Thinking Through Adult Adhd :”

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“THINKING THROUGH ADULT ADHD :”

HOW THOUGHTS TURN INTENTIONS INTO ACTIONS (OR NOT)[W39]

JUNE 21 2019

PENNSYLVANIA PSYCHOLOGICAL ASSOCIATION CONVENTION

PITTSBURGH, PA

J. Russell Ramsay, Ph.D. Adult ADHD Treatment & Research Program University of Pennsylvania Perelman School of Medicine

DISCLOSURES (PAST 12 MONTHS)

• Speaker honoraria : • 2019 APSARD Conference session • 2019 APA Convention CE workshop • Paid fee/royalties for CE webinars/recordings (J&K Seminars, TZK Seminars) • Book royalties (Routledge/Taylor&Francis, American Psychological Association) • Honoraria for article/reviews (New Hope Media, LLC [Additude Magazine]) • Honoraria for APA Psychotherapy Video Training Series DVD • Honoraria for expert opinion survey on best practices (SUNY Research Fnd) • Advisor/consultant for Mantra Health, Inc.

LEARNING OBJECTIVES

• Recognize and summarize the premises about the nature of ADHD and psychosocial treatment that provide the basis for the CBT approach presented here.

• Recognize the main CBT intervention target in each treatment domain: cognitive, behavioral, emotional, implementation, and interpersonal as presented here.

• Name the most commonly endorsed cognitive distortion endorsed in a chart review study of adults with ADHD.

• Leave the workshop with at least three (3) new implementation-focused strategies to use in clinical practice.

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WHAT IS THE PREVAILING MODEL OF ADHD?

“There is much more than the ‘A’ and the ‘H.’”

ADULT ADHD: SYMPTOMS AND IMPAIRMENTS

What are the underlying problems that provide targets for treatment?

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20

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TWO DIMENSIONS OF SYMPTOMS

Inhibitory (H-I symptoms) Executive (Inattention)

• Motor – restless, active, “ballistic” v smooth • Poor persistence toward goals, future • Verbal – talkative, break in • Distractible (poor resistance to irrelevant internal and external events) • Cognition – task-irrelevant thoughts, rapid decisions, internal distractibility • Deficient re-engagement after disruption • Motivation – discount rewards/future, low • Poor working memory, forgetful, poor delay of gratification sequencing (NV > V WM difficulties) • Emotion – impulsive, reactive, poor top-down • Poor self-monitoring, self-evaluation control

INTERDIGITATING MODELS FOR UNDERSTANDING ADHD

• Executive Function / Self-Regulation • Dopamine deficiency • Reward deficiency • Default Mode Network • Genetics • Neuroimaging

ADHD is neurodevelopmental disorder of self-dysregulation . It is a chronic delay in the onset and employment of self-regulation capacities and skills.

WHAT ARE EXECUTIVE FUNCTIONS (EFS)?

• Self-regulation across time to choose, enact, and sustain actions toward a goal usually “(T)hose self-directed in the context of others and actions of the often relying on social and individual that are cultural means for the being used to self- maximization of one’s long- regulate.” 1 term welfare as the person defines that to be – but for which there is not proximal enough reward or consequence. 2

1Barkley (1997). ADHD and the nature of self-control . New York: Guilford. 2Barkley (2012). Executive functions: What they are, what they do, how they evolved . New York: Guilford.

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WHAT ARE EXECUTIVE FUNCTIONS (EFS)?

EF usually emerges as a single factor: “How efficiently do you do what you set out to do?”, but there are five semi-distinct domains that emerge in ratings of daily functioning:

1. Self-management to time 2. Self-organization and problem solving 3. Self-restraint (inhibition) 4. Self-motivation 5. Emotional regulation

Barkley, R. A. (2011). Barkley deficits of executive functioning scale . New York: Guilford.

WHAT ARE EXECUTIVE FUNCTIONS (EFS)?

4 factor model of ADHD (DSM-5) = (1) EF deficits-inattention

(2) hyperactivity

(3) impulsivity

(4) emotional dyscontrol

with EF-inattention being most consistent & discriminating factor.

Adler et al. (2017). International Journal of Methods in Psychiatric Research, 26, e1555. doi: 10.1002/mpr.1555

BARKLEY’S HYBRID MODEL OF EXECUTIVE FUNCTIONS

Self-Awareness (“Self”) ↓ Behavioral Inhibition

Non-Verbal Self-Regulation Verbal Working of Affect, Motivation Re-Constitution Working Memory Memory & Arousal

The capacity to Private, self- Ability to self-regulate Capacity to hold events in directed speech as and induce dismantle mind so as to a means of motivation, drive and (analyze) and use them to informing, arousal states in reassemble control a influencing and support of goal- (synthesize) response controlling one’s directed behavior behavioral own behavior sequences

Barkley (1997). ADHD and the nature of self-control . New York: Guilford. (p. 56) Barkley (2016). In K. D. Vohs & R. F. Baumeister (Eds.), Handbook of self-regulation (3rd ed.) (pp. 497-513). New York: Guilford.

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BROWN’S EXECUTIVE FUNCTION DEFICIT MODEL

Brown, T. E. (2013). A new understanding of ADHD in children and adults: Executive function impairments . New York: Routledge.

ADHD AND EMOTIONAL DYSCONTROL

EMOTIONAL IMPULSIVITY IN ADULTS WITH ADHD

60 ADHD

50 Community

0 Impatience Quick to anger or get Easily frustrated Over-react emotionally Easily excited upset

From Barkley, R., Murphy, K. & Fischer, M. (2008). ADHD in adults: What the science says . New York: Guilford

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EMOTIONAL IMPULSIVITY IN ADHD CHILDREN FOLLOWED TO ADULTHOOD

ADHD-P 40 ADHD-NP Controls 30

0 Impatient Quick to anger, get Easily frustrated Over-react Easily excited upset emotionally

ADHD-P = Persistent ADHD, ADHD-NP = Non Persistent ADHD From Barkley, R., Murphy, K. & Fischer, M. (2008). ADHD in Adults: What the Science Says . New York: Guilford

ADHD AS A MOTIVATIONAL DEFICIT: DOPAMINE/ REWARD DEFICIENCY SYNDROME (RDS)

DOPAMINE: REWARD DEFICIENCY SYNDROME/MOTIVATIONAL DEFICIT

• Dopamine binding lower for ADHD adults when compared with controls Volkow et al. (2009). JAMA, 302 (10), 1084-1091.

• Correlation of Dopamine receptors and DAT and achievement scale of MPQ (trait motivation)

• MPQ lower among ADHD adults vs controls

• MPQ correlate with Dopamine among ADHD; MPQ inversely correlated with ADHD measures Volkow et al. (2011). Molecular Psychiatry, 16 , 1147-1154.

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SUMMARY: CLINICAL IMPLICATIONS OF RDS

• Motivational deficits commonly encountered • Trouble activating , getting started • Easy boredom / trouble sustaining attention • Sense of “being lazy” or insufficiently disciplined (cognitive attribution) • Require more frequent, immediate, and stronger/salient rewards (vs delayed)

• ADHD individuals do best with salient (interesting) tasks and frequent rewards

• Higher risk of developing addictive behaviors • Intense novelty seeking • Chemical dependency • Non-chemical addictions (e.g., internet use, gaming, gambling)

DEFAULT MODE NETWORK (DMN)

ROLE OF THE DMN

• Active during the brain’s resting state, mind-wandering, “idling mode”

• ADHD = difficulties shifting out of this mode into concentrated attention

• DMN must be actively suppressed when brain required to direct attention (degree of suppression correlates with task difficulty)

• “Default mode interference” is thought to be a central source of inattention- distractibility-mind-wandering symptoms, specifically “hypoconnectivity” between DMN and “salience” network

• “Mind-orbiting” issues?

Silberstein et al. (2016). Brain and Behavior, 6 , e00582. doi: 10.1002/brb3.582 Utevsky et al. (2014). Journal of Neuroscience, 34 , 932–940. doi:10.1523/JNEUROSCI.4227-13.2014

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GENETICS

GENE X ENVIRONMENT VIEW

• Recent GWAS meta-analysis identified 12 reliable genetic sites • ADHD has historically been viewed as genetically complex • More recent gene x environment models • View genetics as a predisposition or vulnerability for ADHD • The proclivities interact with various environmental factors: • Toxins • Stress • Lifestyle • These environmental factors are more amenable to change

Demontis et al. (2018). Nature Genetics , Advance online publication. doi: 10.1038/s41588-018-0269-7 Faraone & Larsson (2018). Molecular Psychiatry . Advance online publication. doi: 10.1038/s41380-018-0070-0 Nigg (2018). Getting ahead of ADHD . NY: Guilford.

WHY IS THIS TOPIC IMPORTANT: FUNCTIONAL IMPAIRMENTS

“Show me where it hurts.”

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LIFE OUTCOMES: ADULT ADHD

• Workplace problems • Physical health issues/mortality • Relationship problems • Legal issues • Lower educational attainment • Lower SES • Employment problems • Psychiatric comorbidity (anxiety, depression, substance use) • Lower self-esteem • Substance use disorders • Lower social functioning • Risk for suicide (ADHD + SUD + • Lower satisfaction in life domains psychiatric comorbidity) • Disengagement Barbaresi et al. (2013). Pediatrics, 131 , 637-644. Barkley & Fischer (2018). J of Attention Disorders , advance online. Barkley et al. (2008). ADHD in adults: What the science says . New York: Guilford. Biederman et al. (2006). Journal of Clinical Psychiatry, 67 , 524-540. Biederman et al. (2012). Journal of Clinical Psychiatry, 73 , 941-950. Brook et al. (2013). Pediatrics, 131 , 5-13. Galéra et al. (2012). British Journal of Psychiatry, 201 , 20-25. Harpin et al. (2013). Journal of Attention Disorders , online ahead of print. Nigg (2013). Clinical Psychology Review, 33 , 215-228. Klein et al. (2012). Archives of General Psychiatry, 69 , 1295-1303. Weiss & Hechtman (1993). Hyperactive children grown up (2 nd ed.). New York: Guilford.

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20

ADHD AND ESTIMATED LIFE EXPECTANCY

• “Milwaukee study” (H vs control) • Exercise • Tracked to 27 years old • Current health • 14 health variables entered into • Type 2 diabetes algorithm: • Diet • Gender • Sleep • Age • Smoking • Weight • Driving • Height • Alcohol • Education Results : • Income Child-ADHD = reduced ELE of 9.5 healthy yrs / 8.4 yrs total Adult-ADHD = reduced ELE of 12.7yrs

Barkley & Fischer (2018). Journal of Attention Disorders . Advance online.

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WHY IS THIS TOPIC IMPORTANT?

“Why do we need the “C” in CBT for Adult ADHD?”

WHY IS THE TOPIC OF THOUGHTS, BELIEFS, AND ADULT ADHD RELEVANT?

OLD VIEW NEW VIEW • Cognitions only relevant to the • Cognitions relevant in cases of degree that they are associated pure ADHD and make distinct with comorbidity contribution to treatment

• Behavior change is the ultimate • Yes, but cognitions play a key outcome measure role in the implementation of coping strategies, motivation, and behavior change

• c - B - T • C - B - T

BARKLEY’S HYBRID MODEL OF EXECUTIVE FUNCTIONS

Self-Awareness (“Self”) ↓ Behavioral Inhibition

Non-Verbal Self-Regulation Verbal Working of Affect, Motivation Re-Constitution Working Memory Memory & Arousal

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WHY IS THE TOPIC OF THOUGHTS, BELIEFS, AND ADULT ADHD RELEVANT? (2)

• Executive Functions 1 and “thinking”

• Inhibition: Create space to act with intention, possible futures, PAUSE

• Non-verbal working memory: Allows one to “see” (imagine) possibilities

• Verbal working memory: Self-talk that guides behavior, rules, meaning-making, justification

• Emotional regulation: Self-motivation, change feelings, change actions

• Reconstitution: Innovation, novel solutions, creativity

• Student-rated EF/motivation mediated the relationship between ADHD + impairment 2

• Student-rated EF/organization mediated the relationship between ADHD + grades

1Barkley (1997). ADHD and the nature of self-control . NY: Guilford. 2Dvorsky & Langberg (2014). Journal of Attention Disorders. Online ahead of print.

“When you press the pause button on a machine, it stops. But when you press the pause button on human beings they start.

You start to reflect, you start to rethink your assumptions, you start to reimagine what is possible, and most importantly, you start to reconnect with your most deeply held beliefs. Once you’ve done that, you can begin to reimagine a better path.” (p. 4)

Dov Seidman, CEO of LRN

(quoted in: Friedman, T. L. (2016). Thank you for being late: An optimist’s guide to thriving in the age of accelerations . NY: FSG.

WHY IS THE TOPIC OF THOUGHTS, BELIEFS, AND ADULT ADHD RELEVANT? (2)

• Executive Functions 1 and “thinking”

• Inhibition: Create space to act with intention, possible futures, PAUSE

• Non-verbal working memory: Allows one to “see” (imagine) possibilities

• Verbal working memory: Self-talk that guides behavior, rules, meaning-making, justification

• Emotional regulation: Self-motivation, change feelings, change actions

• Reconstitution: Innovation, novel solutions, creativity

• Student-rated EF/motivation mediated the relationship between ADHD + impairment 2

• Student-rated EF/organization mediated the relationship between ADHD + grades

1Barkley (1997). ADHD and the nature of self-control . NY: Guilford. 2Dvorsky & Langberg (2014). Journal of Attention Disorders. Online ahead of print.

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ADHD WITHIN A UNIFIED THEORY OF PSYCHOLOGY (UTP) 1

• 4 Facets of the UTP • Evolutionary context: Matter, Life, Mind (nervous system, genetics), Culture (symbolic syntactical language)

• Behavioral Investment Theory (behavior as commerce, cost-benefit of action; brain’s reward system as much about anticipation as attainment)

• Influence Matrix (“work and play well with others”) • Power : competition-control (social rank, valuable skill) • Love : altruism-cooperation (self-sacrifice, reciprocity) • Freedom : autonomy-independence (self-sufficiency, affiliation)

• Justification Hypothesis : narrating (what happens; why happens; what I do or don’t) • Language, communication (other animals signal, only humans explain) • Reason-giving (private self, public self, how others view, consistency)

1Henriques (2011). A new unified theory of psychology . NY: Springer

WHAT DOES THIS MEAN FOR ADAPTING CBT TO ADULT ADHD?

• Behavior change , namely the consistent implementation of coping strategies and workarounds for EF and other self-regulation deficits is the primary therapeutic objective.

• That said, the cognitive domain of CBT is a necessary (but not sufficient) mediating factor between intention and action.

• Cognitions, beliefs, and other such information processing issues do not cause ADHD, but they are influenced by experiences living with ADHD that, in turn, interfere with engagement by magnifying and being magnified by the core features and difficulties of ADHD.

• Thus, a cognitive approach for adult ADHD is breaking down tasks and endeavors in a manner that identifies high-yield “pivot points” for the implementation of coping strategies and lend themselves for task-promoting cognitions and addressing various task- demoting cognitions.

Ramsay (2020). Rethinking adult ADHD: Helping clients turn intentions into actions . Washington, DC: APA.

CBT MODEL FOR ADULT ADHD

“How is the CBT model adapted to adult ADHD?”

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PSYCHOSOCIAL TREATMENT: REVIEWS AND META-ANALYSES (SINCE 2010)

• Knouse (2015). In R. A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis & treatment (4 th ed.) (pp. 757-773). NY: Guilford. • Knouse & Safren (2010). Psychiat Clin of North Am, 33 , 497-509. doi: 10.1016/j.psc.2010.04.001

• *Knouse et al. (2017). J of Clinical and Consulting Psychology . Online. doi: 10.1037/ccp0000216

• *Lopez et al. (2018). Cochrane Database of Systematic Reviews, 3 . doi: 10.1002/14651858.CD010840.pub2

• *López-Pinar et al. (2018). Frontiers in Psychology, 9 , 638. doi: 10.3389/fpsyg.2018.00638

• Manos (2013). Postgraduate Medicine, 125 , 51-64. doi: 10.3810/pgm.2013.03.2641

• Mongia & Hechtman (2012). Curr Psych Rep, 14 , 561–567. doi: 10.1007/s11920-012-0303-x

• *Moriyama et al. (2013). CNS Spectrums, 18 , 296-306. doi: 10.1017/S109285291300031X

• Ramsay (2011). Journal of Clinical Outcomes Management, 18 , 526-536. * = meta-analysis • Ramsay & Rostain (2015). Cognitive-behavioral therapy for adult ADHD (2 nd ed.). NY: Routledge.

WHAT ARE WE TARGETING?

BROAD-BAND TREATMENT NARROW-BAND TREATMENT

• Do not focus on a set of specific sxs, • Focus on a subset of sxs, behaviors, or behaviors, or impairments impairments • Seek overall reductions in ADHD sxs • Aim to improve skills, adaptive and thereby improve functioning behaviors and/or decrease maladaptive behaviors • Medications • Psychosocial treatments/CBT • Traditional Chinese Medicine • Coaching • Omega 3 supplementation • Social skills training • Diet • School based interventions

Faraone & Antshel (2014). Child Adolesc Psychiatric Clin N Am 23 , 965-972.

GENERIC CBT MODEL: RELEVANCE TO ADULT ADHD

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CBT CASE CONCEPTUALIZATION: ADULT ADHD

Neurobiology/Environment Case Conceptualization Modified for Attention/Perception/Self-control ADHD

Schema Core beliefs

Compensatory strategies

Current situation

Cognitions Emotions/Physiological Behaviors

Emphasis added

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BECK’S GENERIC COGNITIVE MODEL (GCM)

• New additions to the evolving GCM relevant for ADHD: • Dual information processing • Automatic (“hot EF”) • Reflective (“cool EF”) • Stimulus-Response Network (sources of distraction for ADHD) • Proactive – initiated by goals and drives • Reactive – initiated by events (this overrides the proactive/intention) • ATTENTION • Self-focused • Attention to detail and context facilitates reflective processing • Can be maladaptive when inappropriate or inflexible (or involuntary or fixation) • Associated with affect and proneness to escape or avoid discomfort (or pursue positive emotion) • Attention shift necessary for change

1Beck & Haigh (2014). Annual Review of Clinical Psychology, 10 , 1-24.

HOT AND COOL EF

• HOT EFs • Emotional regulation • Situations with emotional valence • Inhibition, impulse control • Delay gratification • Down-regulate emotions • COOL EFs • Cognitive regulation • Decision-making, problem-solving • Motivation, up-regulate emotions • Organization, planning • Cognitive flexibility

BECK’S GENERIC COGNITIVE MODEL (GCM)

1Beck & Haigh (2014). Annual Review of Clinical Psychology, 10 , 1-24.

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CBT FOR ADULT ADHD FOCUSED ON IMPLEMENTATION

CBT FOR ADULT ADHD: ADAPTED MODEL FOR ADULT ADHD CONCEPTUALIZATION

1. Individuals experience symptoms falling along a continuum of severity and impact, in some form, starting in childhood or adolescence. 2. ADHD makes a direct and causal contribution to functional difficulties, ranging from interference to impairment, with variation within and across domains and settings, as well as secondary skills deficits and co-existing emotional or learning issues. 3. ADHD symptoms influence experience and performance in various life roles and endeavors, with effects on sense of self, identity, and efficacy. 4. There is an ongoing, reciprocal interaction between an individual and their contexts and relationships that can magnify and/or attenuate difficulties, coping strengths, and sense of belongingness and social capital. 5. The experience of ADHD, both cumulatively and in discrete instances, has effects on information processing in the form of thoughts and beliefs, as well as concurrent emotional and behavioral experiences that affect how one acts in and reacts to various contexts and roles and relationships (including stress from impairments and actual or perceived devaluation by others [B. Rosenfield, personal communication]).

Ramsay (2020). Rethinking adult ADHD . DC: APA

CBT FOR ADULT ADHD: PREMISES FOR THE ADAPTED MODEL PSYCHOSOCIAL INTERVENTION

1. ADHD is a quantitative (and not a qualitative) difference in functioning, falling at the disordered end of a continuum of normative functioning (in terms of frequency and magnitude of symptoms and life difficulties). 2. ADHD is an implementation problem related to difficulties performing the necessary skills and strategies needed to effectively manage a task, endeavor, role, or situation (and not a lack of knowledge of what needs to be done or ability to perform the skills). 3. These implementation problems stem from chronic developmental difficulties related to impaired self-regulation . Overall, these self-regulation problems involve difficulties organizing, initiating, and sustaining actions over time in order to achieve a future-focused outcome that is personally salient and desired by an individual. The self-regulation deficits also contribute to : i. Procrastination ii. Poor motivation for behavior (both initiating and sustaining over time) iii. Poor task endurance iv. Difficulties sustaining efforts across time, switching tasks, working towards a deferred reward v. Tendency to discount deferred rewards, which are experienced as less salient than proximal rewards vi. Corresponding difficulties with initiating and sustaining attention, disorganization, poor working memory, and emotional dysregulation which punctuate experience and efforts vii. Difficulties executing otherwise known + effective coping strategies for managing these problem areas

Ramsay (2020). Rethinking adult ADHD . DC: APA. Ramsay & Rostain (2016). Practice Innovations, 1 , 36-52.

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CBT FOR ADULT ADHD: PREMISES FOR THE ADAPTED MODEL PSYCHOSOCIAL INTERVENTION (2) 4. These difficulties magnify and are magnified by co-existing psychiatric and learning disorders, as well as other life stressors and that result in “disengagement ” from what are otherwise feasible and personally- salient tasks, endeavors, roles, duties, goals, and other objectives. 5. These self-regulatory deficits and impairments affect different levels of patient experience, which are targets for interventions 1: a) Cognitive/Justification : self- and other-directed explanations (efficacy) b) Behavioral/Investment : achieving goals, needs, and meeting obligations (engage) c) Emotional/Experiential : affective reactions + goal-value motivations (discomfort) d) Implementation : targeted self-regulatory tactics to employ coping strategies (do) e) Relationships/Influence : social capital to meet needs + roles (roles) 6. The tx alliance is a vital source of empathy, support + focus on effecting

Ramsay (2020). Rethinking adult ADHD . DC: APA. Ramsay & Rostain (2016). Practice Innovations, 1 , 36-52. 1Henriques (2011). A new unified theory of psychology . NY: Springer.

CBT FOR ADULT ADHD: CENTRAL TARGETS OF EACH DOMAIN

• CBT – Implementation Focus (or CBT Extended Release [CBT-XR])

• Main cognitive issue/theme = impaired self-regulatory efficacy [Self-Distrust cognitions; Self-Mistrust schema]***

• Main behavioral issue = engagement , scripting, challenging avoidance/escape

• Main emotional issue = tolerating discomfort , emotional flexibility

• Main implementation issue = transform plan into action , switching modes

• Main interpersonal issue = managing social capital to define and fulfill roles (incl. self-advocacy/compassion)

Ramsay (2020). Rethinking adult ADHD: Helping clients turn intentions into action . DC: APA

WHAT IS THE “IDEATIONAL CONTENT” OR “THEME” OF COGNITIONS? (COGNITIVE SPECIFICITY )1

• Depression = loss (self, experiences, future)

• Anxiety = danger, risk (uncertainty)

• Hypomania = inflated gains, positives

• Obsessions = warning, doubt

1Beck (1976). Cognitive therapy and the emotional disorders . NY: Meridian.

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ADULT ADHD: COGNITIVE THEME (2)

• Self-regulatory efficacy : • “… to plan and structure activities, to enlist needed resources; to regulate one’s motivation through proximal challenges and self- incentives; and to manage the emotionally and cognitively disruptive effects of obstacles, setbacks and stressors.” (p. 53)

• “In many spheres of functioning, people know full well how to perform the needed behavior. Here, the relevant efficacy beliefs concern self-regulatory capabilities – can people get themselves to stick with the behavior given the many dissuading conditions they will encounter? ... (T)hose who distrust their capacities to surmount unpleasant factors have little reason to put themselves through misery. In familiar activities that must be performed regularly to achieve desired results, it is perceived self-regulatory efficacy, rather than perceived efficacy for the activity per se, that is most relevant.” (p. 64)

Bandura (1997). Self-efficacy: The exercise of control . NY: Freeman

ADULT ADHD: COGNITIVE THEME

• Personal agency : The ability to effect change through one’s action

• Self-efficacy : Belief in one’s ability to exercise control over the events in one’s life (in order to pursue goals)

• Self-regulatory efficacy : Belief in one’s ability to organize and carry out actions necessary to effect change in one’s life (and not from lack of skill)

• Gain education  Enroll in class  Attend and complete work

Bandura (1997). Self-efficacy: The exercise of control . NY: Freeman

IMPLEMENTATION-FOCUSED CBT FOR ADULT ADHD:

COGNITIVE INTERVENTIONS ADAPTED TO ADULT ADHD

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ELEMENTS OF IMPLEMENTATION-FOCUSED CBT FOR ADULT ADHD

• The main outcome is behavioral : improved functioning + well-being

• This outcome is achieved through the implementation of coping strategies (CBT targets impairments, not symptoms)

• Cognitive interventions are an essential (but not sufficient) ligament for turning intentions into actions

• An overarching framework is turning “managing ADHD” into “managing” specific, actionable “ pivot points ” (specious present)

STANDARD COGNITIVE INTERVENTIONS ADAPTED TO ADULT ADHD

• Identifying thoughts and their • Other cognitive change tactics effects • HW/field experiments • Cognitive modification • Define terms/specificity • Cognitive defusion • Perspective-taking • Framing and reframing • Problematic positive thoughts • Common cognitive distortions • Enough-sufficiency reframe • Perfectionism • Focusing on strengths and • All-or-Nothing Thinking resources • Magnification-Minimization • Comparative Thinking

COGNITIVE INTERVENTIONS

• COGNITIVE MODIFICATION • “DEFENSE ATTORNEY ” metaphor • Procrastination based on one-sided review of evidence (“PROSECUTING ATTORNEY”)

• What argument would your “DEFENSE ATTORNEY” make on your behalf?

• Challenge the evidence, prolongation to counteract impulsivity

• Not power of positive thinking, but adaptive thinking

• Inhibition (stop escape), managing discomfort, behavioral priming, emotional exposure to the thought of the task

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COGNITIVE INTERVENTIONS (2)

• COGNITIVE DEFUSION • Using legal analogy, Cognitive Defusion is an out-of-court settlement in which negative thoughts have visitation rights

• Ignore content of thoughts, accept/de-energize process of thoughts or loosen the attachment with them

• Notice, observe, acknowledge, name, but do not engage in the thoughts

• Re-engage in the moment

COGNITIVE INTERVENTIONS (3)

• FRAMING / REFRAMING • How information or a task is presented, packaged or “framed” influences perceptions and interpretations

• Core issue is to frame/reframe tasks such that they are viewed as “doable ” and one’s capacity as “ sufficient ” for engagement (enhance self-regulatory efficacy).

• Lower the bar, smallest first step, behavioral scripts, time/task/area- based engagement, “ enough ” focus, energy, time, etc.

TYPICAL TRADITIONAL COGNITIVE DISTORTIONS IN ADULT ADHD

• **Perfectionism 1 • Front-end perfectionism • Back-end perfectionism

• All-or-nothing

• Magnification / Minimization

• Comparative Thinking (others, “shoulds”)

Ramsay (2020). Rethinking adult ADHD . DC: APA. 1Strohmeier et al. (2016). Psychiatry Research, 238, 153-158.

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STANDARD COGNITIVE INTERVENTIONS ADAPTED TO ADULT ADHD

COMMON CLINICAL ISSUES IN CBT FOR ADULT ADHD

• Engaging in Treatment • Emotion Management • Lessons learned from • Tolerative Discomfort “Procrastivity” • Motivation/Values • Managing Procrastination • Impulsivity • Time Management • Assertiveness – “Define Your • Time Role” • Effort • Using skills, handling setbacks • Energy • Schema/Core Beliefs • Task • Organization

LESSONS LEARNED FROM “PROCRASTIVITY”

• PROCRASTIVITY – Avoiding a higher priority task by engaging in a lower priority, less time-urgent (but productive) endeavor that is ultimately self-defeating. 1,2

• Elements of procrastivity (compared with priority task): • Manual – physical > cognitive (or clear cognitive > vague cognitive) • Existing template or behavioral script for the procrastivity task • Better sense of what can be accomplished in a time frame • Clearer sense of task progress and maintenance of gains • Clear end point and completion of procrastivity

1 Ramsay (2017). Professional Psychology: Research and Practice, 48, 62-69. 2 Ramsay (2020). Rethinking adult ADHD . DC: APA.

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INTERVENTIONS: COGNITIVE MODIFICATION

“SELF-TRUST/SELF-REGLATORY EFFICACY”

LESSONS LEARNED FROM PROCRASTIVITY

BEFORE TASK DURING AND AFTER TASK

• Framing • Cognitive defusion • Task • Acceptance, commitment • Time • Challenge “back-end perfectionism” • Effort • Woulda, coulda, shoulda thoughts • Energy • Challenge performance distortions • Normalize discomfort • Trust the plan • Challenge “front-end perfectionism” • “Trust the process” (Phila. 76ers fans)

COGNITIVE INTERVENTIONS

• “What am I thinking right now?” (inhibition, prolongation) • Identify distortions, influence of automatic thoughts • Connection with emotions and behavior (entry point) • Review/question/challenge the evidence, Defense Attorney • Defusion, acceptance of negative thoughts while engaging • The notion of possibility, “What can you make happen?” (agency) • Develop adaptive thoughts (cognitive modification) • REFRAMING, metaphors, analogies, “What do you value?” *** • Behavioral experiment (test your thought)

• “But, I don’t have any thoughts” • “Maybe you were thinking that doing taxes would be fun?” • “What attitude do you think would be helpful in this situation?”

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COGNITIVE INTERVENTIONS (2)

• Influence of cognitions and distortions • “Front-end perfectionism” • Challenge the initial interpretation • Adaptive reframing (“enough” time, energy, etc.) • Define terms, specificity • Perspective taking / scaling • Identify strengths and competencies • Foster sense of “enough,” “sufficiency” • Self-regulatory efficacy for tasks

Individuals will engage in procrastivity tasks requiring more time and effort than priority tasks because there is more confidence in achieving an outcome.

INTERVENTIONS: BEHAVIORAL MODIFICATION

“ENGAGEMENT”

LESSONS LEARNED FROM “PROCRASTIVITY”

• Use lessons from procrastivity to develop priority task plan

• Make the task “manual” or actionable (at least getting “ on task ”) • “Go to work/study station” • Spend first few minutes reviewing assignment, outlining, etc. • Re-read last two paragraphs you wrote • Get / touch an item you need for the task • “Behavioral priming ”

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LESSONS LEARNED FROM “PROCRASTIVITY” (2)

• Define tasks in actionable terms / “Define your role” • Start time / end time (Bounded Task) • Start point, behavioral priming, initiate the “launch sequence” • Behavioral script / recipe • Reaching points of completion • Each task • Across time • Reward / Incentivize • Choreographing a schedule (self-care, down time, SLEEP)

INTERVENTIONS: ACCEPTANCE, MINDFULNESS, PERSISTENCE

“MANAGING DISCOMFORT”

ACCEPTANCE, MINDFULNESS, PERSISTENCE

• “Acceptance” of discomfort/emotion to maintain “commitment” to a valued task. (i.e., Do not have to be “in the mood” )1

• “Mindful” recognition of ADHD symptoms, emotional discomfort without escape reaction (feeling does not dictate reaction) 2

• State/acknowledge what you are feeling 3, emotional labelling 4, emotional granularity 5

• Willing to versus wanting to engage and persist on task 1 1Hayes et al. (1999). Acceptance and commitment therapy . New York: Guilford. 2Zylowska (2012 ). The mindfulness prescription for adult ADHD . New York: Trumpeter. 3Lieberman et al. (2007). Psychological Science, 18 , 421-428. 4Brooks et al. (2017). Social Cognitive and Affective Neuroscience . doi: 10.1093/scan/nsw121 5Barrett et al. (2001). Cognition and Emotion, 15 , 713-724. doi: 10.1080/02699930143000239

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ACCEPTANCE, MINDFULNESS, PERSISTENCE (2)

• Inhale deeply (followed by exhale) – example of coping with anger

• Reframe visceral feelings as “sensations”

• Reframe discomfort or intrusive thoughts as “seasonal allergy”

• Label feelings, “domesticate” feelings, granularity (minimal)

• Focus on moving body to where it needs to go

• Thinking through, imagining future feeling, outcome

INTERVENTIONS: IMPLEMENTATION STRATEGIES

“PLAN INTO ACTION”

IMPLEMENTATION INTENTION STRATEGIES

“Self-regulation by IMPLEMENTATION INTENTIONS entails delegating action control to pre-specified critical environmental cues . In other words, by planning out in advance when, where, and how a goal is to be transformed into action, implementation intentions disencumber executive functions. As a result, deficits in executive functioning should no longer be apparent in the quality of task performance.” (p. 263, 2008)

Gawrilow & Gollwitzer (2008). Cognitive Therapy and Research, 32, 261-280 . Gawrilow (2011). The ADHD Report, 19 (6), 4-8. Gawrilow et al. (2011a). Journal of Social and Clinical Psychology, 30, 615-645 . Gawrilow et al. (2011b). Cognitive Therapy and Research, 35, 442-455 .

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IMPLEMENTATION INTENTION STRATEGIES (2)

• Implementation plan = “IF/WHEN X, THEN I WILL DO Y.”

• “If situation X is encountered, then I will perform the goal-directed response Y!” 1

• Goal focus vs. Implementation focus

1Gollwitzer & Oettingen (2016). In K. D. Vohs, & R. F. Baumeister (Eds.), Handbook of self-regulation: Research, theory, and applications (3rd ed.) (pp. 223-244). NY: Guilford.

IMPLEMENTATION INTENTION STRATEGIES (3)

• Identify task goal but focus on implementation plan • Goal = Do homework • Implementation intention = If I sit at desk, then I can start the task.

• Identify plans for handling the “tipping points” of: • Starting a task • Handling distractions, interruptions, barriers • Re-engaging in a task after breaks or interruptions

• Implementation plan = “IF/WHEN X, THEN I WILL DO Y.”

HOW YOU DON’T DO THINGS

• What is the task/goal you are not • Barriers? Cog/emot/behav doing? What is its value to you? • Task-interfering thoughts ?

• Redefine task in more actionable • Emotional interference? Discomfort? terms Ugh ?

• Define smallest, specific, actionable • Escape behaviors? starting step (off-task → on-task)

• What is your implementation plan ? • Specific time task will be performed (with start- and end-time ) (IF/WHEN “ X,” THEN I WILL DO “ Y”)

• Where will the task be performed?

Ramsay (2020). Rethinking adult ADHD . DC: APA.

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KEYS TO APPROACH

• Cognitions do not cause ADHD but are an important effect (as are emotions)

• Cognitions are a ligament between intention and action (or inhibition)

• Reverse engineer procrastination/avoidance or other problems to understand “how” they occurred (rather than “trying harder” to not do them)

• Identify high yield pivot points , turn “managing ADHD” into something that a patient can “do”

• There are no trade secrets about the coping skills (ADHD is not a knowledge problem, it is a performance problem)

• Look for examples of real-world applications

VIDEO

NEGATIVE THINKING + ADULT ADHD:

RESEARCH AND CLINICAL RELEVANCE

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WHY IS THE TOPIC OF THOUGHTS, BELIEFS, AND ADULT ADHD RELEVANT?

OLD VIEW NEW VIEW

• Cognitions only relevant to the • Cognitions relevant in cases of degree that they are associated pure ADHD and make distinct with comorbidity contribution to conceptualization

• Behavior change is the ultimate • Yes, but cognitions play a role in outcome measure the experience of ADHD, implementation of coping strategies, motivation, and • c - B - T behavior change • C - B - T

PSYCHOLOGICAL IMPACT OF ADULT ADHD

Department of Psychiatry, University of Pennsylvania School of Medicine

ADULT ADHD: EXPERIENCES AND COGNITIONS 1

• Survey of 1001 adults (ADHD= 500; Control = 501) 1 • Childhood and teen experiences (significantly “less likely than peers:”)

• Cultural/educational activities outside of home

• Volunteer work, community service

• School clubs, extracurricular

• Dating

• Recreational or organized sports

• Spending free time with friends

• Spending time with family

1Biederman et al. (2006). Journal of Clinical Psychiatry, 67 , 524-540

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ADULT ADHD: EXPERIENCES AND COGNITIONS 1 (2)

• Survey of 1001 adults (ADHD= 500; Control = 501) 1 • Current mindset

• “I like myself and accept myself the way I am” ( ↓ for ADHD)

• I have a bright outlook on my future ( ↓ for ADHD)

• I often feel sad, blue, or depressed ( ↑ for ADHD)

• I often act without thinking about the consequences ( ↑ for ADHD)

• I often have angry or negative thoughts ( ↑ for ADHD)

• In social situations, I often make mistakes or act in ways that others view as inappropriate ( ↑ for ADHD)

1Biederman et al. (2006). Journal of Clinical Psychiatry, 67 , 524-540

MALADAPTIVE THOUGHTS + COLLEGE STUDENTS WITH ADHD 1

• Longitudinal evaluation (over academic year) of underachievement, self-concept, depression, and anxiety in FT college students with ADHD 1

• Negative self-concept and depression fully mediated the association between prior academic achievement (GPA) and self-reported impairment levels a year later • GPA  negative self-concept  depressive symptoms  impairments ADHD!!! • Functioning measures assessed broad areas of life • Purely behavioral approach in college students may not be effective

1Eddy et al. (2015). Journal of Attention Disorders , 22 , 323-333.

MALADAPTIVE THOUGHTS + ADULT ADHD

• Recent findings on the association of distorted thoughts and impairments common to adult ADHD:

• Associated with MDD, depressive sxs, cog-beh avoidance 1

• Present in cases of ADHD without depression 2

• Associated with high emotions, high escape-avoid coping 3

1Knouse et al. (2013). Cognitive Therapy & Research , 37 , 1220-1232. 2Mitchell et al. (2013). Cognitive Therapy & Research, 37 , 851-859. 3Torrente et al. (2014). Journal of Attention Disorders , 18 , 412-424.

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MALADAPTIVE THOUGHTS + ADULT ADHD(2)

• ADHD > controls on “intrusive/worrisome thoughts” (particularly frequency + removal difficulty) 4

• Positive, low correlation of distorted thoughts and ADHD sxs 5 • Unpublished – Negative self-concept predicts ADHD severity / cognitive distortions predict negative self-concept 6

4Abramovitch & Schweiger (2009). Psychiatry Research, 168 , 230-233. 5Strohmeier et al. (2016). Psychiatry Research, 238 , 153-158. 6O'Brien, D.R.,(2016). PCOM Psychology Dissertations. Paper 366.

High frequency + removal difficulty of negative thoughts

ADHD and distorted thoughts connected (w/o comorbid)

PERFECTIONISM primary cognitive distortion

“Front-end” perfectionism?

“I have to be in the mood to do it.”

Strohmeier, Rosenfield, DiTomasso, & Ramsay (2016). Psychiatry Research, 238, 153-158.

MALADAPTIVE THOUGHTS + ADULT ADHD(3)

• Development of an “ADHD Cognition Scale for Adults” (“incautious optimism”) 7,8

7Knouse et al. (2017). Journal of Attention Disorders, online ahead of print 8Knouse & Mitchell (2015). Cognitive & Behavioral Practice, 22 , 192-202.

Positive thinking can be maladaptive.

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ADHD COGNITIONS SCALE 7

1. I’ll just do this one thing first. 2. I do better waiting until the last minute. 3. I can’t stop right now. 4. Though this usually “sucks me in,” I’ll just do it for a minute. 5. I have plenty of time – I’ll just do one more thing before I go. 6. Being impulsive is a big part of who I am. 7. I know I’m supposed to be doing something else but I want to do this now.

7Knouse, L. E., Mitchell, J. T., Kimbrel, N. A., Anastopoulos, A. D., (2017). Journal of Attention Disorders , online ahead of print. doi: 10.1177/1087054717707580

SCHEMA + ADULT ADHD 1

• N = 204 nonclinical adults (52 M, 152 F, M age = 41.05 yrs [SD = 6.46]) • Adult ADHD Self-Report Scale ( 7.4% screened positive ), Young Schema Questionnaire, Perceived Stress Scale, WHO Well-being Index

• Do adults with ADHD endorse targeted early maladaptive schema (EMS) based on those identified by clinical observation: • Failure • Insufficient Self-control/Self-discipline • Social Exclusion • Defectiveness/Shame

• ADHD symptom severity associated with higher stress and lower well-being • ADHD symptom severity strongly and positively associated with all 4 schema (moderate e.s.) and with total schema (strong e.s.)

1Miklósi et al. (2016). Journal of Nervous and Mental Disease, 204 , 364-369. doi: 10.1097/NMD.0000000000000472

SCHEMA + ADULT ADHD (2) 1

• ADHD symptom severity associated with higher stress and lower well-being

• ADHD symptom severity strongly and positively associated with all 4 schema

• 2 indirect pathways of association of ADHD and emotional well-being • More severe ADHD → more perceived stress → lower emotional well-being • More severe ADHD → stronger schema → higher perceived stress

1Miklósi et al. (2016). Journal of Nervous and Mental Disease, 204 , 364-369. doi: 10.1097/NMD.0000000000000472

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SCHEMA + ADULT ADHD(3) 2

• N = 78 ADHD adults (38m/40f) compared with 80 control subjects(40m/40f) (19-58 yo)

• Adult ADHD = medication naïve patients, diagnosed with DSM-IV, WURS, CAARS, ADHD checklist, SCID, BDI-II, GSI, SCL-90 (German versions)

• Young Schema Questionnaire

• Do adult ADHD patients report dysfunctional beliefs and behaviors?

2Philipsen et al. (2017). ADHD Atten Def Hyp Disord. 9, 101-111 . doi: 10.1007/s12402-016-0211-8

SCHEMA + ADULT ADHD(4) 2

• ADHD significantly more ADHD and comorbidity than controls • Significantly higher EMS than controls on all but one (vulnerability to harm) • Largest effect sizes in descending order (all e.s. > 1.0, large effect): • Failure • Defectiveness/Shame • Subjugation • Emotional Deprivation • Mistrust/Abuse (Self-mistrust?) • Negativity • Dependence/Incompetence

2Philipsen et al. (2017). ADHD Atten Def Hyp Disord. 9, 101-111 . doi: 10.1007/s12402-016-0211-8

Language of ADHD on Social Media

Guntuku, Ramsay, Merchant, & Ungar (2017). Journal of Attention Disorders . Online ahead of print.

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Data Collection 1. Gathered public statements of diagnosis I was diagnosed with ADHD in of ADHD (retrieved 1900 users) on Twitter 7th grade and they stopped but User A the damage was done. I never 2. Manually cleaned for spam/advertisements trusted them and never sought etc. (left with 1399 users) their or anyone’s help. 3. Downloaded 3200 most recent tweets from each user (1.3 million tweets) using At 11 I started smoking weed its keeps me calm and from killing Twitter API. Discarded retweets, and tweets User B ppl I was diagnosed with ADHD which are not in English. to why I’, so lit... 4. Posting period: 1st January 2012 to 30th October 2016. Examples of public statements 5. Matched with a control set of users based on age, gender and posting activity.

Correlation of ADHD with Topics

Summary of Findings ●Reliably differentiate between ADHD and non-ADHD based on posting language

●ADHD use more conditional, hedging language (uncertainty?)

● More anxiety, anger emotions

● More informal language, filler, swear words

● Themes of lack of focus/self-regulation , negation , intention-failure , exhaustion, less self-efficacy

● Post more frequently, more followers, post more b/w 12am – 6am , greater focus on past, less on future

● More references to drugs , ranging from prescription to illicit drugs

● Personality characteristics are more open, but less agreeable (interpersonal)

Guntuku, Ramsay et al. (2017). Journal of Attention Disorders , online ahead of print.

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RESEARCH SUMMARY

• Negative thinking plays a distinct role in ADHD (and co-existing mood/anxiety, though not in an all-or-nothing fashion)

• Hx of ADHD associated with setbacks that can increase negative self-view which, in turn, magnifies and is magnified by the frequency and experience of setbacks

• Adults with ADHD at risk for experiencing more negative emotions, negative thoughts, avoidant behaviors, and impairments

• Negative thoughts do not cause ADHD but they develop as a consequence and are an important (necessary but not sufficient) ligament between intention and action.

LESS COMMON CLINICAL ISSUES IN CBT FOR ADULT ADHD

• Medications • Senior Adults • Emerging/Young Adults • Suicidality • Co-existing anxiety, depression, • Oppositional Behavior + substance use • Therapist Reactions • Sleep • Technology • Relationships

CONTACT ME

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