is generally when I'm talking to them about treatment goals is their goals are quite humble. They're not trying to be the leader of their industry or the top of their class. They're just like you say, they want the effort to match the outcome or be reasonably proportionate to the outcome. And I think that's a really important point. I think there's a lot of cynicism, maybe towards people who have ADHD and a lot of skepticism, but I think understanding the condition in more depth, it's really a difficult for a lot of these people because it's almost some some people say the more they try and concentrate, in fact, the harder it is. So the more effort they put in, almost the more chaotic their mind is. Um, can you comment a little bit on how would you approach treating ADHD psychologically? What kind of. Tips or techniques would you start to use with people? Right? Before I answer that, I'm going to jump back. I greatly appreciate what you said, because I was going to say that's another one of these misunderstandings or myths about ADHD. Oh, these are people looking for an easy way out. They don't want to do the work. They don't want to invest the time. It's the quick results. I want it now, and I don't want to have to do the work. 1s And. 1s You know, mirroring what you said. Many, like I said, many people have very humble desires. And in fact, and you've probably experienced this to the people who are sitting across from are probably working twice as hard because they're staying late at the office to catch up on work. They're spending time on weekends, taking time away from recreation, going to the gym to write the paper that they hope gets accepted, that they don't have to do another draft of. Um, showing up early, staying up late, all nighters, all these unhealthy coping strategies as a way to, you know, in some ways, there's that term out there masking, not wanting to look different, but that can get in the way of and it could sometimes be necessary coping. But the masking, you know how I view it as negative. If it gets in the way of getting necessary support out of a sense of stigma or being treated differently. And a colleague, a colleague of mine in the US and I've. 1s They have used this every podcast I've been on, I think I put it in every book I've written. His line was, adults with ADHD work twice as hard for half as much, and that can be demoralizing, you know, because like you said, just want something commensurate, um, not looking to be the CEO, not looking to get out of work. They want to do that. They, you know, most of the adults with ADHD say, hey, I just want to be in the game. And if that's an A great if that's a C great. And some people it may be yeah I lose points because I'm late with things. And um. Yeah, yeah, it would have been an A or you probably heard this to people saying, yeah, I always felt I wasn't fulfilling my potential. I did okay, but I always thought like if I had a little one more day to work on that paper, it could have been in a paper or it could have been added to the competition or things like that. So this is actually not a bad segue into. 1s How do we or how do I. You know, think about, um, framing. You know, people coming to me for cognitive behavioral therapy. How do I think about treatment? One is, um. 1s And it's a word put out there that. There's no protocol for doing it. But Psychoeducation and I have found on many fronts that self-regulation executive functioning model. Now, there are other things that contribute to the self-regulation. There's um, reward deficiency syndrome, where it's the farther out the reward is, the less pull it has on behavior. There's various other concepts, but that cluster contribute to, um, the self-regulation. But the executive functions are a nice umbrella. And. 2s Describing ADHD in those terms for two reasons one. 1s Like for my money, procrastination is probably like one of the number one problems and presenting issues that I'm treating. 1s Um, and it can have, you know, multiple causes. But rather than having somebody talking about their procrastination in every week, they go, okay, I'm going to try harder this week to not procrastinate. And we know how that will work is going to I'm going to try harder to exercise or try harder to eat healthy. We generally need a plan. 3s And that understanding of. You know, the different executive functions behavioral inhibition, the working memory, the issues, the motivation, and also time management organization, all the other ones. Help people and how that plays out in day to day life and some of the presenting problems, um, that might have been identified in the evaluation as part of the treatment planning so that people can see and understand not just, oh, you're procrastinating. You have to try harder not to do it. Let's look out, look at and reverse engineer procrastination and understand the elements to it. How do you think yourself out of what you're doing? Or do you not have a plan? You're waiting. You're planning to wing it and to be in the mood for it. Um, are your plans realistic? Do you set yourself up for. Okay, it's got to be perfect on the first draft. I only have an hour. Or is it like, now? I just want to spend this first hour outlining or even thinking about. Or maybe writing 25 words, if that's what I can get out. But just getting started, and maybe that's going to require another task. Stuff we all know. And the emotion, you know, how do the emotions play in? What are other things like if this person's a parent, do you have any responsibility that time you set out? Is that when you have to take your daughter to dance class or your son to dance class for that matter? Um, and is that a realistic plan and that granular level of. But that's the exact appropriate level. Um, and so as a clinician, I think that helps me see the, you know, because many clinicians to say, I don't know how to help people because how do you pay attention? It's like, how do you sleep? Oh, how do you sleep? You put your head on the pillow. I could put my head on the pillow right now and sleep well. You close your eyes. Okay? I'm closing my eyes. I'm not sleeping well. You just do it and then you fall asleep. And it's the same thing with attention. Well, I can't pay attention. Well, you just have to just do it. Um, now, attention problems themselves are probably more the purview of medications. If somebody says, no, I'm on time, I don't procrastinate. I just can't focus on the reading. That might be one, like eyeglasses or things like that, where it's like, yeah, I can help with your attention, hygiene, but for other things, being able to see ADHD in their personal life and that way they go, okay, did I not have a good plan for this project if we're dealing with procrastination? Um, how did I psych myself out of it? Oh, this is going to be really hard. This is going to be awful. Let me do this other thing first. And what were the emotions? Oh, I don't feel like doing this. Okay. You can feel that and it makes sense. But can you feel that feeling and also get started. And probably after a minute or two that UGG feeling will go away because the UGG feeling is about the anticipation. We want to get engaged. So okay, you typed a couple words, now you're doing it. It's a reality, not this imagination of how bad it will be. And there's other factors that go in and it it's helpful for the individual. Because also the relapse rate for procrastination and ADHD is 100%. You're going to slip up as you and I will too, and everything. And that's not a flaw. That's our human factory setting. So how do we get back on track and use this model? I've also found it being a useful model for clinicians and training or colleagues at continuing Education. How do you how do we as a field understand ADHD? It's also very valuable valuable in the assessment. So rather than boy did they pay attention enough as a kid. Are they paying attention enough now? Which is part of it. But it's also how are they at organizing and following through on reasonable tasks? Do they over? Do they overextend themselves? Are there factors in there that sometimes they do, but not all the time. And that's what's consistent inconsistency, a phrase I keep going back to. Um, it can be from other things, but it's a helpful way to zero in on the diagnosis of ADHD and anything else that might be going on around it. So moving back to ADHD, usually some form of procrastination. Um, now it could be from lack of planning. So that could be coming up for all right. How do you how do you do everything you have to do in a week? Okay. Let's talk about like some form of planning. It doesn't have to be a digital or book planner. It could be. Um, but there's also sometimes you find what works for the individual, and people can come up with really creative activities. Now, sometimes to create the creativeness can end up being a distraction. I'm going to use multiple colors. I'm going to personalize it every day. I'm going to have a different planner for each month of the year, and I'm going to come up with some cryptology coding that I'll use in case I lose it. And then all of a sudden they're spending like nine hours a day planning their day. Now, that's an exaggeration to make the case, but looking for is this is this helping your coping, or is there any degree of attempts at coping that are getting in the way that might be excessive? Because sometimes simpler is better? Um. That lends itself. Very often. The organization is about organizing time and what you have to do in addition to stuff, but, you know, things that go with people everywhere, the emotional regulation and in terms of interpersonal relationships and the social emotions, very often individuals with adult or adults with ADHD. And you might hear this and see this too. I hear a lot of guilt and shame. I feel guilty or shameful that I didn't do this, that I walked into the meeting unprepared. Now, like many emotions, even the unpleasant ones. 2s They're functional. It's good that we have them. If we didn't have guilt and shame, that would be like us not being able to feel pain. We'd walk around with third degree sunburn, um, nails in our shoes, going through our feet. So guilt and shame are social emotions. Guilt is an emotion associated with the sense we did something wrong. We made a mistake. We might have wronged somebody accidentally. That is a good feeling to have and so we can make amends. Hey, I'm sorry, I forgot this. I will make it up to you. Come answer it. 1s Um. Shame is, um, the perception or the realism? The realistic view that, um, we violated community or relationship standards. Um, this now this can all both of these can come from human beings doing human things, being unfaithful to a dating partner, things like that, getting a drunk driving charge, things that really happen, but also that they're not unheard of and that we can learn from. Um, but usually what I'm hearing from people is relatively minor things. Things that we could say are commensurate, maybe with a parking ticket, that they feel wracked with guilt. Now, some of this can come from the nature of ADHD and the impact it can have on relationships, and then this can only grow later on for other quote unquote offenses. But that's also part of the emotional regulation strategies and the cognitive work of let's keep this in perspective. Yes, you made a mistake. You forgot to respond to the invitation. Um, so you can apologize and make appropriate amends. But that doesn't mean you have to pay them $100 to give them your first born child. I'm exaggerating to make the case, but a lot of people describe inordinate guilt and shame, which would go well, you know, shame, really. And I'm not, like, correcting people. Oh, that's not shame. This is guilt. But we talk about like, hey, shame is stronger and it's important, but do you really think that's involved in this case of. You know, forgetting to pick up milk at the store or something like that. So anyway, that's just a flyover of how we start getting in there because, you know, and but ADHD can go a lot through a lot of things. So we talk about. Procrastination, but that can lead to planning and that can lead lead to. Yeah, I procrastinate on this and I don't do this chore at home and that affects my relationship. Usually you follow one path you're going to get to some other, but you can still go through relatively systematically. And to end, what's most important is what's most important for the individual and helping them again. And a big focus, I say, is about the implementation of the coping skills. We all know what works. There's no trade secrets, but it's the engagement, it's the implementation. And also that draws on the cognitive behavioral therapy and throwing emotions in there too. How do you think about what you're doing? How do emotions affect that. And sometimes our thoughts yeah, we're really just using taking our emotions and putting thought words on them. Hey what's your anxiety telling you. Um, and then how does that affect behaviors one way or another. And then we can deal with all the other, all the other domains of functioning. And the combination of medications and cognitive behavioral therapy have been found to work really well together. But there's also some data, when necessary, that cognitive behavioral therapy alone for adult ADHD, for people who might not respond to medications, they can't take them for, you know, in rare cases when they can't take them for health reasons or, you know, pregnant women. Um. It can also be effective. It might take longer for the skills to take hold and to get practice implementing them, but it can be still be effective if that. If that's the only option. And there's other non-medical non medication options that can be helpful, such like academic support and academic coaching or other forms of ADHD specific coaching for young adults with ADHD and other people. We don't have a lot of data on relationship, um, therapies where at least one partner has ADHD, but there have been some studies on this. And, um, there's a host of things that like supplements and some other non-traditional therapies that are generally, it might be generous to say a mixed bag in some cases, and in other cases, their reputation far, far out distances the data for them. So I'll just leave it at that. Right. Well, I mean, that's a really good overview. And I think people will be able to take a lot from the we'll be able to start with those tips. And obviously we would encourage people to read more online, to do their own research and also to go on forums, talk to other people who have ADHD and discuss, you know, what other things that work for them. But this is an excellent starting point. Unfortunately, we're out of time, but I think this has been an amazing talk, an amazing introduction to ADHD for the uninitiated, for people who aren't so familiar with the condition, I'm sure as I continue to work with ADHD, I'm going to have more questions. So I'll definitely have you back on at some point in the future. But thank you very much for your time and for sharing your knowledge and experience with us today. And I'll just add one more thing. There is the UK adult ADHD network. You can UK an if and that's another good source of uh, good information. All right. Thanks a lot. I gotta I gotta jump off. But this is great. Yeah you're a great host. There's a great check. Uh. Great questions. Take care. 11s Thanks so much for listening this week. If you've got any feedback, as always, do get in touch. If you enjoyed the episode, why not give us a rating on Spotify or Apple Podcasts? Because it really helps other people to find us. If you want to get in touch, you can find us on Instagram or Twitter, or you can drop us an email. And if you value the show more generally, why not bias a coffee? Thanks so much!