Speaking of Psychology - Why are more adults being diagnosed with ADHD? With Russell Ramsay, PhD

Episode Date: February 26, 2025

For many years, ADHD was seen as a disorder of childhood. But in recent years, an increasing number of adults have been diagnosed with it as well. Clinician and researcher Russell Ramsay, PhD, discusses what’s driving the rise in adult diagnoses, what ADHD looks like in adults, how it affects people’s lives – including their work, relationships and health -- and what treatments are available.  Learn more about your ad choices. Visit megaphone.fm/adchoices

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Google Fi Wireless is not subject to data traffic deprioritization during times of high network usage. For many years, attention deficit hyperactivity disorder, or ADHD, was seen as a disorder of childhood. But in recent years, an increasing number of adults have been diagnosed with it as well. In 2023, more than 15.5 million U.S. adults said they had ADHD, and about half of those were diagnosed as adults, according to data from the National Center for Health Statistics. Now, as public awareness has grown, more people are coming forward to be tested, and researchers and mental health practitioners are developing new guidelines for diagnosing and treating adult

ADHD. So what's driving the rise in adult diagnoses? Is ADHD becoming more common, or is it just recognized more often? How do the symptoms differ between adults and children? What treatments are available for adults with ADHD? How does ADHD affect people's lives? in adulthood, from relationships to work to physical health. And if you suspect you might have ADHD,

where can you go for diagnosis and support? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills. My guest today is Dr. Russell Ramsey, the founding co-director of the Penn Adult ADHD

Treatment and Research Program at the University of Pennsylvania. Daniel Perlman School of Medicine, from which he retired in 2023. He's authored numerous peer-reviewed scientific articles and six books, including the APA book, Rethinking Adult ADHD, helping clients turn intentions into actions, and the Adult ADHD and Anxiety Workbook, Cognitive Behavioral Therapy Skills to Manage Stress, Find Focus, and Reclaim Your Life. Since retiring from academia, Dr. Ramsey has transitioned to a telepsychology,

practice treating patients with ADHD. Dr. Amsi, thank you for joining me today. Kim, it's a pleasure and an honor to be here with you. Well, let's start with the first question I posed in the introduction. What do you think is causing the rise in adult ADHD diagnoses? Is it becoming more common or are people just becoming more aware of it? You know what? As one of my colleagues said, there were no headlines years ago about where are all these adults

with ADHD? So part of it, I think the first answer, a large part of it is a correction. And I think especially with the pandemic and lockdown, with the loss of the scaffolding of everyday life going to school, going to work, having to self-organize at home, both children learning at home and adults working from home, as one of my clients said, now the world is getting to understand what every day of my life has been like for me, trying to manufacture this motivation and the structure. So a big part of it is a correct. direction. And I also think with that and the increased attention and seriousness with which

mental health issues were addressed over the pandemic, I think it got more people talking about it. And the credible information out there with ADHD was helping a lot of people to seek out assessment and treatment for adult ADHD. And with the loosening of the state-by-state licensing restrictions for telepsychology and cross-state practice, I think it gave greater access to people like myself who are familiar with the diagnosis and treatment of adult ADHD. What do ADHD symptoms look like in adults? I think we have an idea of what it's like for kids where they can't focus, they act out in classrooms, things like that. I think we may have that image, but how does it present in adults? How is it different from what happens with kids?

Right. You know what? The criteria are the exact same 18 symptoms in the DSM, now the DSM-5-TR. And the most persistent symptoms are the inattentive symptoms, the distractability, the difficulty sustaining, initiating, and sustaining focus, and getting back on track after distraction. Everybody can get distracted, but individuals with ADHD have a hard time re-engaging and whatever the focus was. Interestingly, impulsivity is relatively persistent, but it looks different in adults, whereas with children, it might be impulsively speaking out in school, speaking out of turn, if you will. Grownups can still speak out of turn or overtalk situations, as well as impulsive decision-making, impulsive spending, and a core feature.

of procrastination for everybody is impulsivity. I know I should be doing this, but let me just do this for a minute. That's impulsivity. But we don't think about it because it's very subtle, but it's still moving off and following the impulse. And the third of the big three, the hyperactivity, this generally gets more internalized for adults with ADHD and internal sense of restlessness that may not show up in terms of getting up, moving around, obviously climbing on a chair, but generally within reasonable lengths of time, such as a work meeting or something like that, many adults with ADHD will start to fidget around, tap their foot, maybe wagging their foot a bit. Maybe some of your listeners right now listening to me are fidgeting around looking for something else to do.

And interestingly, one of the, I'd say the perceptions, of ADHD and adulthood for women was that they were overrepresented of in the inattentive presentation without the hyperactivity. But some more recent reviews are finding that actually the rates of the combined presentation, both the inattention and the hyperactivity, women actually manifest roughly the same levels of impulsivity and hyperactivity as males, but it's just manifesting in different ways. And in fact, one review looking at children, girls versus boys manifesting the same behaviors, it did not get categorized as hyperactivity and impulsivity in girls as much as it was in boys, even though independent raters were finding

it about the same behavior. So there are some gender differences in how the symptoms were noted and attributed, and no surprise, with recent CDC data about the prevalence of adult ADHD in United States, which reported that half of individuals with ADHD have been identified in adulthood, 18 years old or later, and of that group, 61% were females. So that's another correction going on that the diagnosis in adults for women generally comes later, even though that may be changing now with the increased awareness. So do we miss it when they're younger because of the stereotypes for girl behavior versus boy behavior? I'd say that's to a large degree true, even though I think, at least with adults, going back to

children, for clinic referred children years ago, it was about a 10 to one boy to girl ratio. Now with adulthood, the differential is about one and a half to one, male to female. So with the increased understanding of the different manifestations, and one of the things to remember, ADHD is not caused by the environment, but it is certainly bound in the environment. Like different settings requiring sustained attention, working on tasks for a long time without breaks or some sort of acknowledgement or reward or something like that, are more difficult for adults with ADHD. But there might be other situations with working in teams, working hands-on work, where there's a lot of breaks

or more immediate feedback or reminders to stay on task, there are situations where individuals with ADHD can do quite well if not thrive. If people are diagnosed with ADHD as adults, does it mean that they've always had it and it wasn't diagnosed or can it develop later in life? ADHD is concerted a neurodevelopmental syndrome. And so it is generally, even if somebody is late identified in adults, part of the adult diagnosis is confirming childhood onset of symptoms. You don't have to have the diagnostic levels or have been diagnosed before.

That is not a requirement of the diagnosis, but part of the evaluation is confirming by the book whether there was symptom emergence, many symptoms showing up before age 12. Now, I follow DSM. However, there's some evidence to say that 16 years old, is probably a better marker because the 12-year-old, it misses those middle school years where there's a developmental expectation for different levels of self-regulation with increased chronological age. Now, another part of the question was, can it develop de novo later? And a few years back, there were a lot of studies looking at the potential for adult onset ADHD.

Now, that's different than late identified. Late identified is, yeah, you had the symptoms in childhood, but you got through school okay, maybe underperform, maybe not, but they persisted and caused increased difficulties. Now that you're 21, 25, 35, 55, 55, it's creating impairments so we can document that it was percolating before, but it wasn't until now that you got diagnosed. The late onset, there were individuals who were described as not having ADHD in childhood, but then it's showing up in adulthood. Now, a couple of the studies, the adults were 19, 20, and that's a fuzzy diagnostic line between childhood, adolescence, and adulthood. And in some of the cases of the studies tracking children

into adulthood, including children without ADHD, who were a control group from some childhood studies, when individuals were showing up in adulthood, in their 20s with ADHD, not having had it before, it was usually normal cognitive difficulties with attention in new circumstances, or maybe substance use problems, or an emergent mood or anxiety disorder. So there was usually another explanation for the quote unquote attention problems. Like one quote, I love, all that glitters is not gold and all that is distracted is not ADHD. It can have, because attention problems are a non-specific symptom, like a fever in medical practice. You go to your family doctor with a fever.

Could be the flu. It could be an infection. It could be malaria. You need more information. And likewise, within attention problems, that's why a thorough evaluation is really important to verify the diagnosis. What effects can ADHD have on people's lives in adulthood, on their relationships or their work lives or even their physical health? Right. That's a great question.

And, you know, I mentioned how ADHD is neurodevelopmental. And my thumbnail definition, it's a neurodevelopmental syndrome of impaired unfolding and execution of self-regulation skills. So these are what are also known as the executive functions, which we all have. And they unfold in a relatively predictable pattern. And these are what, if we wake up to an alarm today, that's your executive functioning, setting an alarm. If you set something by the door so you don't forget it on the way out of out in the morning, that's an executive functioning. There's virtually no area of life in which we don't rely on executive functions. So what generally drives people for an evaluation with children and adolescents,

usually school problems and maybe some behavioral problems in the classroom. And similarly for, like with our ADHD program at Penn, our first year or two, it was a lot of college students. First or second year, beyond the adjustment period, having difficulties managing on their own without the scaffolding of home or teachers in high school and whatnot. So those were still where the difficulties were the most prominent. But with adults, it can also turn into financial difficulties, overspending despite knowing or not tracking or not saving for retirement or whatever. Workplace, ongoing academics, driving. and increasingly we're seeing the effects on physical health.

There was one longitudinal study tracking children from eight years old to mid-20s, 27. And the health profiles at 27 years old predicted more than a decades lowered estimated life expectancy at age 27 based on the behavioral profile at that time. Now, one of the encouraging things in these very discouraging findings is, a lot of the elements are behavioral and can be targeted with all the evidence-supported treatments for ADHD and also making it part of a behavioral treatment plan. Then what is self-regulation as we think about it with ADHD, organizing behavior across time towards a future focus, a larger later goal rather than a smaller, sooner payoff.

This is why we save for retirement, but also these investments in behavior, such as exercise, watching diet, follow through with medication regimens, physical therapy, whatever it may be, but it certainly can affect personal health. And some people, including Russell Barkley, have said thinking about ADHD as a public health issue, but also relationships of all sorts are, you can think of them as an endurance race, including committed relationships, co-parenting relationships, and think about the self-regulation demands of being a parent. And there's no end of the school year in adult life. That's one of the things working with adults. You don't get to start, okay, new semester, new marking period, new teacher. No,

it's cumulative. And so difficulties within relationships, the reciprocity, and keeping up with responsibilities within a relationship. And these could be roommates where everybody has to pay rent, but somebody's always late with rent. Like I said, a co-parenting committed relationship where there's some expectation of reciprocity. And if it's not there, the attributions often in relationships, if you cared about me, you would remember to pay the bills or keep the promises. But we're talking about a neurobiologically driven syndrome that gets in the way of that happening. Now, that being said, one of the lines in my field is ADHD is not your fault, but it is your responsibility. So there are accommodations that can be helpful at school or at work, but they're not infinite. There's some

measures that require coping changes, making use of treatments, other things to navigate. That can help with all these domains of potential impairment across somebody's life. Your summer starts now with Memorial Day deals at the Home Depot. It's time to fire up summer cookouts with the next grill four-burner gas grill on special buy for only $199. And entertain all season. with the Hampton Bay West Grove seven-piece outdoor dining set for only $499. This Memorial Day get low prices guaranteed at the Home Depot. While supplies last, pricing invalid May 14th or May 27th, U.S. only exclusions apply. See Home Depot.com slash price match for details.

There are guidelines for diagnosing and treating ADHD in children, but they don't apply to adults. Is that correct? And there's a need for adult guidelines at this point. Right. And there are, right now, the first set of U.S. guidelines are being put together by the American Professional Society of ADHD and Related Disorders, colleagues, and I'm a member of that organization. I'm not participating on that side, but they are reviewing the evidence for assessment. And I think one of your previous guests and somebody I admire greatly, Dr. Margaret Sibley is leading

the review team for the assessment. But she's also had some wonderful papers, some of which the final. findings I already mentioned here, but she has a very nice paper looking at the recommended diagnostic guidelines for a first-time adult ADHD diagnosis. So they're out there. And I'm part of a parallel group, a consortium under the rubric of Chad, children and adults with attention deficit hyperactivity disorder, probably the largest grassroots organization, where we're going to take the guidelines and turn them into clinical toolkits for different professions. and I'm the psychologist on the team for that.

But there have been international guidelines, the European guidelines, the nice guidelines in the UK, Australian. And it actually works out well because after the U.S. guidelines are out there for a while, another country, another region will come up with theirs, and it'll be this iterative process. We have good guidelines already, but hopefully with the U.S. guidelines, there'll be more focused on dissemination.

Well, let's talk about treatment for a minute. You know, you've got a clinical practice treating adults with ADHD. What kind of treatments are available, both in terms of drugs and behavioral treatments? Right. The two evidence-supported treatments are medications for ADHD predominantly, but not exclusively. And I'm not a prescriber and I'm not a psychiatrist. So I'm just talking about research and what's available, i.e., don't sue me. But predominantly the stimulant medications, even though there are many non-stimulent medications approved for adult ADHD,

for people who don't respond to the stimulants or have intolerable side effects. And based on meta-analyses, and again, I get no funding from pharmaceutical companies. For adults, the ideal starting points based on the literature reviews is the amphetamine-based. And for children and teens, it seems to be the methylphenidate-based medications, at least as a starting point. And then in terms of psychosocial treatment therapy, the cognitive behavioral therapy has emerged as the evidence supported treatment. And as dire as some of the life outcomes of a lifetime diagnosis of ADHD, of different impairments, not everybody has everything, but there's virtually no area of adult life that can hide from ADHD. It can affect any, like I said, driving a whole host of other things. but there's also some of the most effective treatments that we have in all clinical psychiatry and psychology,

including the combination of medications. So there's a lot of options out there. Again, there's a lot of great cognitive behavioral therapists. However, not all of them, or maybe qualify that, not many of them have had direct experience with adult ADHD. In fact, there was a study in the UK within the past several months looking at client experience, is going through cognitive behavioral therapy for adult ADHD. Completing questionnaires and a handful got interviewed afterwards. And the initial reading of the results were awful because clients were saying it didn't seem

my therapist understood ADHD or understood the difficulties folks with ADHD have. So that was the complaints of many clients. Now, one of the interviewees reported that their therapist was very versed in ADHD and adult ADHD, and describe treatment as transformative. I felt understood, and I felt I could understand my brain and work with it rather than against it and felt they made a lot of progress. Now, those are the two evidence-based treatments. There are a host of others that maybe have some studies behind them, like some mindfulness-based

groups for ADHD, adapted for adult ADHD. ADHD coaching is another one. It's been around for about 25 years now. it started off as a metaphor in the book Driven to Distraction, where Ned Hallowell and John Rady said something like, what adults with ADHD is something akin to a coach that can help them keep on track and implement skills. And so it became this ADHD coaching, and there are some very good training programs, but it is not a licensed profession yet, but it does have some empirical research. So it's still gathering research. But I mentioned,

how the coach analogy that people need help with implementation, I think that's an important description of ADHD across the board, but especially for adults. It is not a knowledge problem. It's a performance problem. It's not knowing that you should start earlier to get things done or that you should be on time or anything like that. People know that, but it's difficulty putting it into play. The seven-year-old with the worst ADHD knows they should raise their hand and wait to be called on, but in the moment, I know the answer. I know the Declaration of Independence was not all signed on July 4th, but when was it signed? July 4th, 1776, and then the arm goes up. It's the sequencing. They know it, but it doesn't manifest in the way

we need it to. Now that's a very innocent example, but then later on in adulthood. And I've had people miss job interviews failing a class, not because they didn't do well on the test, but because they didn't hand in assignments or they violated the attendance policy, even though the quality of the work is good. And that's the insidious nature of ADHD, how it can undermine these things, including, as I mentioned in relationships, you're a great person. I trust you, but I can't trust that you'll pay the bills on time or that you won't go out and overspend or things like that.

And that's what kind of even erode committed relationships. So how would coaching in this instance work? Because it sounds like people, adults who have this, need like a constant reminder. It's not like once a week or every two weeks you can see your therapist and get coached there. So how do you on a daily basis get that little impetus? Well, you know what? Within some studies of CBT, now this is worked into studies. There have been some approaches where they would augment the weekly sessions and maybe having calls in between, like every couple days to check on homework. And some old school therapy approaches might say, well, you don't do that.

But if there's between session summary of the homework assignments or inviting people to check in, if they need to double check like what they're working on within my therapy with them or scheduling more frequent sessions. Now, within the field of ADHD coaching, it's not necessarily every day, but they might set up more frequent phone check-ins or even things. things like site visits, if somebody's working on an organization. Now, again, this is where ADHD coaching has been around for a while. It had remote sessions before the pandemic. That was part of follow-up text, phone calls.

So they were much more agile. And in terms of training of coaches, there are some things about sort of training expectations and the wide variety of quality you can get because it doesn't have the same controls as, say, and I'm biased, but like a graduate program in clinical psychology and then the postdoctoral training and the licensing. But it does have a foothold, and I think it filled a need where the cognitive behavioral therapist or other psychologists or whatnot, there weren't as many of them available. Whereas ADHD, that's what it's designed for. They get trained in ADHD. And for most adults, I mean, there's the most effective treatment,

a combination of either CBT or some kind of therapy and drugs, or can you do just one or the other? Right of self-determination. So sometimes individual for various reasons, but overall, it seems like the combined is the best. And actually, there's recent research looking at how the medications are very helpful with the core symptoms. The attention, the motoric hyperactivity, and impulsivity, a restlessness, sustained focus. But you can focus really well and procrastinate on something else or be disorganized, but well-focused. And that's where the psychosocial treatments, I'll say the cognitive behavioral therapy can

come in. And also with that, the executive functioning coping skills. But a couple things there. One, living with a lifetime of ADHD can lead to some negative self-beliefs and negative cognitions because very often the experience of adults with ADHD having lived with it, particularly if it's gone undiagnosed to adulthood, is, you mean I'm not stupid, lazy, or crazy. That was one of the first popular books on ADHD, but I think it resonates me and why I keep

citing it is because that would be the mindset. What's wrong with me? And it is a neurodevelopmental syndrome, as well as one of the things that doesn't show up in the DSM criteria, but we're now appreciating, and one of the executive functions is emotional self-regulation, that emotions, the emotional piece of ADHD is part of the self-regulation. There's two factors, it's emotional impulsivity, the emotions come on unchecked. There's not that initial slowdown to say, whoa, whoa, what am I what's going on here? it comes on quick and then it's harder to soothe it as efficiently.

So that emotional impulsivity, then the deficient emotional self-regulation is the second layer we typically use. Those are both problematic. And even going back to the 1970s, Paul Wender, one of the early experts in ADHD and one of the earlier professionals who identified adult ADHD, both at the time identified the role of emotions, including poor frustration tolerance, quick to anger. And also he's since passed away, but his group headed by Fred Reimer recently identified a two-factor model of ADHD. One was inattention, predominantly inattentive. But the second was emotional self-regulation. Now, it's only based on one or two studies by that group, but other groups have shown the relevance of emotions. And these are separate from the, and this is another part of treatment and how psychosocial and medications can work alongside each other.

And comorbidity is the rule rather than the exception for adult ADHD. The top two being anxiety and depression. And anxiety, and I did the workbook on anxiety, one of the features of anxiety is the intolerance of uncertainty in addition to the perception of risk. And for my money, ADHD is an uncertainty generator. Now, some people will do individual treatments. They might do fine just on medications. and with that they're able to say, okay, now I can be on time, use my plan or whatever.

And I've seen people individually for just CBT, there may be like a rare medical condition that does not allow them to take ADHD medications or that the side effects are intolerable or a pregnant woman or breastfeeding woman. Now, some of the research on medications and pregnancy are equivocal, but usually prescribers and individuals might err on the side of caution, even though it's not. a blanket prohibition, but people just being cautious. Or there might be people say, you know, I want to try it without medications first. And right of self-determination, I always invite it as an option, but it's just pretty much doubling down on the, on the CBT and the implementation-focused

interventions. You know, I read about a recent survey out of Ohio State University that found that 25% of U.S. adults think they have undiagnosed ADHD. Right. The research is speculated that part of the reason might be the popularity of ADHD-related content on social media. What's your take on this self-diagnosis? Is this really a thing or people just reading so much about it and they think they've got it? I think it's part of all of them.

So it's out there. And in a way, it's the part of the career. direction. So 10 years ago, ADHD would be the last thing after everything else got tried. And okay, maybe it's that. Or maybe individuals brought it up. And the provider might say, I say this respectfully, might be going, why not check it out? We got nothing to lose. So some of it is now it's out there in the language and the culture a little more, especially over the pandemic, and maybe on a shorter list of possibilities. Because one of the things about the symptoms of ADHD and the executive functions, they're a dimensional human trait where something like, say, bipolar disorder,

where it has very clear onset. And we could say it's a qualitative difference from, say, the typical range of mood most of us experience. But ADHD feels familiar for a lot of people. Oh, yeah, I do that sometimes. I almost left my iPad on the plane the other day, or I lose focus, which is true. I think like I said before, you get the flu, your executive functioning will go down. You have a bout of insomnia. Your executive functioning will go down. But if you don't have ADHD, as these situations, conditions remit spontaneously or with treatment, your executive function will go back to a baseline. It's normative baseline. With ADHD, the baseline is a moving target. So there was a study of children, and it was a population study. So many of them did not

have ADHD. A handful of them screened positive for ADHD as part of this study. And another group had been identified as already diagnosed. So what this study did, it was all parent ratings. Rate your child using this 18 item ADHD rating scale and also rate their quality of life, pretty much a functioning schedule. So, parents rating their children with zero or one symptom of ADHD. Very high well-being ratings. They're doing well. Two or three, really well.

Maybe a smidge less well. Six, seven, eight out of 18, nine. Probably not diagnostic levels, but the ratings start, the well-being ratings start going down. But maybe not diagnosed with ADHD. And then we get up into the diagnostic levels, you know, 10, left 12, 13, 14, 18, the well-being ratings go steadily down. Now, there's a lot of variation. It's not a one-to-one. But the trend was the more symptoms of ADHD you had, at least rated by your parents, the lower your well-being.

So my take on the Ohio State survey, the 25% guessing, I would say maybe a lot of those people, maybe they fall in that middle sub-threat. threshold range where somebody goes, yeah, I have insomnia every couple weeks for a day or two, but I don't need a sleep study or whatever. And sometimes I've really stressed out and I'm not as well, but I usually rebound and I don't have the time or money or to go see this Ramsey guy or anybody else. But there might be like the two or three or four or five out of those where they self-diagnosed, say, or at least self-screen. And I think self-diagnosis gets a bad rap because Now, somebody could go and say, oh, I must have ADHD then, because TikTok told me I do. And there was a study saying pretty much in a nutshell, 80% of TikTok content is unreliable, if not patently wrong.

But the most influential posts are personal stories. So even if they're wrong, they are compelling and believable. So there's a lot of misinformation, but the self-screening, the self-diagnosis, if that's followed up with, well, let me go get an evaluation that is familiar with ADHD and follows, like, for right now, Maggie Sibley's advice, which will probably turn into a nice skeleton framework for the guidelines, as well as looking for things that could better explain what you think are ADHD. And I know some of my, the evaluations I'm most fond of are the ones where I was able to sit with somebody and say, yeah, you're rating the high on the ADHD scales, but here's a better explanation for what's going on. Because that's, you know, as practicing clinicians, that's what we're looking for. Is it depression? Is it anxiety?

Is it trauma? Is it OCD and substance use and running through everything? And it might sound like, oh, my gosh, this is going to be like an eight-hour evaluation. Well, no, if you go through and you know, what you're doing, and I do a skid. So if you know the skip-out questions on the skid and you get two nose in a row, it's like barring other information to the contrary. You can move on and be relatively efficient. So finally, for our listeners who may be among the 25 percent of people wondering if they have it, how do you decide if it's worth getting tested and where should you go? You know what?

A readily available, reputable screening scale that is available for free is the World Health organization adult ADHD symptom rating scale. And it's available with a quick internet search. And you can download it at six items. Now, like any screening scale, like for diabetes or heart disease or depression, anything like that, screening scales cast a wide net because you want to catch the true positives. And you'll put up with a couple of false positives in there for follow-up evaluation. So that would be a way to screen. If you're in a relationship or, you know, somebody you're comfortable asking and say, yeah, I wonder if I have ADHD and seeing what somebody else says. And I've had people say, other people who said to them, oh, I thought you knew already or

something like that. Or I'm glad you brought that up in early. I was wondering about that too, but I didn't want to hurt your feelings or whatever. So that is a starting point. In terms of where do you go to find somebody, the main professional organizations, Chad, children and adults with ADHD, The Attention Deficit Disorder Association, that one focuses specifically on adults. They will have find a helper, find a professional, find a therapist features on their websites. Absard, I'm not sure. I don't think they have a find a professional yet because it is more of a professional organization. But here's advice I've been giving people looking.

If they're from a state, I'm not, I don't know anybody in or other region. I say look at the board of directors or the professional advisory boards of the ADHD organizations and see what the academic affiliations are and maybe reach out to people to say, oh, I see you're at the University of Wherever. Do you know of any referrals in the state or nearby or things like that? So it's a little bit of a six degrees of separation approach to getting there. But authors of books, I think Ned Hallowell, many of his books, he'll have lists in the back of people he knows. who provide services. I know in a couple of my books, I had some listing of colleagues who had

programs around. But one of things professionally and personally, my experience has been the ADHD community, the adult ADHD community has been very giving, like in terms of, oh, can I use your questionnaire and my evaluations and giving within professionals and wanting to make sure people get the help they need. And I think the forthcoming U.S. guidelines are an expression of that a love letter to adults with ADHD in a way in the U.S. hopefully. Well, Dr. Ramsey, I want to thank you for joining me today. This is a lot of useful information. Thank you. Kim, it was a pleasure and it was honored to be asked.

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