J. Russell Ramsay

This interview features Dr. Russell Ramsey, a cognitive behavioral therapist with 27 years of experience treating adults with ADHD at Penn's ADHD Program. He discusses practical strategies from his forthcoming book "Once I Get Started," focusing on core concepts like "procrastivity" (doing easier tasks to avoid important ones) and implementation intentions ("if X, then Y" statements).

The conversation covers real-world applications for college students and families, emphasizing that action precedes motivation and that small steps like simply getting to the library or gym can jumpstart progress. Dr. Ramsey stresses personalizing strategies, normalizing setbacks, and measuring improvement in realistic increments rather than expecting perfection.

Therapeutic Approach and Implementation Strategies

We’re here with Dr. Russell Ramsay. Such a pleasure to be with you. Before we jump into the questions, you mentioned you have a new book coming out.

Yeah, just got the release date. It'll be May 19, 2026. It's titled Once I Get Started and it's an overview of CBT. I'm a dyed-in-the-wool CBT therapist, clinician, and researcher. But I also take a broad view, integrating whatever works. So even though I come from a CBT foundation, I draw in whatever can be helpful for adults with ADHD. I hope people find it helpful.

That’s awesome. Let’s jump right in. In the typical therapeutic or even coaching model, sessions are weekly. With our clients—many of them young adults and teenagers—a lot can change in a week. Sometimes it feels like the half-life is too long. From your work we’ve learned to try things like texts, externalizing, reminders, nudges. How do you think about shortening that feedback loop so the support is closer to when it’s actually needed?

This is the importance, probably with coaching, medication, CBT, or any approach. It’s the personalization. A lot of the skills we’ll talk about might start as, “Here’s a list of how to do it,” but it’s like a recipe. People say, “I’ll change that ingredient,” or “I don’t need that.” And that’s exactly what I want. I want people to take ownership and do what works.

We can get caught in the classic therapy model of once a week for an hour. But very often I’ll do maybe two 30-minute sessions in a week, like Tuesday and Friday. There’s even research with college students where they’d balance an individual session one week with a group session the next. And in between they’d have coaching calls following up on some of the takeaways.

Some of the strategies are meant to be implementation-focused. They still rely on remembering to use them, but they’re designed to be small, specific things. One of my favorites—and it’s only been researched in children with ADHD, not adults—is the implementation intention statement, the if X, then Y statement. The example I use with my clients, from my own life: If I put air in my bike tires, then I will go out for a bike ride.

Because now I’m touching the bike instead of staying conceptual. I can talk myself out of a bike ride: “Oh, I’ve got to go down to the basement, all the way down the stairs.” And I joke that if I can’t handle the stairs, I probably shouldn’t be allowed to ride a bike in public. But this is how we talk ourselves out of anything. Later on I’ll say to myself, “I had all day. I could have gone for a ride. I’d be done by now. How did this happen again?”

That’s part of the reframe, the normalization. Yes, people with ADHD struggle with these things a whole lot more, with procrastinating on midterms or homework and then pulling all-nighters. But it’s also a shared battle of human nature. The good news is, a lot of strategies can be adapted to ADHD so people can personalize their follow-through.

Procrastivity and the Psychology of Getting Started

To what extent do you see systems lasting once they start working? For example, in your ADHD Toolkit book, you suggest almost overusing a to-do list at first by committing to ten minutes a day. For some of the people we work with, that really works. For others, not so much. But for those who do find it useful, do you see what we call “fade out”—where it works for a couple of months and then they slip back into old habits? Or once they commit, is it usually pretty durable?

Well, the answer in my profession—and I’m sure in coaching too—is “it depends.” There can be a lot of fade out, sometimes over summer break or other times when there aren’t as many to-do type tasks, especially for college students living at home.

But often people find their way. Some will say, “I’ll do one to-do per day, and when that’s done maybe I’ll take on a second.” Some people have a list of three. A lot of people eventually find their way and maintain it.

And when they slip up, which we all do, whether it’s just a lapse or a stretch of time without many tasks, it’s about being able to notice and get back on track. Sometimes, especially if they’ve finished sessions with me, people come back after a while and say, “I need a refresher. I’ve slipped out of this.” Usually, though, they find the cadence that works for them. The ideal is to have it personalized—what works for you.

Yeah, and continuing to revisit that over time feels important. 

Another concept from your work that’s been a big unlock for us is procrastivity. We often see students caught in a kind of substitution. The obvious one is, I should be doing my paper or problem set, but instead I’m scrolling. 

But procrastivity is sneakier. It’s, I’ll skip the assignment worth 35 percent of my grade and do the one worth less than one percent. 

It feels productive, but it’s not real progress. How do you help clients make those priority tasks feel more like the satisfying, bounded activities people naturally gravitate toward?

Right. And I actually learned about procrastivity from one of my clients. We were talking about it, and he described it much as you just did. He said, “Oh, we call that procrastivity.” And believe it or not, Urban Dictionary has had it since 2010.

Yeah. My friend and colleague Ari Tuckman thought I invented it. I’m very clear I didn’t. I learned it, but people sometimes give me credit. I always cite my sources.

What’s useful about procrastivity is looking at why we choose laundry instead of the paper, mowing the lawn instead of taxes. If I had to boil it down, it’s partly behavioral and partly a cognitive reframe. The procrastivity task is usually manual, hands-on. So the reframe is, how do we make getting on task actionable?

Sometimes it’s not even about starting the work itself. It could be just getting to the library, to your desk, to the gym. For me, as you mentioned in our emails, it’s: just get to the coffee shop for the writing session. That blends with the if X, then Y approach: If I get to the coffee shop, then I’ll write for at least an hour.

Making things manual helps. Open the envelope that says “Important Tax Document Enclosed.” Open the document on your computer. In my career, another example is people who want to go to the gym after work. At the end of the day you’re tired. People say, “I’ll go home first, then head back out.” If you do, that’s fine—I’m all for self-determination. Some days you just don’t feel it. But most people, once they go home, don’t make it back out.

The question becomes, do you have enough energy to just get to the gym? Maybe do 15 minutes on the treadmill if not the full workout. And most people, once they start, they keep going.

I used to tell my clients, if I ever wrote a self-help book, it would be called Once I Get Started. And that’s actually the title of this book.

Oh, that’s great. 

They asked me for a list of titles. I put that one at the bottom, just to include it since it’s something I’ve told clients for years. They loved it, so it stuck.

Sometimes it’s just about getting to the gym. In my career, I had one person admit they pulled up, shut off the engine, started it again, and drove away. But everybody else, once they got there, followed through and felt better afterward.

And it’s not illegal, immoral, or unethical to skip a workout. But most people later think, “I’d be done by now, and instead what did I actually do?”

We see that theme throughout your work, including The Adult ADHD Toolkit. I also love your point about just getting started for five or ten minutes. That often snowballs into real progress. 

But you also talk about allowing the discomfort. Saying, “This is unpleasant. I don’t feel like looking at this blank page. It’s hard.” Acknowledging that instead of fighting it. How does that connect with the practical strategy of just getting started?

It’s exactly combined with it, because it normalizes the experience. Nobody in their right mind is ever in the mood to do homework or chores. Everybody goes through that to some degree. That’s where the reframe comes in.

It also draws on exposure therapy for anxiety. Once we face it—like me with the bike. If I put air in the tires, I’m touching the bike. Then it shifts from the big concept of “riding a bike” to something familiar. I’ve done it before. I actually like doing it.

It’s effortful, and likewise, getting started on a paper, even if it’s one paragraph. Once we open the document or the textbook, once we get to the library and we’re doing it, even if we haven’t started the task, it’s behavioral priming. We’re starting the steps, the behavioral script we always follow, and we’re capturing the motivation. It’s like a running start. Okay, I might as well keep moving now. I don’t want to romanticize it. Writing a paper is still difficult, homework is still hard, but we’ve increased the likelihood that we’ll engage, whether it’s for 10 minutes or an hour. At least we can say, okay, I didn’t procrastinate.

You know, I got to the gym, even if I turned around, or I started the paper, and now we have something to go back to. Very often, once I get started, I’m able to get farther. And when we wrap up, we underestimate the positive feeling associated with getting things done. That felt good. With the procrastivity task, the escape task, there’s usually a clear set of steps for getting started, like mowing the lawn or doing laundry, as opposed to a paper or taxes. There’s a clearer sense of making and sustaining progress. Unless the lawn grows behind you, you know you’ll make progress. Whereas with a paper you might think, this is going to be harder than I thought.

But it’s better to get started. Usually with an escape task there’s a clear end. The lawn is done, the laundry is done, the dishwasher is unloaded, I’m free and clear. Many priority tasks require a couple of work sessions to get through. Getting started, getting engaged, and having something to go back to helps. Sometimes the implementation statement is, if I read the last paragraph I wrote last time, then I can write at least one more paragraph. Even though rereading the last paragraph isn’t producing anything new, it helps get over that discomfort and hopefully recalls, that was pretty good, this is better than I thought.

Long-term Tasks and Cognitive Reframing

Taking writing as an example, you’ve written many books and articles. Writing is inherently a painful, long-term process. It’s a project, especially books. In the moment it can feel so far away, and with time blindness the return on investment can feel like, why am I doing this, won’t this take forever?

Do you ever make those long-term tasks feel more like satisfying, bounded procrastivity tasks, like 100 words a day, some kind of game for your mind, or do you focus on the longer term?

You know what, I think it’s Stephen Covey, The 7 Habits of Highly Effective People. He talked about begin with the end in mind, which is great advice. Then couple that with start with the beginning in mind. Beginning with the end in mind, I came up with a worksheet from procrastivity originally called the How You Don’t Do Things form. Awful title, but I insisted on it, because of where it came from.

I like that. How do you not do things. I like that.

Yeah. In the more recent book, The Adult ADHD and Anxiety Workbook, it’s reframed as the Anti-Procrastination Plan. Subtly updated. One of the first steps is the valuation. Why am I doing this? What’s in it for me? What is my buy-in? That is important, especially for students and young adults. Even getting through a class for a semester or getting through an assignment, it’s due next week, but next week feels far away. Why bother working on it today? The rhetorical question is, why bother? In cognitive therapy we ask for a literal answer. Why bother doing it today? What’s the benefit for you?

Including, I don’t want to think about it anymore, or I want to get it out of the way so I can go out with my friends later. What is your buy-in for the larger task, like finishing the class so you don’t have to take it again, and also for the nearer term, I’ll feel better working on it a little bit. Maybe you don’t want to work on it during the game you want to watch later. So there’s that valuation of the task, what’s in it for me.

Baked into all of this is a pause. Let me pause and reflect on what I’m doing and why. That can lead to, I don’t care, I don’t feel like doing it today, which is fine. We all do that. Sometimes it’s an informed decision, I’ve been studying a lot, I need a day off, or I’m not feeling well, I should get to bed early. But it can still be the bouncing back. Okay, I let myself off the hook yesterday, let me double down today. In that pause, at least come up with one other option. If I’m going to do this, what’s in it for me, or another way to think about it.

I’m going to write 100 words or one paragraph, some sort of task bounding. Or it could be time bounding, but there’s an end point. People say to me, so I’m tricking myself into doing this. Absolutely, you are. You’re tricking yourself out of the belief that it’s going to feel too awful, that you won’t be able to think, that it will be a waste of time. Maybe you’re drawing on past experience of brain fog and staring at the document. People may come by that honestly, but we also say, you weren’t trying these strategies then. Let’s see if you can approach it differently this time.

But that pause, the power of the pause, that’s great.

Yes, and the idea of buy-in feels so important, a through line in your work, including Rethinking Adult ADHD. 

We also see some clients doing this mostly to appease their parents. They can say the right things, they’ll use therapy speak, but they’re not necessarily following through. 

With that in mind, when parents ask us for a therapy recommendation, we really like behavioral activation. We know it’s a subset of CBT, but it feels like its own thing and seems to help, especially with our male clients. Do you tend to get people going on the behavioral side versus cognitive restructuring, or how do you balance the two?

I would say, you know what, I’m open about a CBT model. I believe the cognitions are like a ligament between intention and action. I totally value the reframing, like can you get to the workstation rather than worrying about writing a paper. Get to the library. That is a reframing of the task into action-specific, actionable terms. In the most recent published book, I don’t come up with good acronyms, but it’s called the SAP method. S A P. Define a task in specific terms, action terms, and then the P is a pivot point. When are you going to implement this plan in the flow of your day? It could be a time.

So rather than, I’ll do it later, no. After this meeting, or first thing tomorrow, or between when my 2 o’clock class lets out, I’ll go to the library and work on this problem set. The cognitions are important, but we measure progress behaviorally. Am I feeling better, and am I doing the things that help me feel better overall? Well-being is what we’re looking at. We’re not aiming for a particular degree or salary level or contributing to GDP, though those are worthwhile goals.

If somebody’s goal is to finish an academic program, absolutely yes. But within this is overall well-being, including downtime. This goes back to behavioral activation. It draws on behavioral activation as a treatment for depression, yes, but it’s similar here. The more we do, the better we feel. Getting started can be hard for someone without ADHD who is depressed, with vegetative signs like feeling heavy or having a hard time getting up. With ADHD, the course is often more of a winding road.

Right. 

I’ve heard many people describe ADHD itself as nonlinear. My long-winded way of saying, the main outcome is behavioral. Even colleagues who hear me present about the CBT model will say, it’s really behavioral. Yes, because it is acceptance of discomfort. It draws on the third wave behavioral therapies. Cognitive therapy was the second wave, where cognitions influence behavior. There’s value in understanding thoughts as learned behavior and the internalization of language, but dialectical behavior therapy helps with managing emotions, and models evolve. Thoughts affect things, so let’s look at emotions.

And acceptance and commitment therapy asks, can I accept imperfection and discomfort to stay committed to my valued goals. Can I get started even if I don’t feel like it. So yes, it is very behavioral. What I like about the CBT model is that cognitions, behaviors, emotions, and I would add relationships and social connections, are all entry points into our experience. Cognitions are convenient. What did I think about doing this that kept me from doing it, or that led me to leave early. Sometimes cognitions are just putting words on feelings. What were my feelings telling me?

Sometimes the anxiety about a task is, I’m worried it won’t be good enough. There can also be a legitimate reframe. Working on a paper takes energy. Some worry or anxiety might actually be energizing. It’s a high cognitive load task. It takes a lot of thinking to keep going, or to get up and talk in front of people, or even to do something like this. A little anticipatory anxiety can be energizing. It’s ramping up to do something. If we say, okay, 30 percent of it is that, but 70 percent is, I hope I don’t draw a blank with Sean. Different ways in.

But behavior is the main outcome. Am I doing what I set out to do and reaching the endpoint, or making an informed decision. Maybe I don’t need a college degree to do what I want to do. Or I’ve given this job a bunch of tries, maybe it isn’t for me and I want to find something else.

It’s effortful, and likewise, getting started on a paper, even if it’s one paragraph. Once we open the document or the textbook, once we get to the library, even if we haven’t truly started, it’s behavioral priming. We’re starting the steps, the behavioral script we tend to follow, and we’re capturing the motivation. It’s like a running start. I might as well keep moving now. I don’t want to romanticize it. Writing a paper is still difficult, homework is still hard, but we’ve greatly increased the likelihood that we’ll engage, whether it’s for 10 minutes or an hour. At least we can say, okay, I didn’t procrastinate.

I got to the gym, even if I turned around, or I started the paper, and now there’s something to go back to. Very often, once I get started, I’m able to get farther. And when we wrap up, we underestimate the positive feeling associated with getting things done. That felt good. With the procrastivity task, the escape task, there’s usually a clear set of steps for getting started, like mowing the lawn or doing laundry, as opposed to a paper or taxes. There’s a clearer sense of making and sustaining progress. Unless the lawn grows behind you, you know you’ll make progress. With a paper, you might think, this is going to be harder than I thought.

But it’s better to get started. Usually with an escape task there’s a clear end. The lawn is done, the laundry is done, the dishwasher is unloaded, I’m free and clear. Many priority tasks require a couple of work sessions to get through. Getting started, getting engaged, and having something to go back to helps. Sometimes the implementation statement is, if I can read the last paragraph I wrote last time, then I can write at least one more paragraph. Even though rereading the last paragraph isn’t producing anything new, it helps get over that discomfort and hopefully recalls, that was pretty good, this is better than I thought.

That’s so interesting. Taking writing as an example, you’ve written many books and articles. Writing is inherently a painful, long-term process, especially books. In the moment it can feel so far away, and with time blindness the return on investment feels like, why am I doing this, this will take forever. Do you ever make those long-term tasks feel more like satisfying, bounded procrastivity tasks, like 100 words a day, some kind of game for your mind, or do you focus on the longer term?

You know what, I think it’s Stephen Covey, The 7 Habits of Highly Effective People. He talked about begin with the end in mind, which is great advice. Then couple that with start with the beginning in mind. Beginning with the end in mind, I came up with a worksheet from procrastivity originally called the How You Don’t Do Things form. Awful title, but I insisted on it because of where it came from.

I like that. How do you not do things. I like that.

Yeah. In the more recent book, The Adult ADHD and Anxiety Workbook, it’s reframed as the Anti-Procrastination Plan. One of the first steps is the valuation. Why am I doing this? What’s in it for me? What is my buy-in? That is important, especially for students and young adults. Getting through a class or an assignment that’s due next week can feel far away. Why bother working on it today? In cognitive therapy we ask for a literal answer. Why bother doing it today? What’s the benefit for you?

Sometimes it’s, I don’t want to think about it anymore, or I want to get it out of the way so I can go out with my friends later. What is your buy-in for the larger task, like finishing the class so you don’t have to take it again, and also for the nearer term, I’ll feel better working on it a little bit. Maybe you don’t want to work on it during the game you want to watch later. So there’s that valuation of the task, what’s in it for me.

Baked into all of this is a pause. Let me pause and reflect on what I’m doing and why. That can lead to, I don’t feel like doing it today, which is fine. We all do that. Sometimes it’s an informed decision. I’ve been studying a lot, I need a day off, or I’m not feeling well, I should get to bed early. But it can still be the bouncing back. Okay, I let myself off the hook yesterday, let me double down today. In that pause, come up with one other option. If I’m going to do this, what’s in it for me, or another way to think about it.

I’m going to write 100 words or one paragraph, some task bounding. Or it could be time bounding, but there’s an end point. People say, so I’m tricking myself into doing this. Absolutely. You’re tricking yourself out of the belief that it’s going to feel too awful, that you won’t be able to think, that it will be a waste of time. Maybe you’re drawing on past experience of brain fog and staring at the document. People may come by that honestly, but we also say, you weren’t trying these strategies then. Let’s see if you can approach it differently this time.

But that pause, the power of the pause, that’s great.

Yes, and the idea of buy-in feels so important, a through line in your work, including Rethinking Adult ADHD. One thing I want to credit you for is how the four case studies at the end don’t have a neat beginning-middle-end where everything works out. There’s complication. It feels more novelistic and realistic than “and then Evan was cured.” We also see some clients doing this mostly to appease their parents. They can say the right things, they’ll use therapy speak, but they’re not necessarily following through. With that in mind, when parents ask us for a therapy recommendation, we really like behavioral activation. We know it’s a subset of CBT, but it feels like its own thing and seems to help, especially with our male clients. Do you tend to get people going on the behavioral side versus cognitive restructuring, or how do you balance the two?

I would say I’m open about a CBT model. I believe the cognitions are like a ligament between intention and action. I totally value the reframing, like can you get to the workstation rather than worrying about writing a paper. Get to the library. That is a reframing of the task into action-specific, actionable terms. In the most recent published book, I don’t come up with good acronyms, but it’s called the SAP method. S A P. Define a task in specific terms, action terms, and then the P is a pivot point. When are you going to implement this plan in the flow of your day? It could be a time.

So rather than, I’ll do it later, no. After this meeting, or first thing tomorrow, or between when my 2 o’clock class lets out, I’ll go to the library and work on this problem set. The cognitions are important, but we measure progress behaviorally. Am I feeling better, and am I doing the things that help me feel better overall? Well-being is what we’re looking at. We’re not aiming for a particular degree or salary level or contributing to GDP, though those are worthwhile goals.

If somebody’s goal is to finish an academic program, absolutely yes. But within this is overall well-being, including downtime. This goes back to behavioral activation. It draws on behavioral activation as a treatment for depression, yes, but it’s similar here. The more we do, the better we feel. Getting started can be hard for someone without ADHD who is depressed, with vegetative signs like feeling heavy or having a hard time getting up. With ADHD, the course is often more of a winding road.

I’ve heard many people describe ADHD itself as nonlinear. My long-winded way of saying, the main outcome is behavioral. Even colleagues who hear me present about the CBT model will say, it’s really behavioral. Yes, because it is acceptance of discomfort. It draws on the third wave behavioral therapies. Cognitive therapy was the second wave, where cognitions influence behavior. There’s value in understanding thoughts as learned behavior and the internalization of language, but dialectical behavior therapy helps with managing emotions, and models evolve. Thoughts affect things, so let’s look at emotions.

And acceptance and commitment therapy asks, can I accept imperfection and discomfort to stay committed to my valued goals. Can I get started even if I don’t feel like it. So yes, it is very behavioral. What I like about the CBT model is that cognitions, behaviors, emotions, and I would add relationships and social connections, are all entry points into our experience. Cognitions are convenient. What did I think about doing this that kept me from doing it, or that led me to leave early. Sometimes cognitions are just putting words on feelings. What were my feelings telling me?

Sometimes the anxiety about a task is, I’m worried it won’t be good enough. There can also be a legitimate reframe. Working on a paper takes energy. Some worry or anxiety might actually be energizing. It’s a high cognitive load task. It takes a lot of thinking to keep going, or to get up and talk in front of people, or even to do something like this. A little anticipatory anxiety can be energizing. It’s ramping up to do something. If we say, okay, part of it is that, and part of it is, I hope I don’t draw a blank with Sean. Different ways in.

But behavior is the main outcome. Am I doing what I set out to do and reaching the endpoint, or making an informed decision. Maybe I don’t need a college degree to do what I want to do. Or I’ve given this job a bunch of tries, maybe it isn’t for me and I want to find something else.

Yeah, that’s very wise. We find the simplicity of this idea compelling. Your book is about getting started. My colleague and I are publishing a book of case studies called I’ll Do It Later. You mentioned that phrase. This idea of waiting for the feeling to arrive, as opposed to trusting the process that action will precede the feeling. Right, to your point.

Action precedes motivation. David Burns. I think you’ve captured it. I’m not in the mood to do it now, so I justify putting it off until later when I will be in the mood. But how often are we in the mood to do that? A colleague, Michael Manos, a very good behavioral therapist and a friend, had a lovely paper a couple of years ago with a colleague, I think Elizabeth Short. I hope I have that correct. Michael was the lead author. He talked about his conceptualization that undone tasks are the core issue with adults with ADHD, or at least a useful meeting point.

It picks up on procrastination, which I view as probably the most common presenting difficulty across adults with ADHD, sometimes due to lack of planning. It’s bundled within time management and many executive functioning scales. It could be having a plan but not following it, not getting around to finishing it, or not picking it up. It has a lot of parents. Going back to I’ll do it later, it all fits within a cluster. Especially for adults with ADHD, having different coping skills helps, because as you described, one strategy can fade a bit.

It’s nice to have a different take on it. I look forward to seeing the results of the I’ll Do It Later book too.

Family Dynamics and College Life Challenges

Oh, thank you. Part of this, as we work with teenagers, college students, and young adults, is interaction with parents, often the mom. Your section on motherhood in The Adult ADHD Toolkit and other work really resonated. We see a lot of moms quarterbacking moving parts, often unglamorously, in the background. The demands rise in proportion to the executive skills their child has, and when the child struggles, the parent picks up more.

Yes.

We also see many moms who discover or are diagnosed with ADHD later in life, and they see their younger selves in their college students who are struggling. They carry both understanding and some guilt. When you advise mothers to treat their own ADHD first, how do you navigate the urgency they feel to jump in and help their teenager before putting on their own oxygen mask?

Right. That’s a great question. How I frame it sometimes, and it’s usually a one-off meeting here and there, is, how is my son or daughter doing and how can I be helpful. Or I’m seeing the mother and she’s talking about her child. One is the valuation again, for them both, and framing it first. One of the roles, and this is something I’ve been elaborating on since the Rethinking book, is the social interpersonal side and defining your role. What is your role in this relationship? It’s another behavioral reframe. What is my role with this person?

It could be, I’m a student in their class, I’m an employee, I’m a spouse, I’m a friend, I’m a coworker on a work team, or on a sports team. What is my role and how can I fulfill that role? Try to turn it into actionable, specific things. I want to be a better spouse or coworker is too broad and nonspecific. Admirable, but what does it mean here and now? I can hand off the project on time. With a parent, in this case the mother, it’s also looking at your role and other roles, including self-care and self-compassion, the relationship with yourself. That speaks to the oxygen mask example. What can you do for yourself so that, in a developmentally appropriate role with a college-age child with ADHD, you can be a helper who helps.

Oh, I love that.

Well, I’ll give credit to a leader in the field I’ve been happy to get to know over the years, and it’s no fun having the same first name as someone as accomplished as him, but Russell Barkley. It’s actually my middle name, but we won’t let facts get in the way of a good example. Parents of children with ADHD are shepherds, not engineers. Guiding along rather than setting up every circumstance. That works in the short term. Cognitive therapists don’t want all-or-nothing thinking.

There may be times we step in. It might be easier than dealing with readmission to school or getting kicked out of an apartment. Sometimes you don’t want the young adult to hit the ground directly. But often it’s natural consequences and guidance. Here’s the email to contact disability services at school to see what they need. Incremental steps, but hopefully, if the college student gets support, it can also involve coordinating an academic coach or therapist, then trusting the process and redirecting back to that. There are many ways to do it, but where appropriate, give incremental steps that help the student build executive functioning muscle, including waiting until the last minute and having to wait, or not getting the class because they didn’t register on time. I don’t want to be glib. There are risks, like an extra semester, which is more housing, tuition, and time. But when I looked at Department of Education statistics, on-time graduation is five years.

Yeah.

Four-year college is an oxymoron in a way.

One in four kids who go through this process that we think everybody’s going through.

Right, exactly.

Yeah.

Only one in four go four years straight, right out of high school, without having to work. There are a lot of factors. Sometimes an extra semester or two ends up better. Rather than cramming five or six classes, if your cadence is four and it takes longer, it’s less stressful and more successful. I like the developmental psychology concept of equifinality. There are different paths to the same positive outcome. For one student, it might be four years straight, walk on time, parents book the hotel at freshman drop-off and everything ends up on time.

Other times it’s a more circuitous route. Not to be too New Agey, but you never know. If I hadn’t taken that extra semester, I wouldn’t have worked with this professor, which led to this or that. It’s how we make decisions. Another phrase I like: whatever decisions we make, we can actively turn them into good decisions by how we handle them.

I love that. Zooming out, let me zoom in on something you said. In our book we have a student we call Silas, whose dad did a lot of the engineering you mentioned. In high school, it worked. His dad, an actual engineer, set things up in a very organized way and Silas got through. When he got to college, things fell apart on several fronts. Have you seen this with clients, and how do you advise on a unique college issue where a student might have an entire Tuesday off? Literally nothing on the schedule. We have clients with Tuesdays and Thursdays essentially off, maybe a single 30–45 minute class. They struggle because it feels like a weekend, but they know they should be doing things. Are there anchors or routines—beyond the basics like a to-do list—that are most effective for structuring that genuinely empty time?

No, and even for adults, weekends, holidays, vacation. I liken it to the most difficult assignment you ever get in grade school: write a five-page paper on any topic of your choice. Assign me photosynthesis and I’ll get it done. But with infinite options, we end up vibrating in place. Eight different directions, going nowhere. I read a line in a book on a different topic that overlaps with human behavior: it’s not rocket science, it’s harder. We’re working with the individual who technically doesn’t have to get out of bed all day.

I always start with self-determination. It’s not illegal, immoral, or unethical. But is there a reason to get up even if you don’t have to. Maybe go to the gym. Even getting up to walk to your favorite place for a cup of coffee, even though you have a Keurig in your room, just to get up and out. That’s a pivot point. Especially for college students, even getting to your first class exponentially increases the likelihood you’ll keep going the rest of the day.

Yes.

Even show up late for your first class. Coming up with a reason, and even if it’s not as early as typical. Working through that pivot point idea. Yes, it’s healthy to sleep and wake at the same time every day, but try doing that with college students. Maybe set bounds. Often there’s buy-in: if I’m in bed longer than this, nothing happens. It could be things you want to do.

Maybe at 10:00 a.m. go to the gym, and at 3:00 do a load of laundry. Those are the only two plans in the day, but at least those anchors get you up. In between, ideally, add more, maybe a bit of homework. Start smaller and build up. Once I’m up and started, once I get to the gym, I’m more likely to keep going. Going to the gym is productive.

I think downtime is productive too. It’s part of overall well-being. Socializing helps with the homework, and getting the homework done helps you enjoy the gym or social time more, without, as Mike Manos says, the undone task hanging over your head. Even one or two pivots or anchors can help get started. Over time, in an ongoing coaching or therapeutic relationship, work things in, including taking advantage of those days. If I get to the library at 10 a.m., I can spend two hours on homework and then have the whole afternoon free for things I don’t typically get to do on class days.

And especially if the schedule is that every Tuesday there are no classes, there’s more leverage because it’s an ongoing open spot we can work with.

Just a mistake I made in my own practice. I had a client with availability at 10 and at 4. I initially scheduled him at 4, somewhat thoughtlessly, on Tuesday. I was catching him at 4 after a day that hadn’t gone so well. Simply moving that meeting to 10, starting as he’s getting started, helped us mix it up together. That activated the rest of the day, or at least the morning, if he could grab an hour or two he otherwise would have slept through.

Lost, and you probably encounter this. People take the early slot and say, this will get me up. I will not miss this. That is great. Sometimes the best coping is elegant and simple, like, hey, let’s schedule at 10.

Let’s schedule 10, yes. And then on Thursday, maybe there’s someone else you want to meet with. Schedule it, just to get up. If there’s something you can do to get going.

Right, right.

Long-term Insights and Measuring Progress

Looking across your work over the years, I don’t want to say exactly how many.

You know what, the Penn Adult ADHD Program started on March 8, 1999. Tony Rostain was already an expert in ADHD in the Philadelphia area. He had a colleague and was looking for a cognitive therapist. My name was passed along by friend and colleague Corey Newman, the director of the Center for Cognitive Therapy. That was the first meeting for what became the ADHD program. So that adds up to about 26 years. We have already passed the 27th year.

And with the exploding interest and diagnoses, it seems like you were a little ahead of the curve. Is that fair?

It was in the wake of Driven to Distraction a couple of years later. That re-energized the focus on ADHD in general, and it was a watershed for bringing adult ADHD to the fore. There is research on adults going back to 1967 or 1968, and we also see examples in the medical literature going back to the 1700s that sound like attention problems and ADHD.

That’s great. As you look back, what has been most surprising, not only about what helps adults with ADHD, but how the field has evolved or in your own clinical practice? A through line I see in your work is humility. Things might work, they might not. Keep trying, keep going. You might need ongoing support. What has struck you when you take the big-picture view?

You were generous enough to share some of these questions. They are great. Each could be a blog. I am still amazed by how little it takes to make progress. Getting started, defining your role behaviorally, how can I be a better student, show up to class on time. You could fall asleep right away, but you exponentially increase your odds. How little it takes, and how beautiful and fulfilling it is when it is working. I passed the class. I do not have to take it again.

I am on track. The positive feeling associated with getting things done. The workout is done. Okay, I have more work to do on the paper, but I am walking out of the library and I feel good. I did something. Now, if I am going out with a friend or watching playoff baseball, it is without it hanging over my head. You have to do it again, but that is fine.

As much as strategies from our group and others, Steve Safren, Susan Sprich and the Harvard group, Mary Solanto, Alexandra Philipsen in Germany, John Mitchell and the Duke program, Laura, now Laura Knouse, and Russell Barkley with their new Living Well with Adult ADHD book, are helpful for getting engaged, they are also designed for when we slip up. The relapse rate for procrastination or executive slip-ups is 100 percent. They help with getting back on track. Persistence over time is the name of the game. Shakespeare said change happens in matters of degree.

The line I use: someone comes to me and says, I procrastinate four out of five times, 80 percent. We get them to follow through three out of five times. That is a big increase. The thought process is, I am still failing two out of five. So we normalize slip-ups. They will happen. Not all off-task behavior is a slip-up. Sometimes we need a break because we are not feeling well. My line is, if we invented a medication with those results, we would be billionaires. Because it is behavioral, we focus on failure rates.

Yes, procrastination can be devastating and lead to fractured friendships, marriages, jobs, extra semesters, administrative oversights that become failures on a transcript. These strategies are ways to get back and keep trending in a positive direction. With medication, coaching, and academic support, the types of help we have are among the most helpful available. It is hard work, and I am moved by how hard adults with ADHD work. Most people say, I just want reasonable cause and effect. If I put in two hours of studying, I want to pass the class. There might be bigger aspirations, but I want to know I am getting something out of what I put in. It is amazing how little it takes, and how big the little stuff is.

That’s excellent. If I take three themes: normalize the struggle, reframe, and measure improvement. I love your point that one out of five to three out of five is a big improvement. It is useful for parents to see that, and useful for clients to get praise that is precise and authentic.

I am glad you brought that up. It is part of our job to point out incremental improvements.

Yes.

Because this came up, I was working with someone on on-time arrival, including getting ready for our meetings. She typically showed up a couple of minutes late, which in the grand scheme is not huge. But she was also late for work, where a minute late, by swipe card, was late for HR. One day she showed up a couple of minutes early. I pointed it out, and her first thought was, I was almost late. Almost late was on time. I get it, that is her experience, catching the light. But we can still say, you did what you needed to do to be on time and hit the light. Can we look at other buffers.

These authentic incremental improvements are where coaches, therapists, and psychiatrists can help. In a broader sense, look at where you are now compared to when we started. That is also part of time blindness. A side benefit of having a planner is that it is a diary of what you have done.

Yes.

It is objective data. You can go back. I did not feel like I did anything last week. Actually, I did some things. I could have done more, but it was not bad.

Yes. In keeping with that, the third thing I would say is begin again. Setbacks are normal. Begin again. We can just start. It is all good. And the therapeutic alliance matters, especially with ADHD clients. They are vulnerable with you. “Hey, I told you I would do that math assignment. I did not do it.” You need a rapport for that to work. I encourage parents to think carefully about that alliance when they try to support.

Then that is another role you can define, to be supportive and encouraging. What do we need to do to get back. Let you take the reins. It can be new, it does not have to be bloodline. This popped into my mind. I was working with a college student. His parents were on him about getting the oil changed. He asked, do I have to tell them what type of oil to put in. He had never done it on his own. It is not genetic. We do not have the oil-change gene.

Sometimes it is simple. No, you call them, they know. You schedule, take it in. That was one of the most effective interventions I ever had. Sometimes information helps. ADHD is not an information problem, it is an implementation problem. But over the years, we have adapted what we do. Those broad, vague, nonspecific goals, I want a good grade in class. Many people without ADHD, with working memory, can hold that in mind and break it down: get there on time, do this and that, and keep it in mind. With ADHD, it might be too far in the future. There is time blindness and reward issues.

And to your point, the constitutive parts are not obvious, they're not intuitive.

Well, yeah. So it is really breaking it down, almost like a series of steps. And that’s what executive functions and working memory help us do. But sometimes we need it to be more explicit, just like anybody would when doing something totally new. It’s like that line from Denzel Washington in Philadelphia: explain this to me like I’m a four-year-old. 

And if it’s something we’re not familiar with, like using new software, we ask, what are the steps, what drop-down menu? Once we have it bundled in, we’re fine. But folks with ADHD often benefit from that kind of sequencing of a task.

Agreed. Listen, I’ve already taken too much of your time. I really appreciate you taking the time with me and for all of your work more broadly. Thank you so much, and hopefully we can stay connected in some fashion. I think this will be really valuable for parents and hopefully for clients as well. Thank you so, so much, Sean.

Thanks for having me. It was a pleasure.