E119 - How do we treat 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 many books on ADHD, 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. Find out more about Dr. Ramsay here - https://www.cbt4adhd.com/about/

In today’s episode we discuss, what it means to be diagnosed with ADHD, how patients should consider whether or not to take medication, how ADHD can be treated psychologically, how CBT should be adapted for ADHD, how people can improve their focus and much more. 

Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

Alex's latest Guardian article: https://www.theguardian.com/books/2025/mar/31/the-big-idea-should-you-trust-your-gut

TedX conference tickets: https://tedxlondonbusinessschool.co.uk/

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

Give feedback here - thinkingmindpodcast@gmail.com - 
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Transcript

[00:00:00] Welcome back. Today we're continuing the conversation around adult A DHD. This will be our fourth episode that we've made about A DHD, and I'm very pleased to welcome back Dr. Arthur Ramsey to the podcast. Dr. Ramsey is a co-founder of the Penn Adult, A DHD treatment and research program in the us and he served as Professor of Clinical Psychology in the Department of Psychiatry of the Perman School of Medicine at the University of Pennsylvania.

He's the author of Non-Medication Treatments for Adult, A-D-H-D-C-B-T for adult, A DHD, and the adult A DHD toolkit. His most recent book is called Rethinking Adult, A DHD, and that was released in 2020. In addition, he has a popular blog on psychology today. The first episode we recorded back in February, 2024 was an episode all about what it's like to have A DHD, what the diagnostic process involves, what kind of impairments A DHD can cause.

Today we focus a lot on [00:01:00] treatment. What a diagnosis of A DHD means. How a patient can consider whether or not they should take medication for A DHD. Psychological interventions like cognitive behavior therapy, and the difference between applying cognitive behavior therapy for things like depression or anxiety, and applying them for A DHD.

We specifically drill down on how individuals with A DHD can think about things like focus time, organization, task completion, and procrastination. We discuss some of the controversy around the A DHD diagnosis and whether or not it could be being overdiagnosed or underdiagnosed, whether or not A DHD is a disability or a difference, and whether or not social media is a useful forum for people to learn more about A DHD.

Just a couple of updates on my end. My latest guardian article came out last week, and that's an article discussing things like intuition and decision making and whether or not we can follow our gut instinct. So I'll put a link to [00:02:00] that in the description, and I will be speaking at the TEDx Conference at the London Business School, and that's taking place on 28th of April.

Myself and many other interesting speakers will be giving short talks, and this year's theme is Beyond Boundaries. So again, that's taking place on the 28th of April, and tickets are publicly available, so I'll also put a link to that in the description. And if you'd be interested in having me speak to your team or organization about subjects related to psychology or mental health, you can email me at Alex Crummy therapy@gmail.com and put speaking inquiry in the subject line.

As always, there are many ways you can support the podcast and the more supports we get. And as the listenership grows, that means we can continue to make a better and better podcast. Get better guests, improve our production quality and so on. If you'd like to support it, the best ways are by sharing it, giving us a rating, giving us some sort of review wherever you watch or listen and checking out some of the links in the description.

As [00:03:00] always, thank you for listening, and now here's today's conversation with Dr. Russell Ramsey.

Russell, thank you so much for coming back and continuing this conversation with me. Alex, you're very generous. Thanks for having me. Glad to be here. It was a great time last time and I'm expecting great things again today. So just starting off, what does it mean to have a DHD? If you diagnose someone and they say, what is A DHD?

What do you tell them? How I describe it is, and it may, this may be a bit of a repeat from last time, but I'll just start off even with the name, attention Deficit Hyperactivity Disorder, and it's a list of 18 symptoms. And they're pretty good, but it's incomplete. Like a DHD is not really an attention deficit.

It's more of an attention allocation problem. So this sort of starts the discussion of the nuance and hopefully geared towards the person's experience. But you, I'll, [00:04:00] I'll talk about the attention allocation problem. And some of these are analogies, metaphors used within the field that, you know, borrow from others and hopefully they borrow from me.

A DHD is more of a performance problem than a knowledge problem. Most people say, I know exactly what I need to do, but I have a hard time doing it or organizing it, or I come up with great plans, but I don't follow them. So these examples I think, resonate for a lot of people rather than, and these are not wrong, being distracted, being restless, or being impulsive.

And you know, very often people will be forthcoming with their stories either, oh yes, this, that sounds like me, or other things. So it gets at, you know, in a way I'm gonna borrow a line from, uh, you know, one of my early mentors saying that, you know what, there's no cognitive therapy for depression. The cognitive therapy treats the [00:05:00] problems of depression.

The, the low energy, the not doing things, the, you know, whatever it may be. That's really what we target. And I think cognitive behavioral therapy for, uh, adult A DHD is very similar in so far as we're probably not treating the core symptoms, but we're treating the, the executive functioning difficulties, the time management, the disorganization, the motivational issues.

So this sort of. Explanation with clients, how we make sense of A DHD so that we can understand it. And it helps with the evaluation, but also bringing it back. It gives the targets, the real world targets for treatment, um, that are probably why people have sought us out in the first place. And I just wanna make clear that medication treatment, I'm a psychologist.

I do not prescribe. I cannot prescribe. Um, but I have a great respect for what psychiatry can bring to the table for, um, treating adults with A DHD or [00:06:00] anybody with A DHD. And, you know, by targeting the symptoms, that can be very helpful. I like how Steve Ferrone and, uh, Kevin Anhe, they, they differentiated between narrow band treatments and broadband treatments.

So medications would be considered a broadband treatment. You treat the symptoms of A DHD, that it has these broad positive effects. Just like getting corrective uh, lenses. Eyeglass lenses can help with reading, but might help with other things like driving other things. And CBT numbers among the narrow band treatments, very specific targeted treatments like, um, academic accommodations or educational support services.

A DHD coaching would fall into that realm, but so does cognitive behavioral therapy where it's focusing on the, the day-to-day functioning. Now, just because it's within the narrow band, those can be very broadband treatments because it's [00:07:00] really what we're all about is how we spend ourselves, what we do with ourselves.

And, you know, going back to the, say you're getting the academic answer to a very straightforward question, but it's, um, you know, a, you know, part of and what is so insidious about A DHD. It's doing the things that not only the things we have to do. As responsible adults, but also the things that we wanna do, be it for wellbeing or self care.

And you know, that's really the focus of a lot of the psychosocial treatments is overall wellbeing. But that's insidiously what a DHD gets, gets in the way of. Yeah, and that last point you mentioned, I think is really important. Many people who criticize A DHD as a diagnosis would say, you know, don't we all struggle with these things?

Don't we all struggle with, you know, doing the things we kind of have to do the mundane things to get on in life. There's, there's an argument to be made there that, you know, people with a DHD really suffer with doing those mundane things, perhaps to a, to a level [00:08:00] that other people simply don't. But then also I think an even more powerful argument, as you just pointed out, is people with A DHD have a really hard time actualizing their desires, their passions.

For example, may would love to learn the guitar, but they just can't do, you know, doing anything to a high level, enjoyable or not, requires a certain amount of tedium and dedication that might be doing the scales when you're playing guitar or just showing up to practice every day. And, and I hear that, you know, when I see people with a DHD, it's not just that, that they can't do their taxes, that there are very real things, their hobbies or even, you know, spending time with their children or doing things which require a little bit of patience, which they really struggle with.

And often they seek treatment to help with those very things, right? Including following through with healthcare recommendations, physical therapy, a medication regimen like, um, uh, a an um, antibiotic or whatnot. I worked with a client who was diagnosed with Lyme disease, but was very inconsistent in the antibiotic treatment, which [00:09:00] extended the illness, um, longer than they wanted to.

And you know what, you mentioned something about don't we all have a DHD and. Based on some research and it, it's nothing new, but it's, it's a way to answer those critiques to say, well, yeah, in a way a case could be made that, not that everybody has a little A DHD, but the, the difficulties are not unfamiliar.

But the study I used to cite that dimensionality of A DHD, like when we think about it in self-regulation or that executive functioning model, these are standard human factory settings. We all have the executive functions, uh, you know, the impulse control, that, that's part of what makes us human being able to stop and pause and motivate ourself for things that we don't wanna do.

So everybody has this capacity, but there was, now, it was a study of children, it was a population study. I, I forget the country. It might, it might've been the Netherlands, but don't quote me on that. [00:10:00] But it was children rated by their parents. I think they were about eight years old. So the parent based on parent ratings, and they identified whatever percentage in the group was diagnosed with A DHD, but it was a broad population healthcare population.

And so parents rated their children both on, um, the 18 symptoms of A DHD and their sense of quality of life of their child, and it turned out to be a smooth dimensionality. So many children were rated as no symptoms or maybe one symptom, and they had the higher quality of life ratings, again, based on parent ratings.

As the parent ratings of symptoms went up. 4, 5, 8, 10, all 18. There is a stead steady drop in parents rating of quality of life. So that is the definition of dimensionality. With some medical [00:11:00] conditions, there'll be some cliff for blood pressure or some other measure where, oh, once the blood pressure, blood pressure reaches that, or obesity or whatever the case may be.

There's a quantum shift. But this dimensionality, and this is important clinically, one, it's a way to give the non-defensive, oh, you're right, everybody. It may, this is why it seems like everybody has a little A DHD because the problems are not unfamiliar. We all procrastinate at times. We all forget things.

We run late, whatever the case may be. But it's a matter of degree, just like with vision, um, weight, there are many health matters where it's dimensional and at some point it becomes problematic or if you will diagnosable or even more so disordered. So A DHD is is one of those conditions, but it's. I think Edmund Burke said it more eloquently than this.

It's hard to tell when day turns into night, but it most definitely happens. And I stole [00:12:00] that from Ned Hallowell and John Radi and driven to distraction. But it's important clinically, 'cause there could be sub-threshold presentations of A DHD causing many problems, but if somebody's like one or two symptoms short of the diagnosis, um, it's not like, oh no, this isn't diabetes, we don't need to do anything.

It's like, well that could be, and that's unfair. 'cause there could be, you know, borderline diabetes. So that's not the best example. But, um, here with A DHD, there might be a situation where somebody goes, you know what? You, you don't have all the symptoms, but there's no better explanation, but that this is consistent with A DHD.

But you might just have a, a sub-threshold case. Yeah. And I see a lot of those sub-threshold cases. So I think really important to point out wonderful metaphor about dementia, the dimensionality. And of course, yeah, we see this with all sorts of physical. Mental health conditions. You know, most people know what it's like to be sad.

Most people know what it's like to have low mood for a few days, [00:13:00] and for that to be associated with like, some kind of sleep change or appetite change or energy change. But then depression is a categorical difference. We've had many conversations, uh, on the podcast recently about what might be the underlying cause of depression, biological psychosocial, but regardless in terms of the, the patient's experience, we, there's a, there's a, you can argue there's a categorical shift, uh, where things reach a go of a cliff edge, as you said, once, once someone has a diagnosis of a DHD, I assume you said, you know, you don't prescribe, uh, medication because you're a psychologist, but I, I imagine people ask you questions about whether, whether or not they should consider taking medication and I.

From what I can tell in the A DHD world, some clinicians kind of fall into the camp of someone gets a diagnosis. Therefore medication is kind of automatic, automatically recommended. And I think some clinicians would say, actually it's more of a [00:14:00] personal choice. It's kind of contextual depending on what's happening with the patient at that moment.

When people ask you questions, you know about whether or not they should consider medication, how do you counsel them? Right? And you gave some excellent examples. I start with right of self-determination. You know, if you believe in it, you're gonna be gonna be more likely to do it. And with the medications though, if people ask, I'll say, you know what, one, uh, they are highly effective and taken as prescribed safe among the most effective and the safest we have in clinical psychiatry.

Now that being said, they're medications. It's a big deal. And you know, being clinicians, I can speak, hey statistically. No greater risk for addiction than anybody else, if not even some studies saying it might be somewhat protective, but that's why we get a family history or somebody has a history of abusing stimulants.

Um, you know, the, probably the most effective medication class for A DHD that for that [00:15:00] person that is crucially important. Or a health matter. You know, I've had some clients who, for medical reasons or due to pregnancy or breastfeeding, chose either were medically contraindicated or chose not to do it. So right of self-determination.

Now that said, going back to it being a viable option, I'll say, you know what, if you have questions, I mean, I can answer some based on research or, you know, side effects or profiles or whatever, but not definitively. But I, I remind people, and again, I can be like, I tell my clients I can spend your money quite easily, but I.

You could go in and, and meet with a, a prescribing psychiatrist or other prescribing physician and be handed a, a prescription, but you're not mandated to fill it. Uh, and you could go in and get the recommendations, ask questions, um, you know, personalizing the treatment. But, you know, even if you walk out with a prescription, you're not mandated to treat it.

It's information. And, and some [00:16:00] people, you know, and they'll ask, well, what's the best combination? And, you know, there are many cases where, you know, medications alone, just like eyeglasses. Not to minimize it at all, but some people say, you know what, once I got on the right medications, how one person described it at me, described it to me when he got started on prescribed stimulants was it buys me time.

I notice the distractions, I still hear them, but I'm not automatically pulled away. I can stay focused and continue, or. Before I'm about to go away from something, come back. Now again, it's not magic. Uh, you can still procrastinate, be disorganized, run late, um, and you know, sometimes that's people's experience.

They can focus better, but they're still having executive functioning problems. So sometimes the addition of the psychosocial treatment after starting medications alone and vice versa. Some people say, lemme try cognitive behavioral therapy, or, you know, [00:17:00] any other non-medical treatment by itself for a while and see how it goes.

And there's, you know, some evidence of CBT for adult A DHD where. One group was started with combined cognitive behavioral therapy and medications for A DHD and another group, um, either was I think all but one person never took a medication for A DHD and one other person did a six month washout. Both got better at the end of the 12 group, 12 weeks of treatment, but the medicated group got better, more, you know, more better than the, um, the non-medicated group.

But it, I think it was three and six month follow up. Then there were no significant differences between the group. So it took the, the non-medicated group, maybe longer to establish, you know, the coping habits or whatever the case may be. Now, one study, I don't wanna oversell it, um, but it's seeing how there are options if somebody doesn't want to take medications or doesn't [00:18:00] respond, can't tolerate the, the side effects, or maybe has a medical condition that makes it, you know, contraindicated.

So, you know, all options are on the table. Um, but you know, in terms of going through I'll, I, I review it as an option, you know, the evidence, but also, you know, reinforcing, you know, personal choice but also, you know, medical evaluation just to make sure there's not contra contraindications. Yeah. And I think that that's really interesting.

I didn't know about that study. It's interesting, it reflects how I often counsel A DHD patients about the difference between non-medication strategies and medication in that I normally frame it as non-medication strategies take a lot more work upfront, but they may, their, their effect may be more sustainable.

It may last longer, like five years, 10 years, 15 years. Medication may work a lot faster. And I think, like you said, I think it's a viable option, but I do worry about its longevity. Mm-hmm. Yeah, and I think the main reason I worry [00:19:00] about its longevity, and you can correct me if, if I have any of the strong, is I think most of the research about A DHD.

Medication is conducted on roughly a two year time horizon. And that means, of course, it doesn't necessarily mean that a DHD medications don't work beyond the two year time horizon, but it might mean that, uh, the effects may start to wear off. It may mean that side effects increase, people may have to switch between medications.

Some people may stop, uh, medications altogether. Again, that doesn't mean taking medication is a bad idea. And I think anecdotally, a lot of people report that it was still good to have a period of time on medication. It helped them in lots of different ways that could be to help them put non-medication strategies in place or even to get the sense of like, I now have a sense of what it's like to be not, not distracted.

So I have an idea of what mental state to shoot for. And then lurking in the background is some ideas around neuroplasticity, meaning could taking a [00:20:00] DHD medication for a period of time. Could it change the brain in some way? And this, it should be said, this speculation hasn't really been scientifically demonstrated as far as I'm aware, but that's kind of how I frame them.

Non-medication strategies, harder, slower to put into place, but may have more longevity and medication, kind of the opposite. What do you think about that? No, these are, you know, especially with the, like, the hypotheses about all the things and you know, the, you know, nobody's gonna fund the study, Hey, let's follow this group for 30 years on medications and see, you know, compare and contrast.

Uh, even though that's in a way what we need and, and some people will, you know, stay on them and everything you say is very, you know, reasonable and well thought out and clinically indicated and good information to share and ways, you know, things to contemplate. You know, one thing I'll add to that is some of the just published within the last year or two, um, Margaret Sibley.

[00:21:00] Is the first author as part of a larger group and part of the MTA study, the largest study of, uh, combined an individual medication and psychosocial treatment for children back from the nineties that they're still doing, uh, follow-up studies on tracking them over time. Now, this was about the diagnosis of A DHD and tracking, tracking the symptoms from childhood through adolescence to young adulthood, mid twenties.

And this does apply hopefully. Um, and what they did is, and they had the group without a DHD and did follow up evaluations just to see do people catch A DHD later on. Um, but also the, the children with A DHD tracked over time to the mid twenties. And what they found was, I mean, the, the broader takeaway, uh, the children diagnosed with A DHD, there was I think a 91% persistence.

Um, [00:22:00] between the starting time and the end time. Now, within that persistent, there were some that were persistent every time, but very often there, they, there was a certain percentage, I, I forget the exact number, it might have been in the 30%. It was either in the 35, 30 6% range or like the 63, 60% range. But at some follow ups, they would be sub-threshold for a while.

So maybe at age 12, uh, let, let me bump it up at maybe at age 15, they didn't meet the full criteria, but then again, at 19 and 25, they did something like that and they, you can't, there it's more conjecture about what might explain it, even though it seemed like, it wasn't, like it was totally gone. It might be sub-threshold or be below a certain threshold.

And it's not like it, it's cyclical, but part of the hypothesis about what's going on is. At certain times, at least based on just, I, I think anecdotal accounts from the [00:23:00] people going through the evaluations is maybe there's some threshold of busyness where this, between school and maybe work or other things, the schedule becomes, you know, in that sweet spot scheduled enough that you have to do things that if you don't do them, if you don't study after work or something like that, you fall apart, but not so busy that it's overwhelming or lacking busyness, that it's hard to get motivated.

So even how a persistent, uh, presentation of A DHD can go up and down over time, but projecting that into the future about, um, going on and off medications or even going in or, uh, in and out of cognitive behavioral therapy. 'cause I have many clients who will come back periodically for booster sessions or after a few years, um, there may be certain environmental setups.

Getting at a job that works for you, that over time you build up the habits for managing the job or a family situation. [00:24:00] There's a scaffolding that is more a DHD friendly. Um, not that everything is better all the time, but it can be a lot better where somebody goes, I'm on top of this. I have ways, you know, the accountant takes care of my taxes nowadays.

And it's, it's much more manageable, uh, maybe without active treatments at time. But, you know, um, a a, another voice I've heard about the maintenance of treatment though is, you know, if, if you're not in treatment, and this is more specific about the medications, um, there, there may be some risk. I can't cite a chapter verse of a study, but there would be some concerns about some of the long-term effects, like on.

Managing health and some of these things, which is a problem for everybody. Again, going back to the dimensionality. Um, but you, that would be, some of the concerns may be voiced about A DHD, but again, right of self-determination, that's where clinically, you know, any [00:25:00] individual circumstance might be, Hey, I'm doing well.

I, I'll call you if I need you, but, um, I'm, I'm doing well on my own right now. Yeah, absolutely. I always tell patients they're in the driver's seat when it comes to A DHD and, and, and the good thing about A DHD in contrast to other conditions, you can name, there's a lot of things you can do. There's nothing that you have to do.

So they are actually, they do have people with a DH, ADHD do have the luxury of choice. So they can pick and choose different interventions at different times of their lives. As you say, that suit them, that suit the particular difficulties or challenges they're facing. I think it's interesting what you mentioned about the cyclicality of symptoms that they can wax and wane with time.

I have seen that clinically, you know. From some of the ages you described, I think between 12 and 20, I would wonder about puberty if part of A DHD is like impulse control. I would wonder, I'd wonder about the effect of testosterone in that in a young man, you know, and hyperactivity of course. And in the female [00:26:00] population, what I hear reported again and again is, yes, I think I've always had these kinds of A DHD symptoms, but when I hit menopause wow, did they get amplified?

So that, especially as female A-D-H-D-A-D-H-D in women is getting more recognized. This is something we're seeing more and more in the clinic. Right. And senior adults with A DHD at the same time. And Sandra Koi, K-O-O-I-J in the Netherlands, and many of her colleagues too. Um, they're, they're doing a lot of groundbreaking work on, uh, perimenopause and menopause and women.

And actually while I was at, uh, the University of Pennsylvania, a colleague. Kay Neil Epperson, and she's at the University of Colorado now, and very a leader in women's health. There was also a study that she collaborated with Dr. Tom Brown on of the Brown Attention Deficit Disorder scales and world renowned A DHD expert looking at women without a history of A DHD, who [00:27:00] in menopause started having features of it.

Now, they did not have the neurodevelopmental syndrome of A DHD. I get what you're talking about there. It could be many adults who say, oh, I never thought I had a DHD until 30, 40, 50, maybe even 60 and beyond at sometimes. Um, but these would be women with without any history of A DHD. But you know, going through perimenopause and menopause, you know, felt like it.

And, you know. They found that, uh, they did a study using a prescribed medication for A DHD and found that these women had benefits from it. Um, so it's sort of a reverse it, you know, a circumstance where it's not A DHD, but there's a lot of similarities where, you know, an A-D-A-D-H-D medication, uh, was helpful.

Right. Okay. So now diving deeper into non-medication strategies. You know, someone, a patient may choose medication or choose to disregard it, but regardless of that, if someone then comes to you and they say, okay, I want to know like, what are the [00:28:00] most important non-medication strategies I should consider to manage this?

How, how would you advise them? You know, clinically it would be sort of like what they're looking for. Is it academics work, you know, uh, whatever it may be. But broadly in terms of evidence, support, medications, and cognitive behavioral therapy are the two most well evidence supported. Now there's a lot of.

Just like there's probably a lot of medications being studied or being development, being developed. There are, uh, there's a lot more psychosocial needs because generally the cognitive behavioral therapy has been either individual or in group settings, um, has been very helpful and that gives a lot of flexibility.

But, you know, things like, um, adult A DHD coaching have a growing evidence support. There are some emerging, uh, approaches looking for couples and family members with A DHD, you know, both the partner with A DHD and the non A DHD partner. So there's a, uh, a [00:29:00] variety of things that aren't yet too well developed where they're out there.

But obviously meeting needs and as Steve Ferone would remind me, you know, uh, president of the World Federation of A DHD and overall good guy on top of that and very widely published and knows what he's talking about, but said, you know what? Even being evidence-based, we can admit, hey, here's something that might be helpful, but there's no support for it yet.

Um, like that's where, you know, you know, some of the mindfulness based interventions for A DHD are at, they have some support. Um, and these can be helpful, um, on various fronts. Now, some of the ones that people bring up, commonly neurofeedback training, that's one where there's not enough clear cut positive evidence of it being effective more than placebo.

You know, some studies yes. Some studies, no, but it's generally, I. Out there. I don't hear as much about it anymore myself, but you know, some of the other ones that [00:30:00] are available, but maybe harder to study, like academic support and academic accommodations. Now actually with the academic support, that's one of those where A DHD coaching and dealing with college students, with academics, some of the, the growing research support for it, that's where it comes from.

Even though there are some other studies looking at, you know, adults and again, some more studies in the queue and developing, you know, there are things like exercise, you know, especially aerobic exercise, that there's research saying that it can be helpful. Some, uh, one the overall health benefits, but also some, uh, short-term, you know, time-limited benefits on attention and some of the other features of A DHD, but I'm not sure, and maybe it's just.

Definitions, but, um, un unless there'd be some sort of protocol, I'm not sure if it's anywhere near where we would talk about it [00:31:00] being a treatment protocol, even though like, I'll tell my client, spoil or alert exercise is good for you. Um, and, you know, in terms of some of the supplements, again, it's sort of a mixed bag of what works and in what combination.

Um, you know, there are some things like the concept makes sense, uh, but again, and dietary restrictions, uh, apart from people with documented food sensitivities, food allergies, and again, going back to, you know, us, both of us being clinicians, Hey, if you take this food out and you're doing better, keep doing it.

You know, what works for you, even if it's, you know, 'cause yeah, when we're talking about the studies, we're talking about overlapping curves and not everybody gets better with the studies. Um, even the effective ones, there's a lot of people who might need more, or just like with medications, partial response or can't manage the side effects [00:32:00] and psychosocial treatments have side effects, the cost, the inconvenience, the time investment, uh, you know, things like that could be deemed side effects that could interfere with their use.

Yeah, and I guess with a lot of these non-medication strategies, I worry about the problem of not necessarily signs that disproves them, but simply a lack of studies in the first place. So I'm not aware of how, how many studies have been done to test how well exercise helps with A DHD or how well certain diets help or certain supplements, importantly.

Right, right. Uh, I tend to take quite a common sense, pragmatic approach with these things. We know that exercise releases a lot of the same chemicals in the brain, that medication with chemicals like dopamine or neuro adrenalin. And anecdotally, you know, patients very often report that exercise helps with their symptoms.

And you can certainly understand how it could help with relaxation, uh, impulsivity, sleep problems, [00:33:00] restlessness. Yes. And then, and so it goes with nutrition. There might not be a clear food sensitivity or allergy, and yet clearly we know we can have a common sense approach to what kinds of diets are more likely to support the functioning of the brain and, and what are this.

Um, and so I tend to, there are some resources I assign and post patients to, but in general trying to, I, I generally counsel patients to avoid foods that are like overtly junk foods and try and, you know, go to the common sense, good nutrition, the protein, the good mix of fruit and vegetables, et cetera.

And that's the kind of advice I give around that. Diving deeper into the psychological role, which of course this is what you specialize in. What does CBT for A DHD look like and how does it differ from other kinds of CBT or more generic CBT? That's a great point. Um, and I wanna start that with, um, citing a study that came out of the UK again within, I think within, still within the past year.

But what it [00:34:00] was, it was, um, I think I have the number right, 46 individuals who had completed cognitive behavioral therapy through the NHS. And they, uh, completed a course of cognitive behavioral therapy for, you know, for adult A DHD and all 46 completed surveys. And I think 10 of them were selected for interviews about their experiences.

And the results were awful. People saying, I felt worse at the end of treatment. It didn't seem like my clinician knew what they were talking about. They rigidly followed the protocol, whatever it was. And what that speaks for me is, and, uh, let me finish up, but one of the interviewees. Uh, had described that they had a clinician, their therapist was very familiar with A DHD, and they described the treatment as transformative.

I understand my brain and how I can make it work, um, without, you know, comparing myself with it. I can find my own way and, you know, fashion things my way and I'd have to go back and look, but my assumption is [00:35:00] probably some very well-trained cognitive behavioral therapists, uh, for anxiety, depression. And I think if I didn't put it into the blog, I would raise my hand and said, that could've been me if I had not accidentally ended up.

So these are probably very good therapists, but it's a little easier going from cognitive therapy or cognitive behavioral therapy for depression to anxiety and some other things, whereas A DHD, if you're not familiar with it, even apart from making the diagnosis in the assessment, but. How it affects lives and the things that, yo, I know I should start earlier, but I still procrastinate.

Things like that, the performance problem rather than the knowledge problem. And if the cbts not adapted to that, we have evidence about, you know, this study is evidence about what happens. So this is a, a little aside, but you know, this is why A DHD is still a niche specialty. [00:36:00] And later on, if you ask me the question, well, where do people go to find somebody who does this?

It is still hard to find people, at least my experience in the us I would imagine in the UK at least what I remember, some reports about the waiting lists and, you know, things like that. So, I mean, there are people there, but there's only, there's only so many. So all that, going back to, um, how does it look different from say, cognitive behavioral therapy for depression or anxiety?

The, and I, I say this respectfully. Um, the, the fee, the feeling good approach, the mind over mood approach, which are excellent. Change those books change lives and those approaches change lives. But with A-D-H-D-I think it's understanding A DHD and the executive dysfunction focused, like what I describe my approach.

I say it's very implementation focused. So there are still things like, not procrastinating starting earlier, but like with procrastination, I, I think, uh, part of it is reverse [00:37:00] engineering procrastination into all the different steps that go into it. Some of it is, oh, I, I don't have a plan for what I have to do, so it's probably never gonna come online, or I'm never gonna want to do it.

Or even if I have a plan, I might think myself outta doing it. Oh, this is too much. I'm no good at this. Some of the classic CBT stuff, uh, the emotions, ugh, I don't feel like doing it. And escape behaviors, escape avoidance, which is the most common behavioral reaction in adulthood. Um, now with those things.

It's also having a template for, okay, if we can break down procrastination into smaller steps, um, that are actionable, doable, and you believe you can do it cognitively and you can tolerate the likely uncomfortable emotions that go along with it. I don't feel like doing it. The Motivat, which is also the motivational feature, um, at least now we have a couple different intervention points.

It's not just start earlier, start earlier, start earlier. That can be [00:38:00] customized. And very often clients, you know, going back to the clients know best and you know, even some of the strategies that come up with, I've learned from clients and just share them, um, because the creativity that comes from workarounds for A DHD, but now if you have a couple different points, people might have their one or two go-tos.

Okay, if I can do this and this, I'm more likely to. To follow through with my plan or use the planner or whatever the goal is. And these tools are usually as a part of some sort of coping domain or area of difficulty, then I can be more on time arriving to work or to school or to class or getting ahead or an, or at least an earlier start on projects I have to do for work or school or at home or things I have to do as a parent or running a household or other things including self-care.

Um, so in a way these, this sort of executive functioning scaffolding and the [00:39:00] time management, and there again, people can be creative and find their own ways, but usually involves some sort of planner system, digital or otherwise. So I think that's something that's maybe not foreign to cognitive behavioral therapy.

'cause there's activity scheduling. For depression. And somebody who's depressed won't feel like doing anything. And even if they come up with a schedule, they may not do it. But that's part of, you know, the behavioral activation. And likewise with exposure treatments for, um, anxiety, I really don't wanna do this.

And, you know, it carries over with, you know, some of those tips and tools in, in addition to the fact that those are probably the two most frequent coexisting diagnoses with A DHD Depre, some form of depression or anxiety. It maybe even sub-threshold, but it is hacking some of those things. But it is the customizing it to A DHD and I mean, my friend and colleague and world expert Ari Tuckman, [00:40:00] uh, has said that these are the Ramsey, the Ramsey grandmother rules, because I say these are the same thing our grandmothers would tell us.

Break a large task down into small steps. But I think with a DHD and the working memory difficulties where we hold onto information, which also guides behavior, these are the things where the, the, the steps are slippery and they fall out. So maybe even having externalized lists and recipes for what we're gonna do, that's why externalization of information in a planner or a journal or, um, and again, sometimes it is, uh, you know, writing down the steps and I see it in, in, you know, some of the, uh, the adult A DHD client manuals or the, the coping workbooks, if you will.

It's like having the steps out there. Here's what to do because not, and again, this is not meant to be diminishing anybody, but it's, it's personalizing that being able to see these steps, I'm more likely to do them. Because I don't have to spend as much cognitive [00:41:00] energy figuring them out or fits and starts and things like that.

Now that's just one example about how a DHD has to be customized and probably why in that study I mentioned so many people had a frustrating experience because they were probably getting classic cognitive behavioral therapy that would help a lot of other people. But without it being customized, that's, that's where, um, it fell apart, at least in that study.

Yeah, that makes a lot of sense. And I, I think, I love the stairs are slippery analogy. I've never heard that before. 'cause when I think about CBT typical CBT for anxiety or depression, it's predicated on the notion that if you have a basic understanding of how your mind works, how your emotions, thoughts, and behavior kind of interact with each other.

Once you have that map, then you just have to follow a certain steps. So thinking about, let's say mild to moderate depression. Someone may, when they feel their mood is low, that's the feeling. They might have negative thoughts [00:42:00] and between the mood and those thoughts, their inclination, their their behavior might naturally be, well, I'm just gonna stay in bed all day through CBT.

They realize, oh, actually, by doing that behavior, all that does is also further decrease your mood further cause negative thoughts. So you have to kind of short circuit that system by doing a different behavior. Often the exact opposite behavior to what you're inclined to do. So if you feel the low mood coming on, what you do is you make sure you get outside, get some sunshine, speak to some friends.

You might not feel like it before. You will feel a lot better having done it. And then you short circuit that system. That works great for depression, works great for anxiety. I see the problem you run into with A DHD because on the core features of A DHD. Is an inability to translate thoughts into behavior, what we would call executive function the first place.

So the stairs are slippery, as you said. So I can see that having a form of CBT where you really, really focus [00:43:00] on what are the obstacles that people face between thoughts and behavior or emotions and behavior to a high level of granularity that you wouldn't have to focus on otherwise. That's like caused the treatment, I guess.

Yeah. Yeah. And one thing I'll add with that, this is where I also think and, and there's a lot more, and um, thankfully, so discussions about the therapeutic relationship, the therapeutic alliance, and cognitive behavioral therapy, because I think with, when. I, I think it's always been there. But when, uh, cognitive therapy, cognitive behavioral therapy came on the scene, like Dr.

Beck started his work in the 1960s and seventies, and then the late seventies is when the depression manual, I guess there was a depression book, like, um, I, I think it was 72. Um, but that before the manual came out, but it was more about like the, the technique, the manual. Um, but I, I, especially with adult A DHD, that connection, somebody who gets it because usually and [00:44:00] normalize, you know, like one of the reframes I find very helpful working with clients in CBT is normalizing, you know, that yeah, there's gonna be slipups and even with the person that you see, the, the, your, your friend, the student or a coworker who looks like they have it all together and well, they're still using a planner and they procrastinate sometime.

Or even if they get their homework done, they don't wanna do it. Um, it's, it's still somewhat of a struggle. Not as much, but it's that dimensionality. It's in the ballpark, but this is something, it's, it might take a few more steps or explicit steps here, but being able to hear that from somebody who goes, ra, I, I don't think any of the therapists would done this, but some of the messaging that many individuals with A DHD get, it's sort of like, why don't you just get started?

Or how hard is it to pay attention? Or, you know, it's due in a week, why aren't you starting now? Or all these things. And you know, it's, you know, being able to sit, not, not that it's, [00:45:00] oh yeah, there's nothing you can do, let's just have a pleasant meeting. But it's like, Hey, that may, let's, let's find a step that's right for you.

And it might take us a little while, um, but, you know, we can, we can try things on, you know, for size it might take a little while, but we can get there where it's at least better in some way. Yeah. Yeah. Uh, going into focus more, obviously a core problem with A DHD is difficulty focusing one's attention on something specific for a sustained period of time.

What are your thoughts on the malleability of focus? Is focus something that we can train? Can someone with A DHD improve their ability to focus, train it like they would a muscle? How do you think about this? It's a great hypothesis, and I think what we're talking about here is like focusing in day-to-day directing focus and moving it around and, you know, um, you know, the, the focus, the attention allocation, if you will.

You know, the neuroplasticity, you know, my hopeful side [00:46:00] would say it would seem like there are things that we can do that can at least make it better. Again, I, I'm usually a little bit, just more conservative on this. Uh, the example I use, you know, in a session with me, it's not going, okay, we're gonna focus on your focus today.

Look at my notes for 10 seconds. Take a break. Let's see if we can get it up to 20 seconds by the end of the day. But I think focus might be a side effect, at least as you know, with your great question, how I'm thinking about it right now as part of the overall, well, what is the flow of your day like?

Also the rhythms that come with focus and energy about which there are, there is some evidence about this, maybe not specific to A DHD, but how we have rhythms in the day where maybe earlier in the day we have more focus and there's a mid-morning, later morning dip, and then it comes up again maybe later in the afternoon than down and with A DHD.

That might be more variable all the time, maybe, but it's playing to your strengths, including things like. [00:47:00] If you tend to be more focused in the morning or right after your medications, uh, activate, for lack of a better phrase, uh, what are things you wanna do during that time of day to take advantage of this?

And when you're at a lower ebb, how do you know what are some things that that might be better for, you know, things that might not be as cognitively demanding, lower cognitive load, but maybe still work, or heaven forbid, a break or exercise or other self-care. You know, things that can also help replenish, um, our cognitive resources.

So my, my first, you know, reflex is how does it all fit together? Focus being another resource, just like energy. And because thinking is hard work. And that's the other thing about A DHD. Um, you know, usually, you know, it seems like, you know, for my money, procrastination is probably the most common. There's a lot of thinking that goes into procrastination.

I should do it now, but I don't [00:48:00] feel like doing it. Let me do this other thing. And then they'll get to it. It's like all day. And that, that is tiring. Uh, and the mental is physical. You know, what, what is the, the brain is like three, you know, three or 4% of the body's mass, but uses at least 20% of the energy.

I, I sort of see it as another resource, a time resource, if you will. This is the personalization of one's day to the degree that we can, school and work doesn't always cooperate with that. Um, as well as things like interaction with social media or technology and I, I like the phrase the choreography of things.

I think with that comes, you know, getting the most out of the focus available and also things that I. I would say including getting engaged with something. Now this could be a have to like a project for work or school, but usually people say, I feel better getting something done. But then if there are things like exercise, you know, good health practices, including [00:49:00] things of interest, uh, it could be, you know, dose dependent video gaming or whatever somebody's into or exercise things that can, you know, improve the overall brain health, but also maybe, you know, help with focus too.

So that's a very long-winded. I think there are things that we can do to one, make better use of our resources, our cognitive resources, um, interacting with the environment and respecting our flow over the day. Um, as well as having downtime, which I think is underutilized. And that's part of what sometimes gets lost with a DHD 'cause spending all day not doing something.

It's not like somebody goes, I'm taking the day off. I'm gonna take care of myself and then I'll come back tomorrow. No, it's all day not doing it. Also maybe not doing the fun things, including exercise or other things. So, um, I think it's that overall picture and that, you know, focus is one of those crucial resources.

So it's a long-winded, you know, I think there are some things that can be done, even though like if somebody's coming to me, this is an [00:50:00] example I use with clients and they say No, I'm on time with things. You know, for meetings, I hand in things on time. I'm not pulling all-nighters, but I really have a hard time reading text.

Not text, like any text. It could be online books and comprehending what's going on. I'll say, we can talk about your attentional vigilance and the, you know, when you do it, how long, you know, what's your attentional endurance. So you don't try to make yourself, you know, you read 30 minutes at a time and take breaks.

But that would be something more, I think the purview of medications where that sustained attention on, you know, cognitively demanding tasks. I wouldn't be all or nothing about it. 'cause again, if somebody can't take medications, but there might be the reality of. Maybe reading 30 minutes at a time. It might take you longer to get through the chapters or what you have to get through, but you know, finding something that works for you with adequate, you know, breaks and, uh, restoration.

Yeah, I really like the point about how to choreograph your day. I mean, as someone without a DHD I've become way [00:51:00] more conscious about how I might plan certain aspects of my day based on how well my mind happens to work at that time of the day. You know, there's definitely, there's a time of the day where I'm gonna slot in my hardest, most concentration laid in work, and then there's a time where I'm gonna do my most sort of mindless admin, and there's everything in between.

And I think mastering that dance is very important. I think more on the focus issue. I have noticed a lot of people's experience with A DHD is they, when they try and focus on something hard and there's a rush to try and get it done as quickly as possible. Then there's a quick frustration. There's a sense that this should be way easier than it is, or I should be able, you know, negative thoughts can come in with that.

Like, I should be able to do this. This is a sign of me not being intelligent. All these self-critical thoughts, et cetera, et cetera. So something I found really helpful when I'm counseling people with A DHD psychologically is if they're engaging with something difficult, trying to engage with it with a much, much [00:52:00] more relaxed manner, much more of a low bar for success.

I'm more just saying, okay, I'm gonna engage with this for 10 minutes or 15 minutes. I'm gonna do my best. And then maybe see where it becomes a little bit uncomfortable. Maybe go slightly beyond that and then stop. Which is exactly what you would do if I, if in another life, if I became a fitness trainer.

You know, that's what you would do with weights is you wouldn't say, okay, everyone else seems to be able to bench a couple of hundred pounds. So you should also do that. Go and bench a couple of hundred pounds. You in yourself, rather, it would be pick a weight that you can manage and do it for not very much, you know, eight to 12 reps until you get a bit tired.

Maybe push slightly beyond how tired you are and then stop and take a break. You do that, you know, nine times a week and your muscles are gonna grow. And I think, at least very anecdotally, that's what I've seen with my patients and clients, is you take that somewhat more subtle thing. It's almost like a mindfulness thing.

[00:53:00] You take a slightly more relaxed stance to what you're doing. Try not to rush to the end, try not to have a lot of rigidity about the outcome. And then I've found that the, their focus does actually tend to improve over weeks and months. So it's a long process, but I've, I've found that can happen. That's, no, those are excellent points.

I a hundred percent agree with that. And again, it, it's sort of, you know, sometimes popularly known as chunking and, and it, it can be. You know, sort of like, well I just wanna get it done and out of the way, which, uh, which is understandable, but no, exactly what you say, it's breaking it down. You know, I would call it a bounded task.

You know, the example I use, somebody drops you in a body, a, a large body of water and you're told swim, and there's no shoreline or nothing to give perspective. You don't know how to swim or you're gonna tire yourself out, you're gonna sprint or whatever. Um, but you know, we're creating shorelines so we can calibrate.

And that could be time-based. Hey, work on it for [00:54:00] 10 minutes, see how far you get and reassess. Or it could be a task bounding, write for a hundred words. Just get a hundred words down, see how you're doing. And that sort of incremental pacing and seeing like, okay, I can go another 10 minutes or another a hundred words, or, you know, whatever it is that building up to, rather than setting, I have to do the whole thing, which is.

Vague and non-specific and can be overwhelming. It's like, you know, swimming, you know, swimming in a large body of water, but not knowing how far it is. But once we know how far it is, like you said, like with weights, I know I can do this, it's tough. Or five more minutes on the treadmill, we can adjust our expectations.

'cause we, we have that perspective and, and a reframe I go to in a lot, I call it enoughness. I have enough focus to keep going and it also gets at a sense of self like, you know what, even though I'm not great at school, [00:55:00] I'm enough to get through or, or I don't like it or it's hard, but there's enough that I can pass or do a good job.

And this is putting aside just to make sure I cover it. Every now and again, you might've had this, somebody at university who eventually decides what I want to do. I don't need to be in school for, I'm really more passionate and better at this. This is something I can learn by example or get trained in, or, you know, it comes to mind.

A, a young man I was working with in college who had a, a wonderful summer job as an automobile mechanic and working on special cars and like, almost like an apprentice, an apprenticeship. And he learned better that way. And I, I don't know about you, but my mechanic gets enough money from me. It's not a bad job.

And especially if you enjoy it and think about it, it's problem solving. I, I'm thinking some mechanics I had, they were like surgeons with a car, how they figured out and diagnosed the problems. So these are not just, you know, that sort of skill doesn't always [00:56:00] require school. So sometimes somebody's in the right, wrong situ, you know, a, a mismatched situation, but bringing it back and even something like that, it might be somebody needs to take a break.

Okay, I've worked on three cars in a row, I need to take a break. Because now I'm getting frustrated, I'm missing details. I need to respect my endurance. And an analogy I use, and I'm going to use and you will appreciate this, the correct version of the word. Um, I played football for many years and not American football, as you can see, but a good footballer finds their rest on the field and it's sort of that pacing, you know, running for 90 minutes and nobody sprints for 90 minutes.

Uh, but how do you find the pace that choreography again, to make it through the whole match? Yeah, and it's so funny how all of these skills, I think they really apply to A DHD of course. And I think they also apply to anyone that's pushing themselves beyond their boundaries. So even high [00:57:00] functioning individuals I've worked with who don't have A DHD, they just really want to push it to the limit and be like, how successful can I get?

Because both groups where they have a DHD or you're trying to get really, really successful. You're pushing at the edge, funnily enough, they tend to require similar strategies. Yeah. And even, even folks day to day who just start feeling overwhelmed and, and maybe start procrastinating, like I've had colleagues say that they will sometimes, um, recommend, you know, a DHD coping books for their clients with anxiety or depression because it gets at some of these things and breaks it down in a really user, user friendly way.

So that's another reason why a lot of people say, well, doesn't everybody have A-A-D-H-D? These, uh, you know, two quick thoughts. One, these, these ideas could help anybody. And second, there's, um, a concept known as universal design. And I got this on a book [00:58:00] about like learning differences, but it, it, it hearkens back to architecture, making buildings accessible for everybody.

So that's like having ramps and you know, in addition to stairs and other ways to make it useful. But how this idea got carried over into, say, education and some things that are more commonplace now. Like rather than if in grade school students have a big research assignment, okay, this is due in a month and here's what you have to do.

That didn't work for a lot of students, and even the ones who were able to do it probably had help from their parents. But nowadays, and it started with students with learning differences, graduated deadlines after the first week, bring me your proposal, then bring me your outline, then bring me your first draft, second draft, and then hand in the final project.

But now that is not a hundred percent, but my experience over the years is that's a lot more of how assignments are offered [00:59:00] because it helps everybody. Rather than, you know, oh, I got this big assignment, where do I start? It's gets broken down part of what, you know, it's part of what executive functions do, but if we can lighten the load, then we have more energy.

Anybody has more energy, you know, for other, for other matters. So it, it helps everybody, but it's essential for individuals with A DHD. Yes. Something you said earlier where you had an experience of a client who was part particularly good at practical things. Mechanics. That's something I see all the time and it's widely reported anecdotally that people with A DHD often really good at hands-on tasks, sports, things like that, and that feeds into this wider conversation about A DHD.

That is something like, is A-D-H-D-A disorder or condition or is there a small, you know, 5% of the population that are adapted to a very different kind of world than modern society has developed into? [01:00:00] So is it that a DH people with A DHD have a disorder or do they have natural strengths, which were really advantageous in the past, but are less advantageous now?

Would people with A DHD thrive in an environment with, you know, constant different stimuli that need to be paid attention to? Rapid switch of attention, uh, rapid novel tasks that are completed quickly, uh, tasks that are hands-on and practical as opposed to abstract and prolonged into the future. There's this real conversation around autism as well, which is similar as autism and disability or a difference, and I think you can have that debate about A DHD.

Is A-D-H-D-A disability or a difference? What are your thoughts on that? Well, this goes back to that study I mentioned before about dimensionality 'cause that would say it's a, it's, it's a difference. It's a variation. Among, you know, the, the, a bell shaped distribution. I know executive functions are more complex than that, but, [01:01:00] you know, uh, uh, distributed within the environment and that's where context matters.

This might be a little all or nothing, but a line of use before is A DHD is not environmentally caused, but it is environmentally bound, like the setting. That's sort of what we all do. We have these skills and abilities and the things that are not so much so, like the car mechanic. I'm not the most mechanical guy.

I'm a pretty good problem solver, you know, but, you know, I think I found a pretty decent niche with this. And, and likewise, somebody else maybe wouldn't be able to stand my day-to-day job, but something else that I couldn't fathom they can do. But with a DHD, you know, it, it's an interesting question. You know, it's something I ponder a lot.

I, that's why I like the dimensionality. Now, within dimensionality, there are some, there can be some things that extreme ends, like extreme underweight. Extreme overweight. I think there is an end of it. It's a, a style, it's a profile that sometimes [01:02:00] requires some support to fashion a better fit or, or to find what's a better fit.

But you know what, there, there's also some elements with it. An argument could be made. This stems from the mismatch, if you will, that you know, the mood, the anxiety, the somewhat increased risk for, you know, suicide attempts and completed suicide. And, and like the health issues of like increased likelihood of smoking.

Um, other poor health practices that, at least in some research has said by age 27, uh, a health profile at age 27 on a group of children with A DHD tracked into adulthood. Um, now these are often changeable behaviors, but that they're on track for a reduced estimated life expectancy of more than a decade.

Based on the, the health profiles that, that mid twenties age. So I, I guess I'm, you know, how, I guess me, a cognitive therapist in me, I'm hesitant to totally go, like, it's, it's all a style. Um, [01:03:00] because it, it can't be associated with impairments. And again, these are social constructs about, well then, you know, protection under the Americans with Disabilities Act type of thing in the US at least.

Um, but I, I think within society, and I guess more the, the work, you know, that we do in our field, how we frame the treatment and how the frame, the, the approach. Yes. In the US there might be certain requirements that my clients who submit their receipts for my services into insurance company have to put down that are DSM and whatnot.

But, you know, every session, I'm not saying, Hey, our agenda today is we're trying to reduce your disorder. It's like, what do you wanna do? How, how can we help you do what you wanna do? Right. Of self-determination and, and betterment. Not any sort of, you have to contribute more to the gross domestic product, however you Yeah, I got asked this question one time.

It's like, I, I, I think it was from somebody who had a bad experience with CBT and it's like, well, what are your goals? I said, well, it's client's [01:04:00] goals. Uh, I mean, it's like I'm there to help them and to fashion them into doable goals if it's maybe a little too much, too quick. But, and it just seems like they might've had, you know, it might've been like that, that study I mentioned before where somebody got into a really strict classic CBT that wasn't adapted.

So it's really, you know, hope, hopefully meant to be humanizing and empowering. Um, what can you do and personalized, and, you know, you know this too, and the incremental improvements, it's really important to acknowledge those that you know as, Hey, you're, you're more on time nowadays, or your grades are a little better.

Or even before the grades, it might be you're handing you're finishing assignments and handing them in a day early or hours early, rather than minutes early, or. You know, sadly before maybe minutes or hours too late, which it would affect rates more than any of the quality of the work. So those things, I think, and, and it, it's, it's also that dealing with that less than [01:05:00] mindset, um, oh, everybody else is better than me or they can do this better, what's wrong with me?

And, um, which can have manifestations and we could argue whether that's a failure schema or an an inadequacy schema, it's probably the same thing. It's like that, that not just the messaging from others, but just the social observation that we all do. Oh, everybody else gets better grade, or I'm always late, or I left my, I, I forgot to upload my assignment, or whatever the case is.

Um, sometimes it's the natural calculus that we do and it's sometimes not wrong, but that's where the understanding of A DHD and then how we approach it gets personalized and it becomes more that enoughness and empowerment hopefully. It's really delicate bands, clinicians have to strike with a DHD. How do we help people to understand target, acknowledge certain problems, while at the same time empowering them that hey, you know, your reality is malleable.

[01:06:00] There are things you can do. This doesn't have to limit your success. Um, and can come with natural strengths as we've described. 'cause you know, a lot of the criticisms of A DHD diagnosis, and there's a lot of talk of over-diagnosis of A DHD is of course, that by giving someone a medical label, they, they have something they can use to justify, kind of restricting themselves or so, or something that encourages limiting beliefs.

I have a DHD, therefore I can't. And obviously as clinicians we want to avoid that. 'cause you could say that's a form of medically induced or igenic harm, you know, by, by giving someone. Label, I think in the wrong way. You can, it's kind of a prison you're making for them. You're saying, you know, you're, you're, you can sub subconsciously imply they're limited in some way.

You definitely want to avoid that. At the same time, if someone's had assistance set of problems throughout their whole lives, it can be very invalidating to say, actually this [01:07:00] isn't a real thing. So quite a delicate balance we have to strike. Yeah, I, I like, I mean, I've, I've probably heard it said different ways, but I remember Alexander Phillips in, in Germany, a a psychologist, a leading, you know, leader in the field, um, has modified dialectical behavior therapy for adult.

A DH. ADHD was a lead researcher in one of the, probably the biggest, you know, psychosocial and medication and randomized crossover design in history. Uh, but she said, you know, she said about her approach, it's balancing acceptance and change. You know, some, some of it is acceptance. Okay. Every now and again, I'm gonna get off track or I'm gonna procrastinate.

Um. I can bounce back and, you know, stick with, get back on track, which is also the name of the game in CBT for adult, A DHD. But you know, uh, you know, going back to some things you said, um, again, one of these phrases that's out there in the field that I think we all borrow from each other [01:08:00] is, um, you know, A DHD is not your fault, but it is your responsibility.

And even if it's your and, and a point I'd like to make too, though, adding to that, even if it's your responsibility to manage that, doesn't mean you have to do it solo. It's reaching out for help. It's, you know, maybe working with loved ones and, you know, even within a household and, and accommodation can be, oh, I keep forgetting to keep track of the bills.

Can I hand that off to you? And I'll be in charge of, you know, taking, taking out the garbage and the recycling each week, or, you know, other ways that, you know, can be a win-win. You know, for somebody with A DHD, but also somebody else who goes, yeah, I'd rather take care of this chore than do that one, but all these things that, and maybe are going on out there already.

And yeah. And there can be that view that, oh these are people looking for an easy way out. Some of the hardest working people I've known have, you know, are the ones that I sit with who have a DHD because as one of my [01:09:00] colleagues once said, you know, it often involves working twice as hard for half as much, like procrastinating all day and then working on it at night.

They probably worked 18 hours that day, um, getting the one thing done, which is as tiring as it is for anybody else. But that's not somebody looking for an easy without, that's somebody struggling to, to get it done. And, you know, there are things that we can do and changes to be made, um, that you know, are part and parcel of a typical profile of A DHD, but don't say that person's not working hard, we're just trying to help them again, utilize it sounds clumsy, but utilize resources, choreograph so.

As much so you can enjoy time with your family, doing your hobby, doing things that you enjoy, that are enriching, uh, the want tos, which can also fall by the wayside due to disorganization. Oh, I miss my yoga class, or whatever. At the same time, taking care of your roles and responsibilities, whatever they may, may be, but also not that [01:10:00] tho those can also be rewarding even though they may not be fun.

That sort of like goes back to Dr. Beck and, um, behavioral activation or activity planning, mastery and pleasure tasks, pleasure tasks or things you do for recreation for fun. Master your tasks that you have to do and maybe you feel you feel accomplished getting them done, or if not accomplished, from an existential standpoint, it just feels good.

Like, okay, homework is done, the garbage is out, you know, it's, it's nice getting them off your plate. And the worst are the, the gray tasks. That's what I warn people against. It's not the pleasure tasks. Very good. It's not, it's not watching your favorite show after you've had a good day. It's not taking out the garbage.

It's that gray task. It's watching a YouTube video about a subject I already know quite a lot about or watching a movie for the 20th time because I'm delaying, fill in the blank. The great tasks. When I do, I do some coaching with people, and when I do [01:11:00] coaching, the great tasks are the ones. That's the way you can find the most time.

If you want to start a business or learn a new hobby, that's the, you have to target the great time. Very good. That's an excellent reframe. Yeah. You, you wrote a really interesting blog post about social media and A DHD specifically. You know, social media is now increasingly a place where people find out about A DHD and maybe find out they fit a lot of that symptom profile.

A lot of people come to assessments being like, you know, I was on TikTok or Instagram and a couple of videos came up about A DHD. Inherently, that's worrying to the clinician's ear. It makes us worry about over diagnosis, over medicalization. At the same time, you know, people are finding out in the thirties, forties, fifties, sixties, perhaps, that they've had an undiagnosed problem and finally are getting some help for it.

What, what do you think about social media as a viable educational channel for these sorts of ideas? [01:12:00] I, I think that that plug was specifically, um, associated with some research on TikTok and there's actually been more recent research within the past couple months. Uh, I would say supporting that, where just how the vast majority, I think it was, um, 79% of, uh, TikTok posts were misleading.

Um. And, you know, only the rest was viewed as credible and those seem to be upheld. So, but going back to it, it's very interesting because there's, there's a lot of stuff that is wrong. Things that just are not viewed as symptoms of A DHD or oversimplified views or personal testimonials. But that's the tricky thing.

'cause the personal testimonials in general, even if it's accurate, are the most believed by consumers. Um, and this is human nature. We hear the story and that's [01:13:00] often how, you know, family members of somebody with A DHD learn about it. It's like, oh, I know somebody with a DHD. Now this makes sense when you think about it.

Most doctor's visits, let's call it that, and, and broadly start with self screening. I'm not feeling well, I better call the doctor, or this thing isn't going away, or I've been depressed for a long time and, you know, doing an online search, you know, should I be worried about this, uh, spot on my arm? So starting with just maybe not the best, most thorough research, but then following up.

So I think one, in terms of the over-diagnose one, um, it social media is a screening tool, um, and just like a screening tool. I'm not saying it's the best one, but it's out there. Second, even with established screening tools, they are designed to cast a wide net. We'd ra yeah, let's just say it's for depression, diabetes, whatever.

There's gonna be some things in [01:14:00] there to make it general to say. We're gonna catch some people without diabetes, without depression. But we wanna make sure we catch more people. We, it's okay to get the false positive, but we wanna get more true positives and that's what a screening is. Come in and say, no, it's not that.

You're fine. Be on your way. So that also brings it to like the evaluation of a DHD one. Having enough people who can do an accurate job, both catching it when it's there, um, and not, not getting it when it's not there sensitive and specific. And with, even within that though, it's being able to tell people, alright, you endorsed a lot of symptoms of A DHD on these rating scales, but after interviewing you and these other things, and the requirement for impairment, I can't in good faith call this A DHD.

It might be depression, it might be anxiety. The very first person we ever [01:15:00] evaluated in our Penn adult, A DHD, uh, program we sent off for a sleep study 'cause we think it was apnea. He hadn't had a full night's sleep in a long time. So that looked a lot like a DHD, but it wasn't. Um, and, and making, you know, people who go through the whole thing, including verifying childhood onset, there's a lot of steps that will probably come through in the, the forthcoming US guidelines that are probably already out there in the NICE guidelines and European guidelines.

But, um, but, um, there's a lot that goes into it. So if we think about it as screening, because one, even if, you know, there's a lot of people going around saying, oh, I have I-A-A-D-H-D 'cause I look like that person on TIC-Tac. That doesn't mean they have it or that they're prescribed medications or anything like that.

But there are some other very well done, well-constructed studies where A DHD is identified, which this is. Valid, uh, or at least, um, to do research has, uh, and one that [01:16:00] reported on the high rates of, I think it was adolescent boys with a DHD in the US was asking, has a healthcare provider ever indicated that your child has a DHD?

And that could be a provider who says could be, um, you should get 'em checked out, or here's a prescription, or whatever. I'm not saying it was necessarily that glib, but you know, somebody could say, yeah, they said it could be. And then I forget what the numbers were in that study, but it was some more exorbitant number that most experts would say.

Yeah, it's probably closer to like seven or 8% rather than whatever it was. I think it was in the teens, uh, the mid upper teens. So it was, you know, got a lot of headlines, but, and rightfully so, because being aware of we need more clinicians trained. Specializing, or at least at least competent in adult A DHD.

You know, one point I made, and I wanna give him credit, David Goodman in the US an A DHD expert, say, uh, physician, uh, it was the, um, the National [01:17:00] Comorbidity Study in the us um, looking at the range of depression, anxiety, schizophrenia, A DHD in the early two thousands. And David, on one of his slides showed that at the time the number one psychiatric diagnosis was depression.

Number three was anxiety, but number two was adult, A DHD among adults. And, you know, with the more recent, um, center for Disease Control in the us, um, their first study of adults with A DHD that found, um, this time number one was anxiety. Again, number three is depression. But again, adult, A DHD was number two.

So this be this, be like going to your family doctor saying, I can help with arthritis and hypertension, but not just, I don't specialize in diabetes. I was not trained in diabetes. So that's sort of what we're talking about here with adult A DHD. It's not just, oh, it's not what I do, but you know, I'm competent.

I could evaluate and then refer you for treatment or whatnot. No, it's, it's, we don't even [01:18:00] have where somebody says, um, this sounds like a cardiac problem. I want you to go see a cardiologist. Yes, there are some screening scales that can be used, but, you know, A-D-A-D-H adult, A DHD is still not part of adult psychiatry, adult clinical psychology training yet.

Yeah, it's quite siloed. Yes, yes. And it's a niche specialty where even if people, you know, are manifesting, you know, it's, it's a gamble whether they're gonna get, um, specialized care. Do you think any of the concerns about over-diagnosis are valid as the, the rates of diagnosis seem to to increase in the Western world?

And I, I do understand also that the prevalence of A DHD, as far as I know in the US is higher in the uk. Is over-diagnosis something that concerns you at all? Yeah, I mean, because I mean, one, and this could be anybody, this could be a well-meaning physician, even an expert who, they go, what? Like with the [01:19:00] presentation, this looked like this, but then other information comes to light or what, whatever the case may be.

So just in terms of practice, you know, there's gonna be some misdiagnoses, you know, including under diagnosis or a misdiagnosis. I think the rise. There can be ridiculous rises, but within I, at least within the us um, you know, adult, A DHD was the number one increased diagnosis over the, the pandemic years.

Part of that due to access, people could virtually reach out and find people who, uh, were competent in and experience with adult A DHD. And some of the licensing restrictions of practicing across state, state lines were reduced. And the virtual, uh, care, um, increased access, especially for women. 'cause that was the number one group.

61% of women in that CDC uh, study I mentioned were di first diagnosed in adulthood, whereas more like a little under 50% for, uh, males. Uh, so that's been an underrepresented group. So I still think we're in a correction [01:20:00] phase of. It for so long, being undiagnosed. And again, um, again, we're talking about some of the actual prevalence numbers from research, but there's a lot more, it feels like there's a lot more out there 'cause there's a lot more people saying they have a DHD or claiming it.

So, but yes, it is a concern 'cause we wanna be one, right? Because even in cases where it's not a DHD, um, and I, I've had a couple, you know, already this month where it's like anxiety or whatnot, but getting to people, uh, veered to the right, to the right care, it's important. You know, hard stop. But yeah, so I, I think at this phase where we're at.

It's a benefit that A DHD is more on people's radar screens. I think there's probably more use, and this is still something that some of the, the professional societies, uh, uh, associate with A DHD are working on. Like even primary physicians, family doctors doing screenings and maybe more likely to refer for services.

But now I [01:21:00] think the best protective factor we could have is better education in our clinician, um, you know, training programs so that, you know, we can, you know, make sure the numbers are accurate. Um, but I still, I still think we're in a correction phase. A lot of the studies, it's still, like I said, that 8% that's higher than the three to five, three to 5% I had been, um, citing for years.

But I mean, one, uh, concern about overdiagnosis and accurate diagnosis, a hundred percent. Better training, looking at other things and also sometimes where it might be a complex mixture where A DHD might be on the scene, but it's more like the addiction or the depression is more prominent or the untreated bipolar disorder.

You know, I think we we're also at that phase where it's out there and the training and being more on guard for that and being, you know, training clinicians to be able to explain why it's not a DHD when it's not the case. So I think we're, you know, moving and, you know, A [01:22:00] DHD is on the radar screens more.

But yeah, we're probably at that point where we're looking for, you know, still being diligent and calling it A DHD when it is. But, um, being, you know, looking at as always, and I would've said this before, just looking to be accurate in the diagnosis and, and to make sure people are getting the recommended protocols.

'cause that's probably where a lot of the misdiagnosis happens, where it's. I say this respectfully with doctors trying to work within a 45 minute visit and maybe having a hard time, or not having access the scales to use or whatnot, where, you know, sometimes it's people trying to do the right things by their clients, but, you know, making do with, you know, things that just aren't gonna meet the standards.

And, and lastly, 'cause we're running out of time, but lastly, in your experience when it's not a DHD, what does it look most likely to be? So what are the most likely differential diagnoses in your experience? Uh, mood or anxiety [01:23:00] disorder and, you know, and sometimes things like, and I, this falls outside the realm of that, but you know, sometimes it can be an obsessive compulsive disorder where the distractions are the, the obsessive thoughts, uh, or the compulsive worries, some trauma related, especially if the trauma comes later on.

And you can go back and see whether there is preexisting A DHD, but they can layer on top of one another. Or, you know, situations where it was obvious that there was no childhood onset of symptoms and not due to circumstantial situations like, uh, uh, an insufficient school system or other things where, um, there wasn't an adequate way to evaluate child childhood onset.

And another thing is where even with those things that can get in the way of fulfilling life roles, it doesn't seem to be associated with a broader executive functioning difficulty. Uh, there's intact executive functions, like you said, with the cognitive therapy for depression. You know, being able to, oh, can [01:24:00] you do the experiment?

You're depressed, but let's do pleasure predicting how much, how much, if you go to the movie with friends, what percentage out of a hundred, how enjoyable do you think it'll be? Uh, 30%. Can you compare that with your rating afterwards? Uh, it was more like 70%. I liked it more than I did. That requires some executive functioning that.

Intact executive functioning, that can maybe be a, yeah, weakened by mood issues, but you know, still they're sufficient to do, to do the exercises. So, you know, the absence of the executive dysfunction problems during inter episodes for mood or anxiety, you know, situations is another tell for me. Well, Russ, thank you so much for coming on.

I'm sure people will get a lot outta this episode. Where can people go to find out more about your work? The easiest place, and Lori, you'll, you might be getting this re recording from, but my website and it also has a contact form if you wanna get in touch with me, www CBT number four. [01:25:00] adhd.com. You might have this.

Some people hear CB, D and they get really excited. No, CCBT is in cognitive behavioral therapy. Number four, adhd.com. Perfect. We'll put a link to that in the description. Dr. A Ramsey, thank you so much, Alex. It's a pleasure. You're doing great work here, helping a lot of people happy. I can do my little piece to help out.