The adult ADHD tool kit for everday life handling strategies

The Adult ADHD Tool Kit:
Using CBT to Facilitate Coping Inside and Out
CHADD Annual Convention
New Orleans, LA
November 12, 2015
J. Russell Ramsay, Ph.D.
Anthony L. Rostain, M.D., M.A.
Adult ADHD Treatment & Research Program
Perelman School of Medicine, University of Pennsylvania

Disclosures
• Dr. Rostain
• Speaker honoraria (WebMD, Medscape)
• Book royalties (Routledge/Taylor Francis
Group)
• Scientific Advisory Board (Alcobra,
Pearson/BioBehavioral Diagnostics)
• Grant recipient (NIMH, AHRQ)
• Faculty and Course Director, CME Institute
of Physicians Postgraduate Press (Funded
in part by Shire grant)
Dr. Ramsay
• Speaker honoraria (PPA, APA, National
Institute for Children and Families [Czech
Republic], Psychotherapy Networker
Conference)
• CE presenter fee, J&K Seminars
• Book royalties (Routledge, American
Psychological Association)
• Honoraria as reviewer of book proposals
(Routledge, American Psychological
Association)
• Honoraria for chapter contributions to edited
books
• Research Consultant (Shire Pharmaceuticals)
• Faculty, CME Institute of Physicians
Postgraduate Press (Funded in part by Shire
grant)

FUNCTIONAL IMPAIRMENTS
“Where does it hurt?”

Life Outcomes: Adult ADHD
• Workplace problems
• Relationship problems
• Lower educational attainment
• Employment problems
• Lower self-esteem
• Lower social functioning
• Lower satisfaction in life domains
• Physical health issues*
• Legal issues
• Lower SES
• Psychiatric comorbidity
• Substance use disorders
• Risk for suicide (ADHD + SUD +
psychiatric comorbidity)
• Disengagement
Barbaresi et al. (2013). Pediatrics, 131, 637-644.
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 (2nd ed.). New York: Guilford.

Adult ADHD: Symptoms and Impairments
What are the underlying problems
that provide targets for treatment?

Postulated Mechanisms of ADHD
• Inhibition deficit (Barkley)
• Cognitive-energetic model (Sergeant)
• Executive control deficit (Brown)
• Working memory deficit (Kofler et al)
• Dopamine transfer deficit (Tripp, Wickens)
• Prefrontal cortex dysfunction (Arnsten, Rubia)
• Reward deficiency syndrome (Blum et al)

Barkley’s Hybrid Model of Executive Functions
Behavioral
Inhibition
Non-Verbal
Working
Memory
Verbal Working
Memory
Self-Regulation
of Affect, Motivation
& Arousal
Re-Constitution
The capacity to
hold events in
mind so as to
use them to
control a
response
Private, self-
directed speech as
a means of
informing,
influencing and
controlling one’s
own behavior
Ability to self-regulate
and induce
motivation, drive and
arousal states in
support of goal-
directed behavior
Capacity to
dismantle
(analyze) and
reassemble
(synthesize)
behavioral
sequences
Barkley (1997). ADHD and the nature of self-control. New York: Guilford. (p. 56)

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

What are executive functions(EFs)?
• “(T)hose self-directed actions of the individual that are
being used to self-regulate”
Barkley (1997). ADHD and the nature of self-control. New York: Guilford. (p. 56)
• EF is self-regulation across time to choose, enact, and
sustain actions toward a goal usually in the context of
others and often relying on social and cultural means for
the maximization of one’s long-term welfare as the
person defines that to be.
Barkley (2012). Executive functions: What they are, what they do, how they evolved. New York:
Guilford.

The regions of interest for the midbrain are obtained in several planes, and the shadow is projected to the
axial image shown in the figure, which explains why the third ventricle is covered by the region. The x
coordinate maps the left-right position; the y coordinate, the anterior-posterior position; and the z coordinate,
the superior-inferior position.
Evaluating
Dopamine
Reward
Pathway in
ADHD
Volkow N, et al, JAMA, 2009

A, Regions showed significantly lower dopamine D2/D3 receptor availability in participants with attention-deficit/hyperactivity disorder
(ADHD) than in controls (obtained from [11C]raclopride images).B, Regions showed significantly lower dopamine transporter
availability in the participants with ADHD than in controls (obtained from [11C]cocaine images). Significance corresponds to
P 100 voxels. The yellow regions identify the areas in the brain for which the measures differed between controls and participants
with ADHD. The location of the region that differed was similar for the dopamine D2/D3 receptor and for the dopamine transporter
and included the locations of the left ventral striatum (including accumbens and ventral caudate), left midbrain, and left
hypothalamus. The z coordinate maps the superior-inferior position.
Evaluating
Dopamine
Reward
Pathway in
ADHD
Volkow N, et al, JAMA, 2009

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

Psychosocial Treatment: Peer-reviewed studies
• Bramham, J., et al. (2009). Journal of Attention Disorders, 12, 434-441.
• *Emilsson, B., et al. (2011). BMC Psychiatry, 11, 116. doi: 10.1186/1471-244X-11-116
• Hesslinger, B., et al. (2002). European Archives of Psychiatry and Clinical Neuroscience,
252, 177-184.
• *Hirvikoski, T., et al. (2011). Behaviour Research and Therapy, 49, 175-185.
• Philipsen, A., et al. (2007). Journal of Nervous and Mental Disease, 195, 1013-1019.
• *Philipsen, A., et al. (2013). Attention Deficit Hyperactivity Disorder. Advance online
publication. doi: 10.1007/s12402-013-0120-z
• Ramsay, J. R., & Rostain, A. L. (2011). Journal of Cognitive Psychotherapy: An International
Quarterly, 25, 277-286.
• Rostain, A. L., & Ramsay, J. R. (2006). Journal of Attention Disorders, 10, 150-159.
• *Safren, S. A., et al. (2005). Behaviour Research and Therapy, 43, 831-842.
• *Safren, S. A., et al. (2010). Journal of the American Medical Association, 304, 875-880.

Psychosocial Treatment: Peer-reviewed studies (2)
• Salakari, A., Virta, M., et al. (2010). Journal of Attention Disorders, 13, 516-523.
• *Solanto, M. V., et al. (2010). American Journal of Psychiatry, 167, 958-968.
• Solanto, M. V., et al. (2008). Journal of Attention Disorders, 11, 728-736.
• *Stevenson, C. S., et al. (2002). Australian and New Zealand J. of Psychiatry, 36, 610-616.
• *Stevenson, C. S., et al. (2003). Clinical Psychology and Psychotherapy, 10, 93-101.
• Virta, M., et al. (2008). Journal of Attention Disorders, 12, 218-226.
• *Virta, M., et al. (2010a). Contemporary Hypnosis, 27, 5-18.
• *Virta, M., et al. (2010b). Neuropsychiatric Disease and Treatment, 6, 443-453.
• *Weiss, M., Murray, C., et al. (2012). BMC Psychiatry, 12, 30. doi: 10.1186/1471-244X-12-30
• Weiss, M., Hechtman, L. T., et al. (2006). Journal of Clinical Psychiatry, 67, 611-619.
• Wiggins, D. et al., (1999). Journal of Mental Health Counseling, 21, 82-92.
• Wilens, T. E., et al. (1999). Journal of Cognitive Psychotherapy: An International Quarterly,
13, 215-226.

CBT for Adult ADHD
Conceptualize patterns
– WHY don’t I change? (Educate)
Consider alternatives / gain skills
– HOW can I change?
(Execute-Experience)
Gain novel experiences / face challenges
– WHEN do I change? (Engagement-Endurance)

Summary of CBT for Adult ADHD:
Intervention Categories
• Cognitive modification
• Behavioral modification and coping skills
• Acceptance, mindfulness, persistence
• Implementation strategies
Ramsay & Rostain (2015). Cognitive behavioral therapy for adult ADHD (2nd ed.). Routledge:
New York.

Summary of CBT for Adult ADHD (2)
• Strategies + TACTICS
(implementation)
• Engagement > disengagement
(“action precedes motivation”)
• Take Away reminders
(behavioral prescriptions)
• Make treatment “STICKY” (portable, actionable)

Additional observations
• Engagement vs disengagement
• Investing discomfort
• “Touch” the task
• You don’t have to be “in the mood”
• “Once I get started…”
• Expectation of difficulty > positive feeling of doing things
• Generate “enough” motivation
• Make treatment “sticky”

CBT FOR ADULT ADHD IN ACTION:
THE ADULT ADHD TOOL KIT
“I know what I need to do – I just don’t do it.
So what is your approach going to do for me
that I can’t get anywhere else?”

• “Specific understanding of how you DON’T do
things.”
• “From this understanding, develop tactics to
help you use the strategies when you need
them at important pivot points.”

Coping Domains for Adult ADHD
• To Do List
• Daily Planner/Planning
• Prioritize/Choreograph
• Break down tasks
• Get started (Procrast.)
• Keep going
• “Manufacture” motivation
• Thoughts, emotions, escape
behaviors
• Outsource coping
• Data management
• Materials mgt.
• Environmental Eng.
• Prob mgt./Dec. making
• College, Work
• Relationships
• Health, well-being
• Technology
Ramsay & Rostain (2015). The adult ADHD tool kit: Using CBT to facilitate coping inside and
out. New York: Routledge.

TO DO LIST
“What do you have to do?”

To Do List
• “How do you spend yourself?”
• Spend time, effort, and energy
• Externalize time and tasks
• “I shouldn’t have to do this”

Planning Time To Plan
1. Devote 10 minutes (600 seconds) to planning.
2. Find a place free from distractions.
3. Spend an honest 10 minutes (600 seconds) planning out your day.
4. Write down your plans in your Daily Planner.
5. Define To Do tasks using specific, behavioral terms for what you will
“do.”

Comprehensive To Do List
1. Get a notebook or open a computer file that will be devoted
to your Comprehensive To Do List.
2. Find a place free from distractions.
3. Write down all of your obligations, plans, errands,
commitments, recreational ideas, etc. for the upcoming 1 to
6 weeks (or whatever time frame suits your needs) – this is
your “dump list.”

Comprehensive To Do List (2)
4. Store your notebook or computer file in a place where you
can retrieve it and refer to it later.
5. The Comprehensive To Do List provides you with reminders
of tasks and obligations without relying on your memory.
Refer to it periodically for helpful reminders of things that
you can do, but this is not your Daily To Do List.

Daily To Do List
1. Find an index card, back of an envelope, or other disposable piece
of paper.
2. Devote 10 minutes (600 seconds) to defining your To Do List for
the day.
3. Your Daily To Do List is made up of tasks you want to do that are
not part of your typical schedule but that require a special
investment of time and effort to complete.
4. Limit your list to no more than 2 to 5 items. When in doubt, err
on the side of fewer items rather than more – you can add more
after you complete these, if you like.

Daily To Do List (2)
5. Define tasks in specific, behavioral terms or actions that you can
“do.”
6. Set a realistic time frame to spend on each task.
7. Use your Daily Planner to find times in your day when you will make
an “appointment” with yourself to perform each task.
8. Do each task at the scheduled time – get it off the list.

“Enter a Room with a Plan”
1. Specify your reason for entering a room (or office, or sitting at a
desk, etc.). What is your intention and why is it this intention of
value to you?
2. Define the behavioral steps or the actions you will take in the room
in order to start the task and act consistently with your intentions.
3. How might you get “off task”? What could interrupt your
intentions? Predict a likely barrier or distraction you will encounter
while working on the task.

“Enter a Room with a Plan” (2)
4. How will you handle the interruption? Devise your strategy for
dealing with this barrier/distraction using an “IF-THEN” plan. (“IF I
encounter X, THEN I will handle it by doing Y”).
5. Proceed and “enter the room with a plan” to perform your intended
action by following your step-by-step plan.

• “I’ve been busy all day but have not gotten
anything done.”
• “I don’t like limits. I’ll just wing it.”
• Pseudo-efficiency
• “Ready, fire, aim” or “Getting ready to get ready”

Additional observations (2)
• “It is too overwhelming to look at everything I
have to do.”
• Perfectionism

DAILY PLANNER
“How do you ‘spend yourself?’”

Daily Planner
• Externalize time and effort
• Track throughout day and across days
• “See” the future, placeholders
• “Do the experiment” (informed decision)

Daily Planner
1. Decide on paper vs. electronic planning system – if in doubt, start
with paper planner.
2. Find a planner size and format that fits the scheduling demands of
your life.
3. Plan to “over” use your Daily Planner. It is a place for scheduled
appointments, work and school commitments, as well as personal,
recreational, and self-care tasks.
4. Err on the side of “under” scheduling, leaving enough buffer time
between tasks and meetings.

Daily Planner (2)
5. Keep your “task appointments” as specific and behavioral as
possible.
6. Define start times and end times for tasks and activities, whenever
possible – “lower the bar.”
7. Your Daily Planner a “tool of daily life,” along with your keys, wallet,
purse, cell phone, etc.

• “Leave room for cream”
• “60 mph syndrome”
• “If you had $24….?”
• Schedule “down time”
• Highway signs
• “Anchors”

TIME AND TASK MANAGEMENT
“Define, prioritize, and choreograph what you do.”

Time and Task Management
• Energy management /
“recharge battery”
• Down time
• Tour de France
• “Choreography”
• Google maps: satellite v.
street level
• Recommended daily
allowance

Review Planner
1. Review your Daily Planner at the start of your day (or night before).
2. Glance at, review, and “refresh” your Daily Planner throughout the
day to give yourself reminders of upcoming tasks and plans.
3. If your situation involves frequent changes to your plans, have some
set times that you can make the adjustments to your Daily Planner.
4. Record any new, future commitments in your Daily Planner as they
arise.

Review Planner (2)
5. Use Daily Planner to keep track of what you have completed in
addition to checking off tasks from your Daily To Do List.
6. Repeat.

Using Your Planner
1. Get your Daily Planner and take it to a reduced distraction setting.
2. Devote at least 10 minutes (600 seconds) to planning your day.
3. Review any obligations you have already recorded in your Planner.
4. Record any known commitments or obligations for that day,
including meetings at work, classes, picking up and dropping off
from school, etc.
5. Reserve times for self-care tasks, such as sleep, meals, exercise.

Using Your Planner (2)
6. Leave adequate buffer time between tasks for breaks, commuting,
etc.
7. Make appointments for tasks from your Daily To Do List.
8. Make sure that tasks in #7 are defined in reasonable, behavioral
terms.
9. Schedule “down time” and other recreational or social activities

Using Your Planner (3)
10. Make sure the order of tasks throughout your day makes sense and
is realistic.
11. Trust the plan – focus on engaging in your first task and take it one-
step-at-a time.
12. Refer to your Daily Planner frequently throughout the day.

Make Tasks Behavioral
1. Look at the tasks on your Daily To Do List.
2. See if any tasks are worded in ways that seem overwhelming or are
too broad. (e.g., “write paper” or “clean house”)
3. Reword the task in terms of a smaller, more specific step that
seems reasonable and doable (e.g., “re-read last paragraph of
paper” or “unload top drawer of dishwasher”).
4. Keep doing #3 until you have defined a task as an action that you are
confident that you will carry out.
5. Use this re-defined task on your Daily To Do List to get started.

• Apollo 13 example / sequencing
• Visible time piece!!
• Customization (without rationalization)
• Placeholders
• Get started: Jack LaLanne (“Almost every day…”)

GETTING STARTED
Putting the plan in motion OR “Once I get
started…”

Getting Started
• Procrastination (central
issue) – “How do you
NOT do things?”
• Navigate chasm from
“not doing” to “doing”
• Zeno’s paradoxes
(leaving a room)
• Getting “engaged”
(“Once I Get Started…”)
• Seinfeld – “You know
how to take the
reservation…”

Break Down Tasks
1. Identify a task you want to complete.
2. Is there a deadline for completing the task or some other time limit?
3. Break down the task into its component steps. Develop a
“behavioral recipe” or a set of instructions that would allow
someone else to perform this task in the time allotted.
4. What are the different steps you need to take from the starting point
in order to reach the end point at which the task is complete? You
can also work backwards from the end point to the starting point.
5. Make the steps specific and behavioral.

Break Down Tasks (2)
6. Use your Daily Planner to budget out the steps across the time
leading up to the deadline. Make appointments to perform the
different steps.
7. Define the smallest, first task you can perform to get you engaged in
the task or at least “touching it” today.
8. If you are still procrastinating, break down this first step into even
more specific steps until you find a first step you can do.
9. Perform this “smallest step of behavioral engagement.” You are no
longer procrastinating.

Implementation Plan
1. Define the smallest, first behavioral step to get started
2. Specify how long you can spend on this task. Err on the side of less,
rather than more time.
3. Make an appointment with yourself for this task. Have a start time
and an end time consistent with #2.
4. Devise a plan for getting started using the “If X happens, then I will
do Y” framework

Implementation Plan (2)
5. Predict the most likely distractions or barriers that will get you off
task.
6. Devise a plan for handling risks for procrastination using the “If X
happens, then I will do Y” framework

Implementation Strategies
• Ideal is task goal + implementation plan
• “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.

10-minute Rule
• Define the “smallest step of behavioral engagement” that will get
you on-task.
• Define the briefest amount of time you think you will be able to
endure this first step of the task – even if it ends up meeting your
expectations for a “worst case scenario.” We recommend at least 10
minutes – an honest 600 seconds.
• The clock starts when you are in position to perform the smallest
first step.
• Devote 10 minutes (600 seconds) of a good-faith effort to the task
and then reassess.

Procrastination
1. Identify the specific task on which you are procrastinating.
2. Pinpoint your thoughts about doing the task. In what ways do you
MAGNIFY the negative aspects of a task?
3. Label your feelings about the task, including sense of boredom or
simply a gut feeling of “Ugh (I don’t want to do this).”
4. Now, think about and highlight why this task is of value to you and
how it will feel to get it done.
5. Pinpoint the positive aspects about your ability to face the task that
you may MINIMIZE.

Procrastination (2)
6. Think about the positive feeling you will have when you complete
the task.
7. Break down the task into a small, first step you can take to get
started despite how you feel.
8. Invest a few moments of discomfort and uncertainty as you take
the step in #6.
9. You are no longer procrastinating.

• Magnification – Minimization distortion
• Overgeneralization, Comparative thinking
• Tolerating discomfort
• “Swing votes”

KEEPING THE PLAN GOING WHEN
THE GOING GETS ROUGH (PART 1)
Managing motivation, emotions, and energy.

Keeping the Plan Going (Part 1)
• Reframing “motivation”
• Behavioral change
• Emotional (+ energy)
management
• Pairing tasks with
enjoyable stimuli
• The emotion of “UGH”
(or “Taming Your Inner
‘UGH’”)
• “I knew I was
procrastinating as I still
did it.”

Manufacture (Enough) Motivation
1. Define a task in specific, behavioral terms to make it doable.
2. Define the smallest, first step of behavioral engagement.
3. Identify negative emotional reactions to the task that create barriers
to getting started.
4. Identify the ways in which you are magnifying your negative
expectations and minimizing your ability to handle the task, tolerate
discomfort, and achieve positive outcomes.

Manufacture (Enough) Motivation (2)
5. Notice, label, and accept your emotions about the task. You can
feel these feelings AND get started on the task.
6. Remember the simple behavioral steps that you can do to get
started and that you do not have to be “in the mood” for the task
7. Once you take that step, you are no longer procrastinating and will
feel much better.

Old Behavior Script
1. What is the new behavior plan you are trying to implement?
2. When during your day is a good time to implement it?
3. As it is now, what typically happens instead of implementing the
new plan? What is your “old behavioral script” that keeps you stuck?
4. List out the steps that define the “old behavioral script” to see what
interferes with your new plan.
5. What do you get out of this “old behavioral script”? What about it is
enjoyable or rewarding, even if it keeps you stuck?

New Behavior Script
1. Using your “old behavioral script,” develop an alternative script that
will promote the implementation of your new behavior plan.
2. For each step of your “old behavioral script,” develop an alternative
and realistic step that will be incompatible with the old patterns.
3. Develop a “new behavioral script” made up of the action steps
consistent with following through on your new plan.

New Behavior Script (2)
4. Identify some rewards you can set up for following the new plan.
5. Use other Take Away suggestions for handling implementation
issues, such as breaking down a plan into steps and defining small
first steps.
6. Use your “new behavioral script” and follow it step-by-step.

Managing Energy
1. What are some important ways you can “recharge your battery” and
maintain your energy throughout the day? How does the order of
tasks or their “choreography” affect your energy?
2. Do you need breaks? What is a reasonable length of break? What
can you do during a break? What should you not do during a break?
3. When do you eat? Do you need some sort of snack between meals?
What are good food choices for you? What foods should you avoid?
4. Does physical activity and movement help you? What are your
options for exercise, including brief walks, standing up from your
desk, etc.?

Managing Energy (2)
5. How well rested are you? Do you get enough sleep at night? Is it
helpful to use relaxation strategies during the day?
6. Do you have some “down time” during your day? What are some
recreational activities you value? Do you have any activities you do
that actually make you feel worse?

Rewards
1. What are some rewards you can give yourself for following through
on your plans? What are immediate rewards you can earn for a task
plan completed today? What are some longer term, bigger
incentives you can use for larger tasks?
2. What are some enjoyable things that you can link with your task
plans in order to increase your follow through? Is it helpful to listen
to music while you exercise or do chores? Do you enjoy having tea
or coffee while doing paperwork?

Rewards (2)
3. What are some of the positive experiences you notice when you
follow through on your plans and get things done?
4. Conversely, what are some escape activities that might “reward”
procrastination? Is there a way to transform these activities into
positive rewards for task completion?

Managing Discomfort
1. Identify your emotional reactions that contribute to avoiding an
immediate task.
2. Recognize your feelings, including boredom, mild anticipatory
stress, or “Ugh” (“I don’t want to do this right now.”).
3. Rate your “discomfort” along a continuum. How strong is it, really?
Rate it on a “0” (relaxed) to “100” (worst pain I’ve ever felt) scale.
4. Notice your emotion and how it feels – without trying to make it go
away. Is it tolerable even if it is somewhat uncomfortable?

Managing Discomfort (2)
5. Focus on breathing through your feelings with a slow, steady pace.
6. Recognize that your feelings need not dictate your behaviors.
7. Consider that you can follow through with your plans AND feel a
degree of discomfort.
8. Engage in and focus on the smallest behavioral step for your task.
9. Observe what happens to your feelings once you get started on the
task.
10. Practice these skills when facing other situations and tasks
throughout your day.

KEEPING THE PLAN GOING WHEN
THE GOING GETS ROUGH (PART 2)
Managing attitudes, beliefs, and self-esteem.

Keeping the Plan Going (Part 2)
• Cognitions
• Beliefs
• Experience of
engagement
• Method acting
• Change the
negative:positive ratio
of expectations
• Does your self-talk have
a “tone of voice”?
• Driving a new car off of
the lot.

Catching A.T.’s
1. Use changes in your feelings, including discomfort about a task, or
the fact you are avoiding a task as signs that you are having negative
automatic thoughts.
2. Think back and figure out what situation, task, or event triggered
this reaction.
3. What was your thought about or interpretation? (“What thought
went through my mind about it? What does this mean to me?”)
4. How does this thought influence your feelings and your behavior?
5. Are you engaging in any thinking errors? How might you look at
things differently? (refer to list of Thinking Errors)

Changing A.T.’s
1. Recognize your automatic thoughts about a task that affect your
follow through.
2. Reconsider these negative thoughts as though they were arguments
made against you or the task by a “Prosecuting Attorney” who is
presenting a case against you to a Judge and jury.
3. Now, consider how your “Defense Attorney” would object to any
thinking errors, incomplete information, and exaggerations in the
Prosecutor’s argument and make a case on your behalf focused on a
balanced, realistic view of the situation.

Changing A.T.’s (2)
4. Weigh the evidence and consider ways that you can take action
using an adaptive view.
5. Use previous Take Away suggestions for getting engaged on a task.

Modifying Thoughts
1. What am I thinking about this situation? Am I using any thinking
errors?
2. What is another way to think about this situation? What would my
“Defense Attorney” say?
3. What is the worst possible outcome? What is the best possible
outcome? What is the most likely outcome in this situation?
4. What are some specific steps I can take to influence this situation?
Can I handle the situation?

Modifying Thoughts (2)
5. If a friend of mine (particularly someone with ADHD) was in this
situation and had these reactions, how would I advise him or her?
6. In the grand scheme of things, is this situation as bad as I’m making
it out to be? How will I look at this situation in an hour? A day? A
month? A year from now?
7. What can I do to handle this situation, such that I can look back on
it with a sense of satisfaction? What is a small step I can take to
make this happen?

Recommit to Plan
1. What is the plan with which you are struggling?
2. What about this plan has been difficult for you? What has interfered
with follow through?
3. Is this plan still worth the time and effort it requires? Have
circumstances changed?
4. Make an informed decision about your commitment to the plan by
weighing its risks and benefits. If it is no longer a priority, you can let
it go.

Recommit to Plan (2)
5. If you still want to pursue this plan, why is it still important to you?
What is its value to you?
6. How will it benefit you in the long run?
7. How would you feel if you abandoned this plan? How would it feel
to keep working on it? How do you anticipate you will feel when you
complete your plan?

Recommit to Plan (3)
8. Are you willing to face and tolerate the discomfort in order to take
the next step?
9. What are the next steps you can take to move forward, even a little
bit?
10. Are there any additional resources or assistance you need to keep
going?

• Defense Attorney
metaphor
• Cognitive distortions
– Pessimistic bias
– Positive bias
• Core beliefs, sense of
self (Downward arrow)
• Ability to experience
• Task = collect experiences
• Self-mistrust

PHARMACOTHERAPY
Treating the symptoms of ADHD

Common Patient Questions
• Why should I consider
meds?
• What are they? How do
they work?
• What response can I
expect?
• Must I take every day?
• Side effects?
• Any dangers?
• Any conditions that
obviate ADHD meds?
• Take rest of my life?
• What if I have
depression? Anxiety?
Substance use
problems?

FDA Approved Pharmacologic Treatments
Methylphenidate-based formulations Duration of effect
Concerta® ~12 hours
Ritalin® 3–4 hours
Metadate® CD 8–10 hours
Ritalin® LA ~8 hours
Focalin ® (XR) 3–4 (8–10) hours
Daytrana® ~12 hours (worn for 9)
Amphetamine-based treatments
Adderall XR® ~8 hours
Adderall® 4–6 hours
Dexedrine® Spansule 6–8 hours
Vyvanse® ~12 hours
Nonstimulants
Strattera®
Intuniv ®
Kapvay ®
Up to 24 hours
Up to 24 hours
Up to 24 hours

ADHD Medications
ADHD medications Effect size
Immediate-release stimulants 0.91
Long-acting stimulants 0.95
Nonstimulants 0.62
Faraone et al. APA 156th Annual Meeting: May 17-22, 2003. San Francisco, Ca. Villalba. DPP Safety Review. February 28, 2006.
Liberthson. N Engl J Med. 1996;334:1039-1044.
Effect size: Probability that a treated patient will show a level of improvement that exceeds
that of a randomly selected placebo patient.
0 = No difference; Negative = Placebo better than drug; Positive = Drug better than placebo
Courtesy of Jeffrey Newcorn MD

Overall Response Rates for
Pharmacotherapy
• Stimulants: 75 – 80 %
– Of responders, 1/3 do better on MPH, 1/3 do better on
AMPH, and 1/3 do equally well on MPH or AMPH
• Atomoxetine: 65 – 70%
– Different mechanism of action may be beneficial or may
be seen as not as effective for those used to stimulants
– Combination with stimulants is safe but should be closely
monitored

Adherence by Medication Type
• Within 2 to 3 months, a majority
of patients with ADHD have
stopped taking medication
consistently1,2
• Adherence rates tend to be better
for long-acting medications for
ADHD3
• One study has shown similar
adherence for the long-acting
agents OROS MPH, MPH LA, MAS
XR, and atomoxetine1
• Patients renewed their monthly
prescriptions about 2 to 3 times
per year1
1. Capone. Presented at CHADD Annual International Conference, Dallas, Texas; October 27, 2005.
2. Perwien et al. J Manag Care Pharm. 2004;10(2):122-129.
3. Sanchez et al. Pharmacotherapy. 2005;25(7):909-917.
0%
20%
40%
60%
80%
100%
1 3 5 7 9 11 13 15
Month
Patients
(%)
OROS MPH
MPH LA
MAS XR
Atomoxetine

First line pharmacotherapy
• Psychostimulants first line agents
– Multiple FDA approved agents (adult)
• Long-acting preparations preferable
– compliance, treat through the day
– minimize abuse
• May be useful to orient according to
weight
– E.g., 1-1.5 mg/kg/day MPH ~ 70-100mg/day;
– 0.5-1.0 mg/kg/day MAS
In part, Nutt, 2007; CADDRA, 2007; AACAP 2007

Psychostimulant Use Guidelines
• Trust your patient – if you are concerned about potential
substance abuse or misuse do not prescribe stimulants
• Explain the principle of a “medication trial” and the need for
patient to keep a medication response log
• Up to 30% of patients respond better to either AMP or MPH,
while 30% respond equally well to both
• Start with MPH at varying doses – once the optimal dose is
determined, can adjust the schedule with longer acting
preparations
• If MPH is not optimally effective, switch to AMP and
determine responses to variable doses

Psychostimulants: Side Effects
Adverse effects are generally well tolerated
Reduced appetite and consequent weight loss
Abdominal pain, nausea, constipation
Difficulty falling asleep
Mild increase in heart rate and blood pressure
Jitteriness, jumpiness
Motor tics
Dysphoria, moodiness, irritability
Rebound effects

Psychostimulants: Drawbacks
• As a class, orally administered stimulant formulations
have several drawbacks including:
– in adults, almost all (with the possible exceptions of
Concerta™, Daytrana™ and Vyvanse™) require multiple
daily dosing leading to inconsistent times of
administration,
– they produce variable blood levels including daily peaks
and troughs,
– interference in absorption caused by stomach contents
(except Daytrana™),
– loss of efficacy in the evening (except Daytrana™)

Psychostimulants – Other issues
• Dietary caffeine: recommend decrease in
consumption to avoid over-stimulation
• Nicotine: similar caution
• Alcohol: no toxic interactions seen at moderate
doses, but normal response to alcohol may be
altered
• Decongestants (e.g. pseudoephedrine): should
reduce dosage or stop stimulant for duration of use
• Diet: should be adjusted to avoid significant weight
loss [i.e. this is not a good diet drug!]

Why Nonstimulant Treatments?
Advantages of non-stimulants
– No drug abuse or diversion potential
– Longer duration of action – difference mechanisms
– May treat several existing co-morbid conditions (e.g. anxiety,
depression, tics, sleep disturbances, morning or evening
oppositional behavior)
– Different side effects profile as compared to stimulants (i.e. don’t
lead to reduced sleep and appetite, personality suppression,
accentuation of tics, cardiovascular issues)

OUTSOURCING COPING SKILLS
Trouble avoided is a problem solved (but stay
away from “Fool’s Gold”)

• Workarounds
• Set up systems
• Develop habits
• Move from cortical to subcortical
Outsourcing Coping Skills

Outsourcing
1. Set up automatic payment systems for recurring bills.
2. Set up automatic deposit of your paycheck
3. Use online banking.
4. Set up reminder features for recurring important dates, i.e.,
birthdays, anniversaries.
5. Sign up for reminder texts or e-mails from pharmacy, medical office,
etc.

Outsourcing (2)
6. Consider if there are challenging tasks for which you can hire
someone to perform, i.e., tax preparation, lawn care.
7. Consider if you can barter services with someone else.
8. Are there other options for outsourcing or automating tasks?

• E-mails folders for
different roles
• Unique credit card AND
e-mail account for
automatic payments
• Separate e-mail account
for “store offers”
• Visible time piece
• Hiring and bartering
• Announce your plans
• Find useful tools but
avoid “Fool’s Gold”

DATA MANAGEMENT
Recording, organizing, and managing info

Data Management
• Get it before you lose it
• Reinforce basics
• Widen definition of “data” and ways to “manage”
in different settings
• Interpersonal

Assertiveness
1. Assertiveness is the ability to state a question, assertion, request, or
suggestion.
2. Assertiveness can be communicated in a cordial, professional,
collaborative way.
3. Identify the specific question, statement, request, or suggestion you
want to express.
4. Do not engage in “mind reading” and do the other person’s thinking
for him or her. Focus on what you want to say. (“What is your role
in this situation?”)

Assertiveness (2)
5. Make your statement in as simple and straightforward a manner as
possible, what may be restating your view of the facts (e.g., “I think I
ordered a vegetarian meal.”).
6. Once you have made your statement, your job is done and you have
been assertive. It is now up to the other person to respond.
7. Assertiveness is a coping skill for ADHD that can be used in the
following ways:
8. Request follow-up e-mail summaries after work meetings

Assertiveness (3)
9. Request reasonable accommodations at work
10. Suggest and negotiate deadlines for projects
11. Asking for help, such as weekly meetings to monitor progress on a
project
12. What are other ways you might use assertiveness as a coping
strategy?

• “Get it before you lose
it.” (Leonard,
“Memento”)
• Record, repeat back,
review, re-confirm
• Digital back-up
• Go paperless
• Work/School issues
• Delay tactics (impulsive
compliance)
• Say “no”

MATERIALS MANAGEMENT
Organizing and managing “stuff”

Materials Management
• Handling and managing items, possessions
• Keep vs discard
• What bring into home (buy book vs. library)
• Central place for “tools of daily life”

Managing Stuff
1. Have a specific location where you keep your “tools of daily life.”
2. Reduce clutter by going paperless, as much as is feasible for you.
3. Define storage spaces and tools for keeping essential paperwork
and other items.
4. Go through incoming mail each day and only keep those items that
are essential (e.g., bills, tax items, etc.). Store essential mail in a
shoebox or other container. Schedule a few minutes each week for
paying bills and taking action on these items.

Managing Stuff (2)
5. Remember that managing “stuff” takes a small investment of time
and effort each week but will pay off dividends in the long run.
6. Your organizational system need only be “good enough” to do the
job.

Getting Started on Organization
• Task-based – Target one item to get started (e.g., Unload
bowls from dishwasher)
• Time-based – Get as much done as you can during a specific
time frame (e.g., “I will pick up and put away as many items as
I can until my friend arrives.”)
• Terrain-based – Target one location to organize (e.g., clean off
kitchen table)

• Something is better than nothing
• Specific areas of disorganization
• Manage discomfort
• Daily mail

ENVIRONMENTAL ENGINEERING
Managing your surroundings

Environmental Engineering
• Stimulus control
• Sensitivities
• Personalization (without rationalization)

Work Station
1. Define a place where you can devote to doing work.
2. It is useful to define a work station in your residence as well as an
outside one (e.g., library, coffee shop). One can be your primary
spot and the other a back-up.
3. Make sure it has the minimal requirements you will need to do your
work.
4. Be mindful of your sensitivities (e.g., lighting) or potential
distractions.

Work Station (2)
5. Use stimulus control to minimize distractions in and around your
work station.
6. “Going to” your work station is often the “smallest first step” to
take action on a task.

• Alternative work station
• Study stations for students
• Sleep station

PROBLEM MANAGEMENT
DECISION MAKING
Putting skills together to manage life

Problem Management
Decision Making
• Handling real world scenarios
• Integration of multiple skills
• Managing uncertainty (and discomfort)

Problem Management
1. Define the problem to be managed in specific, behavioral terms.
2. Brainstorm as many options for handling the problem as you can
think of – do not edit yourself.
3. Assess the pros, cons, and feasibility of each of the options.
4. Implement the best option (which may not be the easiest or most
comfortable one).
5. Assess the outcome. If the problem persists and if possible, re-enter
the template at Step 1.

Decision-Making
1. Define the decision to be made in specific, behavioral terms.
2. Identify the different choices or options for making the decision.
3. Weigh the pros and cons of each of the options in order to define
the best option.
4. Consider if more information is needed in order to differentiate
options.

Decision-Making (2)
5. Select the best option, make and commit to that option. (“Live into
a good decision.”)
6. Assess the outcome. If needed and if possible, re-enter the
template at Step 1.

• Pocket veto
• “Live into a good decision.”
• “If you flipped a coin…”

MANAGING COLLEGE
The underappreciated effects of ADHD

Managing College
• Whether / when to go
• Where to go
• Preparing to go
• Handling it when there
• Going back

SQ4R for Reading
• Survey text
• Questions text will answer
• Read
• Record answers (also Reflect on answers)
• Recite
• Review

SQ4R Technique for Reading
1. Survey the text, particularly section headings, bold face terms,
illustrations, etc.
2. Develop questions about the topic of the text based on your survey
of section headings, etc.
3. Actively read each section of the text. Make notes on the page or
elsewhere.
4. Actively take notes and record information that helps you to
understand the text and to formulate answers to your questions.
Write them down in your own words.

SQ4R Technique for Reading (2)
5. Recite what you have read by answering the questions for that
section and summarizing it in your own words.
6. Review again the headings, etc. and your answers to the questions,
your notes, etc.
Robinson, F. P. (1970). Effective study (4th ed.). New York: Harper and Row.

Writing Papers
1. Read the description of the assignment to make sure that you are
clear about it, the specifications for the paper (e.g., pages, format),
and the due date.
2. Break down the paper into different tasks, including any research,
reading, outlining, drafts, as well as any intervening due dates, i.e.,
topic approval, submitting a draft, etc.
3. Using the due date for the final paper, work backwards and define
times to work on the different tasks required to complete the paper.

Writing Papers (2)
4. When it comes time to write the paper, start with time spent
thinking about and outlining your ideas, which is considered a step
in “writing.” Write down ideas and points you want to make or use
index cards to remember and organize your ideas. You may also
organize ideas by thinking how you would present them in a Power
Point presentation.
5. When actually writing the manuscript, follow your outline. The first
draft involves getting ideas down even if they are incomplete or the
wording and grammar are not finalized. Do not edit your writing,
yet, just get down your ideas.

Writing Papers (3)
7. After getting the ideas down, you can return to the document and
start to clarify the expression of your ideas. This is a different task
from #5, which helps make each of the tasks distinct and
manageable rather than trying to do it all at once.
8. “Lower the bar” and aim to meet the minimum requirements of the
paper so that you can submit it by the due date. This is an easier
target than trying to write an “A” paper.
9. Trust the plan.

• College is a huge test of EF/RDS
• ADHD Coaching for college students
• Use resources, personalize trajectory
• SLEEP and other health issues

MANAGING THE WORKPLACE

Managing the Workplace
• What to do
• How to make what you do work for you
• Using supports and skills
• Impossible to cover all types of jobs

Coping with Work
1. Consider the “goodness-of-fit” between you and the demands of
your current job or a prospective new job or career.
2. Where there is a “poor fit,” determine if there are reasonable
accommodations that can be made (informally or formally) that will
improve your ability to manage the situation.
3. Use the skills of assertiveness and negotiation to handle tasks and
deadlines at work. You are allowed to be proactive and to make
requests of a supervisor and to suggestions and proposals that will
improve your ability to handle your job well.

Coping with Work (2)
4. Get information down before you lose it.
5. Use your Daily Planner and Daily To Do List (and other skills) at
work.

• Career counseling
• ADHD Coaching
• Informal accommodations

RELATIONSHIPS, FAMILY, AND
ADULT ADHD

Relationships and Family
• Partners
• Co-parents
• Parenting
• Co-workers, friends, incidental interactions

Coping with ADHD-affected
Relationships
1. Confirm diagnosis and get individual treatment for partner with ADHD.
2. Schedule regular check-in times with each other. At least 10 minutes, sitting
together, face-to-face, without interruption from children, cell phones, television,
etc.
3. Use check-in times to coordinate the business of daily life, as well as to arrange
positive time and activities with each other.
4. Use empathy and communication skills to manage emotions during conversations
and various other interactions.
5. Couples therapy with a clinician familiar with adult ADHD can be helpful.

• Assertiveness, negotiation (“impulsive compliance”)
• External coping reminders
• Have a plan for handling predictable situations
• Emotional management skills

Additional observations (2)
• Communication skills/ “3 sentence rule”
• Express appreciation, affection, ask for help
• Define your “role” to determine your actions

TAKE AWAY – Communication
1. Disarming
2. Thought empathy
3. Feeling empathy
4. Inquiry
5. Summarizing
Burns, D.D. (1989). Feeling Good Handbook. New York: Plume.

HEALTH AND WELL BEING

Health and Well Being
• Under appreciated domain of functioning
• Important for college students, women’s
health, chronic conditions, etc.
• Not “treatment” for ADHD but it does improve
foundational well being for better coping

Sleep
1. Treat sleep as a priority task.
2. Define the time at which you must awake in the morning.
3. Work backwards using the number of hours of sleep you require in
order to calculate the time at which you should go to sleep. This
sleep time should be entered in your Daily Planner.
4. Devise a sleep routine that promotes getting into “sleep mode.”
This routine might include preparing your clothes and other items
for the next day, setting aside electronics 90 minutes before getting
into bed, engaging in reading or other relaxing activities, etc.

Sleep (2)
5. Adhere to standard sleep hygiene principles throughout the day,
such as no caffeine after a certain time, limit alcohol use, using your
bed only for sleep, avoiding exercise too late in the day, making sure
the bedroom is a comfortable temperature, limit daytime naps, etc.
6. Be mindful of thinking errors about sleep. Even if you have a poor
night’s sleep, you will have enough energy to function adequately
the next day, even if you are not at your best.
7. Do not to watch the clock if you awake during the night.
8. If you have difficulties getting back to sleep, get out of bed for 10
minutes or so to read or sit quietly before going back to bed.

Health & Well Being
1. Adequate sleep is a priority.
2. Define a reasonable amount of activity/exercise as a priority task in
your daily schedule.
3. Focus on implementing at one healthy eating habit and reducing
one unhealthy eating habit.
4. Use your Daily Planner to plan and monitor your health behaviors.
5. For women, be proactive in seeking help with changes in symptoms
due to menstrual cycles, pregnancy, perimenopause, or
menopause.

Health & Well Being (2)
6. Practice safe sex, including using birth control devices that also
provide protection from sexually transmitted diseases.
7. Practice safe driving. Take your medications as prescribed on a daily
basis if you will be driving. Do not drink alcohol at all if you have
ADHD and are going to drive. Do not ever text or talk on a cell
phone at all while driving.
8. Monitor and take steps (including seeking treatment) to reduce
unhealthy behaviors, namely substance use, including nicotine and
excessive caffeine use.

DEALING WITH TECHNOLOGY
Good servant, poor master

Mount Rushmore of ADHD
rationalizations
• Hyper-focus
• Night person
• Multi-tasking

Dealing with Technology
• ADHD is a risk factor for over use
• Source of distraction, deficit of attention
“surplus” (perseveration)
• Must develop a healthy relationship (akin to
an “eating disorder”)

Turn on Device with a Plan
1. Specify your reason for using this device. What is your intention and
why is it of value to you?
2. Define the behavioral steps or the actions you will take in order to
stay “on task” and use the device in a way consistent with your task
intentions.
3. How might you get off task? What could interrupt your intentions?
Predict the distraction you might encounter using the device that
could get you “off task.”

Turn on Device with a Plan (2)
4. How will you handle the distraction? Devise a strategy for dealing
with this barrier/distraction using an “IF-THEN” plan. (“IF I
encounter X, THEN I will handle it by doing Y”).
5. Proceed and “turn on the device with a plan” and follow your step-
by-step plan.

Managing Technology
1. Identify the technology habit that is problematic for you.
2. When is this habit particularly risky for you? First thing after you
awake? Late at night? When trying to do work? When bored?
Around bedtime?
3. What is your old behavioral script for this habit?
4. What is a new behavioral script that is more adaptive and realistic?
What are the steps that will allow you to perform or “do” this
script?
5. Why is this new behavioral script beneficial and of value for you?

Managing Technology (2)
6. How might you fall into your “old script” when you try to implement
your new plan?
7. How will you handle it if you drift into the “old” script? Devise a
strategy for dealing with this drift using the “IF X happens, THEN I
will do Y” framework.
8. Give your new plan a try.

UNDOING THE EFFECTS OF ADHD
The long range plan

Committing to “Undoing” ADHD
• Long view of coping with ADHD
• Lifestyle change (diabetes model)
• Undoing the effects of ADHD (paying down debt)
• Define realistic expectations and sustainable steps
• “What is the alternative?”

Contact us
ramsay@mail.med.upenn.edu
rostain@mail.med.upenn.edu

The adult ADHD tool kit for everday life handling strategies

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