Good morning and welcome. I'm Tom Brown. I'm very happy to see all of you here so early in the morning and I hope you'll find the information we have to share helpful and I hope you'll keep in mind any questions you have as we go along because we're going to do all the questions at the end so that we can get each one of the presentations completed. Before we go I'd just like to ask how many of you work a lot with ADHD in kids? Thank you. And how many work also or rather with ADHD in adults? Looks like most everybody's doing both. Okay well I'm very happy you're here. I hope you'll find what we're talking about helpful and we are happy to learn from your questions. These are my disclosures. There's basically some books and rating scales I've done and a little bit of consulting. And as I'm sure most of you are well aware until 2013 the DSM did not include diagnosis of ADHD for anybody who had any pervasive developmental disorder. The assumption was that if you're looking at somebody with a pervasive developmental disorder like autism that that ADHD stuff just sort of went with it and they didn't want to make a separate diagnosis. Finally they came to their senses in 2013 and with the data that we've now got depending on which study you're looking at indicates that between half and three-quarters of the people on the autism spectrum also have ADHD. And one of the things that I invite you to think about is if you've got somebody who has the limitations of autism spectrum who has also ADHD, isn't it pretty important as Blabonsky reminded us that people who have both of these things tend to have worse outcomes if you're not treating effectively both of them. And so one of the main messages that I'm hoping to bring to your attention and many of you probably already know this very well, that it's important to take a look at both. Which means that for people who are coming in looking for help with ADHD, if you get the feeling this person's having a lot of difficulty just sort of understanding other people, maybe you might want to look at the possibility that there's some autistic characteristics there too. And if you've got somebody who's been identified as being on the autism spectrum, you might want to think about ADHD because it's likely, not for sure, but it's likely that they're going to be having some trouble with the executive functions associated with ADHD as well. We've been hearing a little bit more about the incidence and the prevalence of autism spectrum over recent years. The number keeps creeping up. 1 in 54 back in 2016 and then 2018 has gone to one out of every 44. But the thing I would emphasize is CDC does the counting of people who are at eight years old. Many of the people who have higher level of intelligence are not identified as having autism spectrum disorder until well beyond their eighth birthday. And so what I'm suggesting to you is I think that that count is probably not picking up a lot of the people who have more severe problems with spectrum but not severe problems with IQ. A recent study that was done in a male, it was a population-based study of over 31,000 kids, found that between 42 and 59 percent, depending on how strict a definition of ADHD and autism you're working with, of those who did have autism, average or above average IQ, which they were defining as something 86 or above. Now normally we think of 90 to 110 as the average range for smarts on the IQ test, but they were using, for whatever reasons, 86. But the point is a lot of people think that anybody who's on the autism spectrum, I use that because of my opinion, but with Asperger's I think what we're recognizing is that some of these people have impressive strengths in more logical or linguistic or math intelligence. If you think about the many different ways you can be smart, but tend to be relatively weak in empathy and emotional and interpersonal or social intelligence. But I think it's really important to keep in mind that these people that we would have called Asperger's, I still do it, you know, except I must have to write a formal definition down, or a diagnosis down, that their social difficulties often are not due to being disinterested in social interaction with other people, but rather to the fact that they have impaired skills for social interaction, especially with their peers. Adults are more predictable when you're a kid, usually, but it's not the case with peer interaction. Now among the kids, let's look at it from the other side. If we round up a group of kids all diagnosed with ADHD, how many do you think are likely to meet criteria for autism spectrum disorder? Well, Zabotsky addressed that question in his paper of 2020, and they looked at about 2,000 kids who had been diagnosed with ADHD, twelve and a half percent met diagnostic criteria for autism spectrum. So that some of the people that you may be seeing in your clinical practice, and may obviously have ADHD, but who also are having a lot of trouble getting along with other people, you might want to consider the possibility that it may be that you've got an autism spectrum issue with this particular person as well. Now the topic for today is one where we're taking a look at those patients who are fairly smart, superior IQ, and you can do that in terms of are they at least average, or you can do it in terms of how far above average are they, but the fact is being smart and having ADHD, one thing, just being smart period, if you're a lot smarter than most of the other kids in your class, that can make for trouble. Often the struggles of people who are very bright and have ADHD are not recognized as part of ADHD. The assumption is you're so damn smart and you're not getting your work done, you know, the most likely thing is you're lazy and you just don't give a damn about meeting the expectations of the class. And as a result, often for many of them, the work in middle school, at least into middle school, is easy enough that they can do it without running into much trouble. And so as a result, sometimes you don't begin to see it, and you get a lot of parents and some teachers who repeatedly are saying, you're so smart and you're just not getting your work done, what's the matter with you? Often the need for accommodations is not recognized, and what happens with these kids often is there's a diminishing expectations for them. Well, this kid's just not going to be able to cut it. Their self-esteem, they lose their challenge, they get dropped out of some of the honors classes because they can't keep up with the increased problems in terms of getting that homework done, and some of them just end up giving up on themselves, while some others do manage to mobilize. The point is that being really smart is also a burden, particularly when you're in school. Now, the overall estimate about the autism spectrum tells us that on average, and these numbers depend a lot on how you make your definitions, of course, about 32% average are intellectually disabled, and that's a whole set of problems, and fortunately over recent years there's been a lot of good work done in being able to understand and recognize these individuals and to develop some effective educational and treatment program for them. There's another quarter of those on the spectrum who might be thought of as borderline disabled, that's not borderline personality disorder, it's just hanging in between the part of, you're not that bad off intellectually, but you're missing a lot too, and then you get about 44% average or above average IQ. However, Alvarez does a nice job of talking about the fact that having high IQ does not necessarily mean that you're going to be higher functioning in all the activities of daily life. What you measure with IQ tests doesn't explain all the kind of skills you need to get along in this world, and Shattuck did a study where they were looking at what was happening after kids were getting out of high school, and what they found that 50% of the autism spectrum kids, after high school, for the first two years after high school, no participation in any employment or in any education. Most of the elementary and high school systems these days have pretty good resources available to address the needs of people on the autism spectrum. However, the transition, once they get out of that structure, is one that makes it very difficult for many of them to manage. And as they grow older, those who are identified as higher functioning children with autism spectrum disorder tend to get further behind in a wide variety of executive functions, and this really has implications for things like their being able to get a job and being able to carry on social relationships. It's the old thing, book smarts are not always what it takes to make it on the street. Children on the autism spectrum who exhibit some symptoms of ADHD, Yaris reports, even if they don't fully meet diagnostic criteria for ADHD, tend to have significantly more difficulty with adaptive behavior in school, in home, and in the community. Another study that Rue and Shattuck did, what they found was of the 42% who never worked for pay while they were in their 20s, these are post high school students, what are the things that made the difference between their making it? Some of them made it and some didn't. Having conversation ability, being able to make small talk was a big thing that made a difference. Having had some work experience during high school, big factor. Race and ethnicity in the usual ways, significant factor, and basically if your family's got a lot more money you've got a better chance of being able to do something more productive after you get out of high school. Not amazing, but what it's saying is that's true for this population especially. John Robeson, who's done a couple of really pretty impressive books on this and identifies himself as having autism spectrum disorder, said you know many descriptors of autism and Asperger's describe people like me as preferring to be alone. He said no, I played by myself because I was a failure at playing with others. And Cynthia Kim, who did her own book on talking about her struggles with autism and Asperger's, said you know when you arrive in adulthood lacking the social skills that most people have already mastered by sixth grade, life gets exponentially more confusing and a lot harder to navigate. So the point here is this is a vulnerable population that I think we need to take a look at. What I'd like to do now is to shift to talking a little bit about the way I think about ADHD and what's involved in it. Because I think that you can write an equation basically that says ADHD equals developmentally impaired executive functions. You know there's some places where they say oh if you know executive functions, that's something that people with ADHD may or may not have trouble with. I don't think so. I think when you're talking about ADHD you're talking about somebody who's developmentally impaired with their executive functions. And what that means is that those impairments you know are going to impact a whole lot of things as they grow up. Now this particular model I've published quite a bit on it and if you want to get more information about it it's certainly easily available. But what I've got are these six clusters of symptoms of ADHD and if you think about them as just baskets of related cognitive functions. Activation, getting organized and prioritizing, getting started. Focus, being able to hold focus and shift focus from one task to another. Being able to regulate alertness including sleep. Sustaining effort on tasks and processing speed. And emotions, not included in the DSM criteria for ADHD but I think those of us who see people with this recognize managing frustration and modulating emotions is a big problem for a lot of folks with ADHD. Big issues, utilizing working memory. Many people with ADHD can tell you a lot about things that happened a long long time ago. You know every play they saw in a Super Bowl game two years ago. All the words of lots of songs that have been popular back in the 70s that have a lot of trouble remembering what somebody just said to them or what they were about to do. And then monitoring and self-regulating action. Now I don't have time in this situation to go into great detail on this but let me just mention a couple of things that I think are important. One is that these symptoms are dimensional. It's not an all-or-nothing thing. All the things that I'm talking about here as aspects of executive function are things every one of us has trouble with sometimes. It's just people they have a lot more trouble with more often. And the thing that's more puzzling, I'll talk about this in more detail in a couple of minutes, is situational variability of the symptoms. There are many people, I think I could say every patient I've ever seen with ADHD has a few activities in which they have absolutely no difficulty utilizing these executive functions I'm about to talk about. Even though they've got a lot of difficulty with doing them and almost everything else. And it comes down to that one phrase, if I'm interested. Which means ADHD often looks like it's a problem with willpower when it's not. Okay what we're talking about here, I'm going to zip through these quickly. Just emphasizing that the organizing means organizing tasks and materials. Estimating time, prioritizing those tasks, and then getting started. Focus doesn't mean just zeroing in on something. It's more like focus on your driving. Being able to hold focus while you're listening and not get distracted too much either by things around you or things in your head. One of the samples, one of the things that shows up a lot in people with ADHD is when they're reading. If they read something, they can understand perfectly well what they're reading. They turn the page to the next page and realize they don't have the foggiest idea of what they just read. That's one of the important areas where working memory comes into play. To be able to then to pick it up and then to be able to pull it back when you need it. Regulating alertness. Difficulty falling asleep. Difficulty staying asleep. Difficulty waking up. Difficulty with getting too sleepy during the day. Quickly losing interest in a task, especially longer-term projects, unless it's something they're really interested in. Difficulty with time. It's like they've got a slow modem. Often they've got great ideas for what to write for an essay, but have a lot of difficulty in being able to put it together. Now DSM-IV and even DSM-V, no mention about problems with managing emotion, but those of you who work with it, I'm sure see a lot of those difficulties. At least I do. Working memory. Being able to hold one thing in mind while doing something else. Then remembering to remember, oh yeah I've got to pick up a gallon of milk on the way home today or we're gonna have problems getting the supper finished. Then being able to utilize that working memory as a search engine for activating stored memories. And keep in mind that with monitoring and self-regulating action, that's not just being hyper and terribly impulsive, but difficulty controlling action. Slowing down when you need to slow down. Speeding up when you need to speed up. And being able to size up situations and keep an eye on what you're doing. And we've got a variety of ways in which we help our kids gradually to learn how to develop these skills. When do the problems become obvious? There's some preschool kids you'll be hearing about, you know, the mother will say this kid was hyperactive when he was still in the womb, kicking around. And then there are others where it doesn't become so obvious in preschool. Sometimes they begin to see it when they have to deal with more than one teacher at a time in middle school. And for some you don't see it until the kid moves out of the house to go to college or go do something else. This leads us to the central mystery about ADHD. And that is this variability of symptoms. Why is it that people with ADHD can do some specific things that they happen to be really interested in, or where they feel like if they don't take care of this right here right now, something they do not want to see happen is going to happen fast. Why is this motivation so variable? It looks like it's basically a problem with willpower. And parents and teachers often say if you can do it here, why the hell can't you do it there? If you can be that interested with this sport you're playing in, or those video games you're doing, why can't you exercise that same kind of intense and sustained concentration for all these other things you know damn well were important for you. I had an example given to me years ago by a college student that seems to work pretty well. He said, you know, having ADHD is like having erectile dysfunction of the mind. If the task you're trying to do is something that turns you on, that really interests you, you're up for it and you can perform. But if the task you're trying to do is not something that's intrinsically interesting, if it doesn't turn you on, you can't get it up. And if you can't get it up, you're not going to be able to perform. And in that situation it doesn't matter how much you may say to yourself, I need to, I want to, I should. You can't make it happen. It's simply not a willpower kind of thing. So when are the most difficult times? You know this as well as I do. Middle school, high school, first couple years of college, moving away from home and parenting, or trying to get administrative responsibilities at work. Now what about assessing this? I'd first call your attention to the myth I've noted at the bottom. At the risk of pissing off any neuropsychologists in the room, I have to tell you, I think neuropsychological tests are not usually helpful for assessing ADHD. You need a lot of information about how people function day by day. For kids who are in school, yes, some school reports. And then an age-normed ADHD rating scale, Connors or mine or Barclays or the brief or the BASC, something like that, put together, helps you be able to take an idea of what's going on in daily functioning. Now the question of how you assess for social impairments associated with ADHD is not quite as easy. But for those of you who don't know it, I would recommend you might want to take a look at the social responsiveness scale, second edition, by Constantino and Gruber. It's got those five different characteristics. It's a nice series of questions that gets you some idea of where people's social problems are and how often they really want to be more involved with other people, but they just don't know how to play that game. Everybody knows that there are many other disorders which often occur with ADHD, and we've got to take that into account, and not least specific learning disorders. And the CDC years ago found out at least half people were diagnosed as kids with ADHD also have a specific learning disability. But this is a study that came out of Harvard. Being a Yale guy, I'm still willing to talk about it. This was a study that Joshi and his colleagues did. They had a group of a hundred and seven kids that were brought in consecutively to their program for autism spectrum, and what they found was that of those hundred and seventy kids, seventy-six percent of them also warranted an ADHD diagnosis, and that forty-one percent of them had never been assessed or treated for it. And Joe Biederman, writing at the end of that article, said, you know, failure to recognize ADHD, especially in intellectually capable youth with autism spectrum disorder, can seriously undermine educational and social functioning, worsening an already compromised social performance, and can predispose these youth to increased risk for mood disorders, dysregulation, and also substance use. So to wrap it up, forty to fifty percent of those on autism spectrum have at least average IQ and some of them way above average. 50-75% of them also have ADHD, which I think of as impairment of these executive functions. I think it's important to use interviews and normed rating scales to assess for ADHD, and I'm recommending the SRS-2 to screen for autism spectrum disorder, and that effective treatment of ADHD can improve both academic and social learning. That's important for these people. These are some resources that you might want to look into. I'll do a commercial for the book I just recently published on ADHD and Asperger's Syndrome in Kids and Adults. And here are a couple of other books I've done. And I thank you very much for your attention. Meanwhile, I'd like to introduce my friend and colleague, Ryan Kennedy, who is a nurse practitioner who went on and got his doctoral degree, and he's been very patiently working with me for the last 10, almost 11 years, and is the associate director of our clinic in Manhattan Beach, California. And he's here to talk about some of the things that are important in terms of treatment, specifically for this population. Ryan. Thank you. Everybody can hear me okay in the back? Okay. I'm going to give my assistant a laser pointer in case anyone falls asleep. Joking. Let's get started. I'm going to be talking about how to optimize and fine-tune medication treatment for this population, piggybacking off of Dr. Brown's presentation. Here are my disclosures. Without getting too wordy, this is basically a layout of how I approach treatment for basically any patient that comes into our clinic. We're lucky enough to have three-hour evaluations with our patients, and that can involve with the individual, usually with their collaterals if they're younger. It's nice when an adult has another adult with them. But having everybody in the room together to have an understanding of how the medication works is fundamental to even getting started. We spend a good half an hour at least talking about how the medication works, and I use some plastic brain I have in the office and have a story of elaborating of how your brain works depending on how old you are so that it's digestible and understandable. From there, we can start talking about the types of medication I'll select. After we have done the evaluation, of course, and have a clear diagnosis. I'll do a little flip-flopping with the slide here to give you an idea of what I mean by selecting compound, which I'll get back to later. Basically, I'm selecting one of the compounds if we're going to be starting with a stimulant, meaning methylphenidate class or the amphetamine class. For most patients, I'll tell them up front that there isn't a one-size-fits-all perfect pill for anybody. You're very lucky if you get one of the long-acting medicines to cover you through most of the day. It does happen, but it's rare. With most people's schedules, they like to have a combination of the two or something, long-acting and short-acting, especially when people are in college and their classes are all over the place. Generally, most people, I like to start them with an extended-release medicine, and then we titrate week to week. Everybody from the smallest doses up to what is most tolerable. The best pill is the medicine that people are going to take. Then people will follow up with me at least within two to three weeks. It's really difficult to get the titration process started when I don't see them for weeks and weeks and weeks, when this stuff can be very fast. Of course, for monitoring any response. I do block off time in my schedule two to three weeks in advance for these new evaluations, so it's protected time. We do have the luxury of having the three-hour evals, but my follow-ups are at least 30 minutes. Sometimes they go up to 60 minutes if we need to. Then once people get on a stable regimen, I do see them every three months, so it kind of fits like a primary care model, but it's a little bit more involved. People seem to really like that. But that's not it. There's lots of other factors to consider when selecting medicine. Some patients, it's more the exception to have people who are fresh, never had an ADHD evaluation before. That makes it very easy. For a lot of our other patients, they've gone to two, three, four other evaluations. They're on multiple medicines. Some deeper scribing and deeper thinking is really important. I have to first consider, what have you tried in the past? Trying to help patients understand that what happened in the past may not predict your future results of how I'm going to treat you, but I'm not going to forget, maybe this medicine really is not a good fit for you. Of course, monitoring growth and appetite. As I get into more of my follow-ups in the second, third, fourth month, it becomes less and less about medicine, more about how they're behaving day-to-day. I really care about how people are functioning in their family, at their school, their work, if they're staying involved with things, and what sort of the structure of their day looks like. The medicine that we prescribe is really going to have a better effect if someone is more regulated in their day-to-day schedule. It's a chicken and the egg sort of thing, but both are important to talk about together. I'm not going to touch too much on the metabolism piece, but there are some patients where I've done some specific enzyme testing, and it did make a huge difference in understanding why we've tried so many medicines and it's not working out. We have this company, Quest, that I'll send some blood tests to, but it's kind of rare for it to happen. But it's interesting with the autism Asperger population, where the effects they have on the medicine are generally, there's a lot of variability. You'll see this little red asterisk here, if you want to call it, this thing right here. It's sort of to allude to either a case study I'll talk about, or why there's a sensitive response to a medicine. First slide I'll start with is the high-dose crash. Raise your hands if anybody heard of what this is talking about, having a crash from stimulants. A good majority of you. This could be with any stimulant, long-acting, short-acting. It doesn't matter how old you are. It doesn't mean it happens every day, but it's a pretty common thing to happen, especially with younger people who maybe skips their lunch. They don't want to eat mom's ham and cheese sandwich that's been sitting in their backpack for six hours. Understandable, but they have to eat something in the afternoon. But if they don't, and then their medicine's not making them feel hungry, there's a big reason why they may be feeling pretty agitated when you pick them up. Not always the case. Maybe they did eat, but it's the medicine wearing off rather quickly at the end of the day. And it looks like usually irritability, I'm tired, I don't want to do anything, or just very emotionally reactive, whether it's anxious or irritable, angry, agitated. But it gets better as the medicine fully metabolizes or they get a Snickers bar. This is a slide that's not sort of a one-size-fits-all for all the long-acting medicines. It's just sort of giving you an illustration of what some types of the extended release capsules, how they metabolize with the biphasic peaks. So for most people in the room, by a show of hands, how many people are international? Okay. So there is quite a difference in the medicines we have here in the states versus internationally as far as the amphetamines are concerned. So this PowerPoint doesn't touch on any one specific medicine, but I think just the general principles of it will apply to whatever country you're in for the most part. So what do you do about it? One of the easiest things to do, even though a lot of people want to do the one pill only in the day, this is a very successful strategy I found, which is adding on this booster tablet at the end of the day. And you want to try to find the pattern of how quickly this morning capsule is wearing off or if it's a tablet. You want to add that third tablet, the second tablet of the day, generally after noontime, sometimes between noon and three. And that makes that crash from here a lot more smooth. So they can have a longer duration out of their medicine if they need it. Not every age needs it, but it really helps extend the duration of the medicine, especially when kids are coming home from school and parents need some extra help getting things in order. Let me go back here. So for the booster in the afternoon, there isn't any one I specifically recommend, but it's whatever one is most tolerable. And it doesn't have to be necessarily the same strength as the capsule in the morning. Sometimes that works out, but sometimes that's a little bit too much and it interferes with trying to get some rest at night or have an appetite. But rule of thumb, I usually say same dose in the morning, take it earlier, or do a half a dose. Another interesting thing that sort of piggybacks off the last slide is, I can't tell you how many conversations I've had with people about the long-acting stimulants and their wonderful duration of action of 12 to 14 hours. I like to meet these patients because I don't see them maybe one or two times a year. But they generally have the newer medicines, like Vyvanse, for example, Midaeus, a couple others. They have a nice, smooth, long-acting duration that gets through most of the school day. But still, with that long, smooth-acting duration, you can still have the crash happen at the end of the day. I see it with Vyvanse quite often, so it's not inappropriate to have a booster at the end of the day. There is no short-acting Vyvanse, so it's whatever is available at the pharmacy, if it's Adderall or Dexedrine or if it's Ritalin if it's a younger child. Next, I'm going to kind of bounce back and forth between different problem-solving strategies I've encountered with this particular patient population. Generally, if I have a patient with ADHD and Asperger's or autism, and it doesn't seem like there's any other comorbidity beyond that, the most straightforward approach is to start with something that's easy to metabolize, like methylphenidate. Depending on how old they are, I'll usually start on the five-milligram tablets, half a tablet or a full tab, just to get them used to how it feels, and then slowly increase this dose depending on how they're responding to it. My preference is to go with the longer-acting stuff because it's a little bit smoother. For example, Ritalin LA is generic. It doesn't cost a lot of money, so you don't get a lot of pushback on getting that started. Once we get the medicine dialed in correctly, it's easier to get the next step in their formulary to something that's a little bit longer-acting and more consistent. I've noticed a lot of problems with generic medications in the past couple years where it seems like there's cutting corners in how they're being compounded, so I get variable responses sometimes with generics. Not everybody, but generally, this is from a systematic review of Ritalin for the ADHD versus the autism population, and there's a positive response for both of addressing core symptoms of each disorder. However, with ADHD, you're getting a more robust response. It's not a surprise. My first case, we'll touch on this triple whammy. This was a 55-year-old married woman. She's a retired pharmacist. She has six children and maybe seven. When I first met her, she was on menopause and was having complaints about her memory, something that Dr. Brown had touched on. As we got to know her, we had done several measures in figuring out what sort of the complex amount of problems that were going on with her. The ADHD was very clear from a very early age, and we were lucky to have her brother-in-law and his whole family as patients too, so we really had a good grasp with the genetic pool. It seemed like this was the common trend in both sides of the family, but each had a unique treatment. Before we had seen her and then when I had seen her, we were just having no luck with any of the amphetamine trials. Most adults that are over, teenagers and adults, all start with the amphetamine class. We were not having any luck. She was getting very jittery even on the lowest doses. I tried this other approach with her. It says, okay, let's take a break from stimulants and let's switch over to guanfacine. She's a very hyper person. At 11 o'clock at night, she was putting together an elliptical machine because she just has so much restless energy, driving her kids nuts. What's interesting with starting with this approach, with this little asterisk here, is it helps desensitize the response to stimulants because of its norepinephrine reuptake. When you add on a stimulant a couple weeks to four weeks later, it doesn't feel as intense. That could be with any stimulant, methylphenidate or the amphetamine class. We did not start at four. We started at one milligram. She's under 150 pounds, which I found to be the good dose to choose between one or two milligrams as a starting point. Then instead of going back to the amphetamines, we switched to the Ritalin LA, and she responded much, much better to that. That activated a lot of her OCD, and that was an underlying problem all along, but it wasn't her primary issue. But she did respond quite well to the combination of fluvoxamine and Abilify at two milligrams. It was tricky trying to find out the right balance with her, particularly when we were having the ADHD-Asperger's overlap because a lot of their symptomatology just has an overlap that seems it's hard to separate the three. So we definitely spent some time with some rating scales. This is a busy table here. The important three things to look at are the things that are highlighted in yellow. This is an amalgamation of data from a meta-analysis of many studies over the past five, seven years, and it's split in half between core ADHD symptoms and then emotion and behavior. And the category I'm focusing on here is for adults. You'll notice that it's pretty weak as far as how the non-stimulants are compared to stimulants. That's not a surprise. But as a combo together, they're quite effective. There's not enough data for me to say is that an accurate number, but from clinical practice I'd say that's a pretty good high rating for the combination treatment. It's not for everybody, but for some patients it seems like having something as a non-stimulant or something in another class helps regulate their mood or their anxiety along with their ADHD. But I tend to choose amphetamines as a starting point for most adults because it generally has a higher effect size compared to using Ritalin for adults. Other countries don't have that luxury and you have to do what you have to do, but this seems to be the most favorited by patients, but it also comes with more side effects. So this becomes a nice handy add-on as an augmenting agent for a few reasons. One is it helps the side effects on this medication seem less potent. Or if someone has trouble with sleep, adding guanfacine at 5 p.m. helps them wind down at night and helps with some of the emotional regulation in the daytime. This is a generic slide about biphasic capsules. I think it was designed for Ritalin LA. Just to give an idea, I share this slide with patients when they get overwhelmed with the amount of milligrams that are in the capsule, but just reminding them that we're not giving you this all at once and that we're splitting this up over several hours. I'll mention this in just a moment. So this is just a little brief table of where we are today as far as the non-stimulants. It's pretty pathetic when we have these choices here. Half of them I tend to not use. The other half, it's more of an augmenting or an add-on. But they're underappreciated in the adult population for sure. I'll explain why in a moment. Busy slide here, but my main takeaway is to not veer away from using guanfacine in extended release in adults. Even though it's not approved for adults, although in Japan last year it finally was approved, I use it quite often. Not for everybody, but particularly for people who are sensitive to stimulants as in the autism Asperger population and people who have trouble with falling asleep or just have a lot of motor restlessness. It helps tend to also desensitize the response to stimulants. I just need to see at least like 50% benefit out of the stimulant to say we should try to continue taking it, but we need to maybe take a step back from it for a second. It's more flexible. The designs for this study back 20 years ago, whatever it was, they titrated the medicine way too fast. People had lots of complaints about it. When I first learned about guanfacine, I thought, why was this even a suggestion? It sounds like a terrible medicine. But it was all in the design trial. In fact, I'm very slow and careful with this one if I'm going to start titrating it, at least waiting two, three weeks before going up. But it really is sort of the gift that keeps on giving if you can stay patient with it over time. The nice thing about it is it can be taken in the morning. I often start people around 5 o'clock at night because if it has any effects, if people feel tired, if you take it at 5 with its 3 to 5-hour peak, you'll be in bed asleep and you won't even know if it's making you tired. Usually those effects are gone by the morning. Then you can switch to the morning if you like after a few days. I do have quite a few people who like to take it BID. I have one patient on the Asperger's spectrum where she takes it with her stimulants both morning and afternoon and it helps it be more tolerable, which is interesting. Kids are more prone to the side effects on these, so it's interesting seeing my adult population have much better response to this medication. But with kids, a little bit more careful. Sometimes you can crack the tablet in half at night or separate the dose into one milligram in the morning and one in the evening. But this is a great tool that I like to use for this population. I'm not going to spend too much time on this slide. This is just a general overview of where we are today as far as what stimulants are available and all the fun and creative ways that they've been developed. But generally, I'm starting with right over here and then right over here. I like to share this slide with patients because the ratios underneath it are very important whenever we're going to switch something, maybe a pharmacy is out of the drug or they don't like it anymore for whatever reason. And then if they want to switch to just IR, it's not just a simple equation. We have to take into consideration what formulation works best for them. Some of these kids can be kind of quirky with how they like a little bit more up front in the morning or they like less in the morning and more towards the end of the day. So it kind of depends. I tend to use these a little bit less over here. I'm going to try to speed through the next couple here. Next one here, I'll touch on this one. This is a method that I like to use. Dr. Brown had taught me this one back when I started prescribing, which is this bookend method. I think it's really an unused method, but quite effective for patients who have trouble getting up in the morning and have a long day of work. This particular patient I did close to a year of psychotherapy with, once a week for about an hour. He was going through a crisis after he got fired from his job during COVID. His boss had closed down the warehouse and he was eating beans out of a can, and he was sleeping in the daytime and awake at night, and just really having a hard time struggling with his emotions. This was what we had stable for a long time. He would take one of these tablets in the morning, Zenzetti, dextroamphetamine, and then he would take his Vyvanse at the same time, so when the Zenzetti is wearing off, the Vyvanse is covering through most of his day, and then if he needed it, he would take the extra tablet in the afternoon. That worked well until he got fired from his job. We had added in, this was a PRN here, but the Paxil and Abilify were a huge help to him. They made him feel, he said to me, when he had conversations with me that he was on fire. I felt so bad when he told me that, like, I wish he had told me that at the moment. He's like, no, no, no, no, this is just how I am with everybody. I just feel like I have this really nice, well-worn leather jacket on me, and it's on fire. I just get so anxious, and then I have to go take a nap after I talk to anybody. But with the off-label Abilify, he said, now the coat's off, and it's in the other room. I still have it, I swear, from time to time, but I have more control over it. Let's skip on this one. Am I out of time? Am I out of time? You're about out of time, so just wrap it up. Okay. This is my last slide here. I'll touch on depression. This is for a 17-year-old man. I'm still seeing him. He's struggling with accepting the fact that he's going to leave his parents' nest and go on to college. When I first met him, he said to me, even if I had anything wrong with me, I'm not going to tell you, which I took as a nice challenge. I had been in his position. I worked with him quite slowly. He had gone through a lot of different evaluations and psychiatrists. We spent a lot of the first couple of sessions really just trying to get some rapport with one another so we could build some trust. Then I let him lead the way a lot in what the decision-making was for the medicine, but these were medicines he had striped out with before I saw him. As for an adolescent, I wasn't willing to give up on the amphetamines just yet, so I did my guanfacine trick and then added in this long-acting amphetamine. That worked. It was nice. He had done much better in school, but he still had a tremendous amount of social anxiety and anger and irritability, which is why these got added in. My rule of thumb is try to have patients on two or three medicines at most. It's hard to tell what's doing what when you get to four or more. Sometimes you have to, but I usually have a plan with patients to wean them off over a period of time. I think I'll leave it at that. Here's a couple of resources, and I'll send these slides to anybody if you would like them. Thank you. Thanks, Ryan. It's now my pleasure to introduce Lidslibeth Walkison, who's on the faculty at UCLA and has developed a really impressive program called the Peers Program, which she will tell you about, for dealing with social interaction problems with a variety of age groups. This is a program which has been picked up and is being used in many places throughout the world now. Here's the person who built it. Liz, we're grateful that you're being here. Look forward to hearing you. Good morning, everyone. Thank you so much to Dr. Brown for organizing this symposium. I am going to go ahead and just pull up my slides here. This is not my computer, so my apologies if it takes a second. Wonderful. Good morning. As Dr. Brown mentioned, I'm going to be sharing a little bit about one of the few evidence-based social skills interventions for neurodivergent youth. This would be youth with autism spectrum disorder, ADHD, but we also work with kids with anxiety and depression, adults with the same, even people without diagnoses that are just struggling socially. Before I get started, just a couple of disclosures. I receive book royalties from Taylor & Francis and Wiley & Sons, and also get research funding presently from NIH, ACL, and Autism Speaks. In terms of what I'd like to share with you this morning, just briefly, I'll talk about some of the social challenges that you see among neurodivergent youth. We heard a bit about that this morning from Dr. Brown. Also, some of the consequences of these social challenges. And then I'll give you a little overview of the peers intervention. I'm actually going to give you some tools today for teaching social skills in various areas, particularly related to communication skills and also handling bullying. Then I'll give you a brief overview of some research findings and end with some resources. As we heard from Dr. Brown earlier, some of the hallmark features of neurodivergent youth, like those on the autism spectrum, those with ADHD, relate to things like social communication. One of those hallmark features, social impairments related to communication, conversational skills. What does that look like? Well, for a lot of our kids, they kind of have these one-sided conversations where they perseverate on topics of interest. They might have difficulty with things like topic initiation, knowing what to talk about. And that really kind of impairs their ability to make and keep friends and develop relationships with other people. We also know poor social awareness is another area that a lot of our youth struggle with. This is sort of understanding the social landscape that they live in, picking up on social cues, and just basically kind of decoding the social world. We also know that, unfortunately for a lot of our kids and adults, they have less constructive social engagement. They're either enrolled in maybe fewer extracurricular activities and social activities, or they might be kind of intrusive in their peer entry attempts, maybe barging into conversations with people, and just not having very constructive interactions in those ways. Poor social cognition is another one of those hallmark features of neurodivergent youth. That's sort of the perspective-taking, putting yourself in somebody else's shoes and being able to anticipate how they might think or feel or react in a given situation. We often associate that with things like empathy, theory of mind, and we often think of that in terms of the autism spectrum. People on the spectrum tend to struggle with that, but youth with ADHD also struggle with things like social cognition. And then finally, kind of bottom line, a lot of these youth, they really struggle with developing close, meaningful, reciprocal relationships with other people. But interestingly, if you ask a lot of these kids and adults if they have friends, what will most of them say? Yeah, absolutely. Then you investigate a little further, and they either can't name anybody that they're friends with, or they'll name everybody at school, but they've never hung out with anyone before. So they tend to have kind of poor friendship quality. Now, what are some of the consequences of these social challenges? Well, this is research that goes back decades, and this is not specific just to autism or ADHD. What we know is that peer rejection is one of the strongest predictors of mental health problems. So things like anxiety and depression, if you want to predict who's going to be anxious or depressed later in life, go into a typical middle school or high school, at least in North America, and look for the kids who are rejected, and that will be one of the strongest predictors of things like anxiety and depression. We also know peer rejection very strongly related to things like poor self-esteem, loneliness, also poor academic performance, early withdrawal from school, juvenile delinquency, substance abuse issues, and probably at its worst, suicidal ideation and suicide attempts, strongly predicted by peer rejection. I would argue we're not doing enough for those kids. Often, in fact, in North America, often we're mandated to provide social skills training in the school setting for kids on the autism spectrum, but what about all the other kids that are struggling socially? If you look at the peer sociometric data, which I wasn't planning on sharing, but I'm going to now, one-third of kids in middle school and high school in North America are struggling socially. One-third. Do you think they're all getting services? Probably not. When you think about the consequences of this, it's pretty disturbing. We should probably be doing more preventative work. This is really what led me to develop the peers intervention. Also, the fact that when I first developed the intervention back in 2004 at UCLA, there really were no evidence-based social skills interventions for adolescents on the autism spectrum, which is pretty shocking. We know this is an area of challenge for neurodivergent youth, but those types of programs didn't exist. Most of them focused on elementary school-aged kids. Fast forward back to 2022. This program originally was developed for adolescents on the autism spectrum. Now, we have programs for preschoolers, for young adults. We have programs related to employment, like a college-to-career transition. We have programs around dating etiquette. This program is not just used for neurodivergent youth. It's used for anyone who's struggling socially. PEERS is now used in over 150 countries, and it's been translated into over a dozen languages. These are some of the books that have been published around PEERS, not all of them. Everything that we do, though, is definitely something I want to point out is evidence-based. We don't publicly make manuals and books available unless we have a strong evidence-based to support the effectiveness, the efficacy of these programs. That's sort of a unique aspect of our program is it's one of the few evidence-based. Another unique aspect of PEERS is that we use parent assistance or caregiver assistance, basically teaching other people to be social coaches out in the real world. These are time-limited interventions, like 16 weeks in length is average. They come once a week for 90 minutes. This is not a lot of time in the grand scheme of life. Parents, other caregivers, adult siblings, job coaches, life coaches, teachers, educators, they're around a lot more than we are as practitioners. We're going to teach them to be social coaches out in the real world. That's going to be a much more robust, durable program, and also is going to help to generalize the skills into other more natural social settings. Another unique aspect of the program, and I wish it wasn't unique, is that we're only teaching ecologically valid social skills. We're not teaching what adults think that kids should do, but what actually works in reality. We're determining this by research. I'm going to give you some examples of this, but you would be surprised. Most social skills interventions are actually not teaching what socially successful kids and adults do. It's just what people think you're supposed to do. Finally, another unique aspect of this program is that it's been cross-culturally validated in different parts of the world. I'm happy to answer any questions about the differences there. In terms of the targeted skills that we teach in peers, it kind of depends on the program. The program I'm focusing on today focuses more on making and keeping friends and handling conflict and rejection. This would be for adolescents and for adults. Things like finding and choosing appropriate friends or romantic partners. The dating aspect, the romantic partners, we focus on in our adult program. We did a lot of focus groups early on in developing the teen program and discovered that that wasn't a huge treatment priority for that population. Fast forward to adulthood, it does become an important priority for a lot of people. We also focus on conversational skills quite a bit. That's really fundamental to social interactions once you hit adolescence. We also talk about things like starting conversations, entering conversations, exiting conversations, get-togethers, good sportsmanship, electronic communication, also very important. Then also things related to dating etiquette for adults. How do you let someone know that you like them? How do you flirt with someone? There's actually ecologically valid skills for how to do that. You can break that down into concrete rules and steps. Just general dating do's and don'ts. On the managing conflict and rejection side, for dating this would be things like accepting rejection or turning someone down if you're not interested in them. Handling unwanted dating pressure from a partner. Also things like handling arguments and disagreements. Conflict resolution skills. Then finally we also focus on all the different forms of bullying. Research suggests there's four types of bullying. There's verbal bullying, that's teasing and name-calling. Physical bullying, that's more aggressive, but it could be pranking or practical jokes, things like that. Those are all direct forms of bullying. Then the indirect forms are things like cyber-bullying and rumors and gossip. Those are completely different behaviors and so we need completely different strategies for how to handle those types of bullying. Now I'm going to get to the good stuff. Now we're going to talk about some skills we teach. Conversational skills. Really, really important. Once you hit middle school and the rest of your life, this is how people interact. I want to ask you guys a question. It's not rhetorical. I want you to answer. What do you think that most kids and adults are told to do to meet new people? Imagine you're working with a kid. Maybe not you, maybe what other people would say. Imagine there's a kid going to school for the first time. It's their first day. They don't know anybody. What are they told to go up and do to meet new people? Introduce yourself. Say hi. I ask every group of kids and adults I work with this question. They always say they're told to go up and say hi, go up and introduce yourself. Have you ever thought about what that would look like? Imagine, maybe not in this conference hall, because people get away with doing things differently in work settings, but imagine we're out on the French Quarter, and there's a group of you and I just walk up to you randomly, never met you before, and say, hi, I'm Liz. What would you think of me? I'm weird. Who's this weird social skills researcher? Research is me-search. That's not appropriate. But that's what kids are told to do. They're told to go up and say hi and introduce themselves. That's not actually what works. Then you have to also think about, what are the common social errors that a person might make here? When it comes to social challenges, you tend to get these two groups of people, regardless of diagnosis. You get the peer-rejected and the socially neglected. The peer-rejected kids, those are the kids with ADHD, impulse control issues. They're going to barge into conversations, be off-topic, talk about whatever they want to. The socially neglected, they don't even try. Those are the ones that are more anxious and depressed. They often go unnoticed. We have to demonstrate what not to do when we're teaching social skills before we get to what you do. The reason is they need to see what this looks like because they might be making these social errors. There's a whole formula for teaching social skills. We'll start with an inappropriate example first. In this video, you're going to see someone come into the screen in a second. Her name is Alina. I would introduce this role play by saying, watch this role play. Think about what Alina is doing wrong here in starting this conversation. Hey, do you ever go roller skating? What? Do you go roller skating? No. Why not? You should go. Okay. It's really fun. I go every weekend. Sweet. There's this new skate park that just opened up. I'm here to watch something right now. Oh, well, I'm just saying. It's really fun. They have a student night every Thursday. Cool. You should definitely go. Okay. Okay. Then we time out. We ask, what did Alina do wrong? Here's the interesting thing. When you teach these types of programs in groups, collectively, they can always tell you what the person did wrong. They can do all the perspective taking and everything. Even when they make the social error. Even when you have the kid that would do that. When it's not them, they can tell you what's wrong with that. They'd say, well, she just walked up and she randomly started talking about roller skating. There's no context for that. The thing about that, too, is that if they were in a roller skating rink, that would be okay. Or if she had a little roller skate on her T-shirt or something, that would be okay. But there was no context for that here. Now we have to get into the mind of the other person. You ask these little perspective taking questions. What was that like for that other person? It was confusing. It was weird. It was annoying. What did she think of Alina? She's weird. She's kind of random. That was odd. Would she want to talk to her again? No. Definitely not. People get bad reputations for doing stuff like that. You start with the social error first. How people start conversations. You probably do this all the time. You just don't think about it. The thing is, you could have good social skills. That does not mean you know how to teach good social skills. So much of it comes automatic. You don't even think about what you're doing. By the way, I was just realizing, this is kind of towards the end of the conference. It would have been good if we were at the beginning of the conference to teach you guys this. But you can feel free to use after this, too. Step number one. You're going to kind of casually look over at this person. You're kind of noticing them. But you don't want to look like a creepy stalker staring at the person. So most people will use a prop. Like a phone or something. Not a text message or email or something. Your conference program or something would make sense. But it needs to make sense. Some kind of prop. And really what you're trying to do is you're trying to find a common interest. And by the way, friendships, relationships, all these things, they're always based on common interests. Think about that. Think about who you're friends with. Think about the way of things in common with them. Those are things you talk about. Those are things you do together. People are always looking for some kind of common ground. So that's what you're looking for. You're trying to find a common interest. Now in that video, that person that was on her phone, that was Jordan, she was on her iPhone. And she was watching a music video. Okay, what could be some common interest? Could be the song that she was listening to or the musical artist. It could be the phone. It could be the app that she was watching the music video on. So you're looking for that common interest. Let's say you find it. You're going to mention this common interest. And you do that in one of three ways. You can either make a comment, you can ask a question, or you give a compliment. So what would be a comment? Oh, that's the new such-and-such video. What would be a question? Oh, is that the new such-and-such video? And what would be a compliment? Oh, I love that song or I love that artist. Those are ways that you mention the common interest. You're having a good reciprocal two-way conversation. And there are a lot of rules around that. I'm not even going to be able to get into that. But this whole reciprocal kind of back and forth. And then you have to assess their interest. Now this is also fascinating to me. When you ask most people, how can you tell if somebody wants to talk to you? Most people will say it's a feeling that you get. Okay, for some of us, we might get the feeling. Some people don't get the feeling. But here's the reality. If you get the feeling, you are picking up on concrete behaviors that give you the feeling. So how can you tell if somebody wants to talk to you? What are they doing with their eyes? They're looking at you. What are they doing with their body? They're facing you, not giving you the cold shoulder, kind of turned away. And they're actually talking to you and not giving rude remarks or short replies. Those are the three behavioral signs that tell us if somebody wants to talk to us. And you don't have to get the feeling. You can teach kids and adults to pay attention to those. Are they looking at me? Are they facing me? Are they talking to me? It's really simple. And then, if things are going well, then you get to introduce yourself. But if there's going to be introductions, they come later. They don't come at the beginning. So now, teaching this formula for teaching social skills, next step is to now show the good example, followed by some of those perspective-taking questions. So I'd introduce this by saying, watch this role play. Oh my god, I love that song. Yeah, me too. This is the new video that just came out today. No way, I'm dying to see that. Yeah, it's so good. That's awesome. Have you ever seen her in concert? I have. I actually have tickets for her upcoming concert. No way, the one that's coming up in two weeks? Yeah, it's going to be so great. That's so cool. Have you ever seen her perform? No, I wish. I really want to. Oh my gosh, she's amazing in concert. You need to see her. Yeah, that's what I've heard. By the way, I'm Alina. I'm Jordan. Nice to meet you. It's cute, right? It's cute. Okay, so we'd time out. We'd say, what did Alina do right? We'd go through the steps she just followed, and then some perspective-taking. What was that like for Jordan that time? It was natural. It was comfortable, right? What did she think of Alina that time? Would she want to talk to her again? Yes. Okay, and then the next step of the formula, of course, is to have your patients, your students, practice this with some coaching with you. And then give them assignments to practice outside of the treatment setting. That's going to generalize the skills. And follow up to make sure that it worked out. That's sort of the formula. All right, I can't help myself. I'm a clinician, first and foremost. I'm a researcher, too, but I've got to give you one more strategy before we go. Oh my goodness. You know how I said well-intentioned adults give really bad advice? This is the worst. And it's across the globe. I know we've got a lot of international people here, so I'm going to ask you guys this question. Not rhetorical. What are most kids told to do in response to teasing? Ignore it. What else? Walk away. And what else? Tell an adult. Everybody says the same thing. Ignore, walk away, tell an adult. Then I ask kids if it works. What do you think they say? No. You know why? Because those are not ecologically valid strategies. Think about that. Imagine that Tom Brown over here was a bully, which we know he would never be. Imagine Tom Brown over here is teasing me, and I ignore him. What will he do? Yeah, he's going to keep teasing me, and I'm likely to be teased by Tom? More likely. It was easy. Right? Let's say I walk away. What is Tom going to do? Follow me. Right? And keep teasing me. And again, I look weak because I didn't do anything. Am I more or less likely to be teased by Tom? More likely. And now imagine I go tell somebody. I go tell Ryan Kennedy. Right? Try to get him and Tom in trouble. And what is Tom going to want to do now? Well, think about it. I tried to get him in trouble. He's going to want to retaliate against me. Right? Get back at me. Right? Because I tried to get him in trouble. These are not ecologically valid. And yet, that's what adults tell kids to do. And by the way, do not feel bad if you've been telling kids to do that because everybody tells kids to do that. I probably would have told kids to do that if I didn't do research in this area. It's just what you were probably told to do that. I was told to do that. An epidemic of bad advice. Okay. So instead, this is what we want to do. We want to do, we want to teach what socially successful kids naturally do. And the reality is every kid gets teased. Even adults get teased. It's how you react to it that determines how significantly, how chronically, how severely you're teased. All right. So it's really simple. Kids who are able to escape this, they do this really simple thing. They give a short comeback that shows that what the person said didn't bother them. And actually what they said was kind of stupid. Right. So they'll say things like whatever. Or yeah, and. Am I supposed to care? Is that supposed to be funny? So what? Big deal. Who cares? Any of these things. They roll their eyes. They shrug their shoulders. And they act like what the person said was kind of stupid. And it makes it not fun for the other person. Right. And in fact, it even kind of embarrasses the other person a little bit. And then they don't want to really tease you. And you don't just give like one comeback. Sometimes you have to give a couple. But you don't stand there and take it. After you've given a couple or a few comebacks, then you can walk away. Or you can turn away. Or kind of like start talking to somebody else. This is probably the simplest social skill I teach. And it works faster than any other social skill that I teach. If I could only teach one social skill for the rest of my career, this would be the one. Especially because think about what the consequences of peer rejection are. Right. All the mental health problems and things like. It's so simple. We should be teaching this stuff. Okay. So in this case, I would not show a bad example of what not to do. Because it's too emotionally triggering. I mean, kids could have like PTSD flashbacks watching someone have like not handle teasing well. So just show the good example. In this case, you're going to see someone named Gabe in the shot. And Gabe's going to be teased here. Watch to see what Gabe does right in handling this teasing. I don't know why this isn't working. Oh, I can tell you. I can do a role play right now. Oh, that might be kind of fun, actually. But I still want to show you the video. Okay. We're going to do a role play. And Ryan is going to be the bully. Not Tom. We're going to give Tom a break. Actually, Tom, do you want to be the bully? Okay. He's going to be the bully. All right. This is fun. Okay. Good. So we weren't planning on this. But we're going to do this. So I'm going to actually walk you through. Because if you do this with your patients, with your kids, then you'll want to know how to set it up. Do not choose an actual, like, real teasing remark that they might have experienced. Like, you're weird, or you're a loser, or whatever. That's too emotionally charged. Choose something benign. So we're going to choose something benign. I'm going to have Tom tease me about my shoes. Okay. Now, I mean, if shoes were a big deal to me, then I wouldn't do that. Because that's not a big deal to me. And I know my shoes are cute, too. So that's okay. All right. So he's just going to be commenting on my shoes. You're going to say things like, Liz, those are really ugly shoes. And I'm going to respond. And you're going to say, no, seriously, you need to rethink your footwear, or something like that. No, get some new shoes. We're going to do this, like, three times back and forth. Okay. So are you ready? You're going to tease me about my shoes. Liz, where the hell did you get those shoes? They don't really go with what you're wearing. Whatever. Have you thought about getting something with a little more color in it? It looks like some crocodile died to make those for you. Am I supposed to care? Well, yes, you're supposed to care about the crocodiles, as well as the rest of the environment. Anyway. All right. So time out. Round of applause for Tom. So he was really coming at me, by the way. That was. I would not recommend doing that with your patients. Like, set them up for success. Like, just really simple things. But I felt good about it. I still felt good about it. And I also noticed I kind of walked away. I was like, I love a good anyway to end on, because that feels good to walk away in an anyway. I kind of want to ask you, though, what was that like for you? Because I feel like you struggled a little bit after the first one. Did you? What did that feel like to you when I was like, whatever. Am I supposed to care? Anyway. Truthfully, how did it feel? Yeah. I had to pause for a second and think about how he's going to come back at you. Yeah. Was it fun for you to do that? Or did it feel like it was a little bit more work than you expected? It was more work. I thought you were probably going to, you know, wither after my first comment. No. No, because you know what happens in this example? Is that you flip the control. Because I got a roadmap. I have like, I know how to deal with this. I'm just not giving him anything that's fun. I'm not reinforcing that. And the thing that could happen, and I'm going on way too long. I'm sorry, but I couldn't play my video. So, you know. But the thing is, is that there could be like an extinction burst. You know, like Tom might be used to getting a certain reaction out of me where I get mad or upset or I tease back. And he's going to think, no, no, no. This is not how this works. And he might try harder at first. That's an extinction burst. But it does not last long. I mean, usually in a weekly group, when I see them the next week, the extinction burst is gone already. There might be some spontaneous recovery, if you know that. Like maybe a couple weeks or months go by. He might be like, oh, it used to be fun to tease Liz. Let me try again. But other than that, I mean, this is a very powerful strategy. Thank you again for doing that. Kind of cool that the video didn't play, right? Oh, now it started to play. Did you see that? Whatever. All right. So, let's move on. I'm going to wrap things up so we can do a little Q&A. So, I mentioned that PEERS is one of the few evidence-based social skills programs out there. There's over 40 peer-reviewed papers on the program. I wish I could geek out with you all afternoon or morning talking about this. But instead, I'm going to give you a quick snapshot about what we're talking about in this session, which is youth that have co-occurring ADHD and autism or Asperger's. And so, this is a study that we just recently did with 136 kids between 10 to 18 years of age that had either a diagnosis of autism alone, ADHD alone, or the combination of both autism and ADHD. And this is archival data from our clinic from patients we saw between 2014, 2019. About three-fourths of the sample was male. Average ages around 13 or 14. Somewhat ethnically diverse. About 44% of the sample had autism, 32% ADHD, and then 24% had both co-occurring diagnoses. The outcome measures we're using in this study are pretty simple. We're looking at the social skills improvement system by Gresham and Elliott. And we're using the social responsiveness scale, which Dr. Brown mentioned by John Constantino and Gruber. So, first thing we're looking at is baseline differences. You might find this interesting. So, the blue group here, the bar graph, is the autism only. The red is ADHD only, and then the purple is autism and ADHD. That's overall social skills on the left here. And notice that, you know, the groups are all impaired. These are standard scores with a mean of 100 and a standard deviation of 15. The ASD group and the ADHD group, they're almost two standard deviations below the mean. But look at the combined group with autism and ADHD. They're even more significantly impaired in terms of their overall social functioning. If you look at the social responsiveness scale, this is an autism screening tool, so you're expecting the ASD groups to be a little bit higher. But this is using T-scores with a mean of 50 and a standard deviation of 10. Look at that ADHD group. They're still really impaired. They're still actually in the clinically elevated range in terms of the, you know, impaired social responsiveness, which is related to symptoms of autism. So, these groups are definitely struggling, but there are differences between the groups at baseline. Good news though, is when you look at the treatment outcomes in these two measures across the groups, again, the blue is the ASD only, the red is ADHD only, and the purple is the ASD and ADHD, they're all improving at the same rates. Even though they started at a different point, there are no significant differences between the outcomes across these groups, both in relation to overall social skills and social responsiveness, which you want those scores to be going down. So, that's the good news, is that they're all gonna equally benefit from the intervention. They're just starting at a different point in time. Okay, just in terms of some other things that we're currently doing, we have three RCTs right now at the UCLA Peers Clinic. One of them is looking at Peers for Careers. It's a college to career transition program for adults on the autism spectrum. It's a 20-week program that teaches the soft skills related to finding and obtaining employment, but also working with employers on setting up a protective, sort of supportive environment for these neurodivergent youth. We also have Peers for Dating, my currently, currently my favorite study, I think it's just really fun to teach, skills related to developing and maintaining romantic relationships for adults on the spectrum. And then we also have Peers L-DOPA. So, this is a study for adolescents and adults on the autism spectrum. Lots of them also have ADHD. And we're looking at comparing the drug L-DOPA to a placebo. And the idea is, if maybe by increasing the amount of dopamine in the brain, could we make socialization more rewarding, right? More pleasurable. So, kind of interesting study there. Wanna give a shout out that we do do a lot of training seminars, and we have five teleconferences that we do per year through UCLA. We do a lot more outside of UCLA, but then UCLA, we've got one coming up in June on our school-based adolescent program. It's a three-day certified training, again, over Zoom. We do our young adult trainings, again, twice a year. The next one will be in September. And then we also have our parent-assisted adolescent program. We do certified trainings around this twice a year. And next one is in November. Some helpful resources, hopefully, for all of you. I would like to give a big shout out to Dr. Brown's book, ADHD and Asperger's Syndrome in Smart Kids and Adults. He's such a great storyteller. I don't know if you've read his books before, but really, really helpful. Lots of stories about kind of the struggles, but then also some inspirational stories about the support received, useful treatment for this unique population. Those role-play videos I just showed you earlier, we have a library of over 100 role-play videos on our UCLA Peers Clinic website. They're free of charge to anyone to use, so if that's useful to you. We also have a Peers virtual bootcamp. We do in-person bootcamps at UCLA, but this is virtual. It's 35 episodes covering all the skills we teach in our adolescent and young adult program. Kind of go at your own pace on a YouTube channel. We have an app, a free app. Not much in life is free, but this is. And so this is covering all the skills we teach in our adolescent and young adult program. It kind of operates almost like a video game where there's different levels, and you have to take little quizzes to kind of move to the next level. There's little assignments and things like that, but it has all those videos, two over 100 role-play videos attached to this app. I also have a book called The Science of Making Friends that's just really for families that can't access a Peers program, but teaches all the skills we teach in Peers. If you haven't seen this adorable documentary, have any of you seen Love on the Spectrum? Super cute. This was originally developed, or a series that came out of Australia. And if you're interested in our dating bootcamp, maybe take a look at season one of Love on the Spectrum. It features a dating bootcamp that we did in Sydney. Finally, I'm gonna leave you with our contact information if you guys want more information, want slides that I shared today, I'm happy to do that. I know we're kind of running out of time. I know one of you definitely have some time for a Q&A here, but thank you so much for your attention. Thank you to Tom Brown for the cool role-play. And I think we'll open it up to Q&A if you guys wanna come up to the mic. My name is Markham Kirsten. I think the question to ask is, how many people here think they have ADHD? And how many people here think they're on the spectrum? So this is the problem I'm confronted in my daily work as a psychiatrist with Riverside in California. About one quarter of my patients think they have ADHD. It's become an epidemic like COVID. And another 10% think they're on the Asperger's syndrome. And this is becoming a fad. And I've been around long enough, practicing 46 years, to see psychiatric diagnoses come and go, like multiple personality and narcolepsy, which of course required stimulants. And I've gone to the lectures on the methamphetamine addiction. Are you aware that you are part of a problem that I have patients who are successful in life, they are corporate leaders, and they think they have ADHD. I have people who have- Excuse me, what's your question please? Are you aware that you are fostering a fad, that you are fostering an addiction? Now, I'm not saying there aren't people who have Asperger's. Okay. But they're not the people that- Let me try to respond. Sure. The problems that we're talking about here are problems that many people feel they have. And when they come into a clinic, my first question is, how did you decide to come and see us? And I take my lead from what they can tell me about it, rather than trying to paste a label on them. Next question, please. Hello, thank you. Hi. Thank all of you for your presentation. My first question for you is, is any of you on the spectrum? Are any of us on the spectrum? Yes, any of the presenters, are you on the spectrum? Not that we've noticed. All right, okay, it's great to know. I am autistic. Okay. And I found your presentation quite insightful, yet there's something that especially caught my attention. What is the feedback, especially for the doctor, what is the feedback that you have received from the young autistic community on your work? Yeah. So I actually, I'm not on the autism spectrum, but I do have a number of people in my lab that are on the autism spectrum. And I always publish with people that are neurodivergent. It's important that you include neurodivergent individuals in your research or clinical work as much as you can. Nothing about us, without us, if you know that saying. And also, I didn't get to mention this, but we only work with people who are socially motivated to learn the skills. Like I would never force social skills onto somebody who doesn't wanna learn them. I mean, it's not gonna work, first of all. And I actually don't think it's ethical to force social skills onto people who don't wanna learn them. So that's the first thing we always assess for and making sure that they actually want to learn the skills. Because a lot of the people we work with, they're very lonely and they wanna have friends, they just don't know how to. And so we're just trying to decode the social world. But even when we teach the skills, like they don't have to use them. I mean, it's just, it's sort of, it should be optional. But I get what you're asking with the question. And I just really, I always include people that are neurodivergent on my staff and in my team. And a number of my students are on the spectrum and they act as behavioral coaches in our groups. And I think they were very inspiration to a lot of the people we work with. I think all of us try to learn from our patients. Next question, please. Okay. Thank you for all your work that you're doing. I love this presentation and I need to buy the book for myself and my kids. But about ADHD, I didn't hear anything about Vanderbilt scales and is that falling out of favor and what do you recommend in terms of assessment? I didn't mention the Vanderbilt scales. I know they're available free to pediatricians and that they're widely used. But the other scales that I mentioned of the various possibilities, and it's not just my own, but also Barkley and BASC and the brief. These are age-normed and they have many more specific questions that I think help to get a clearer picture of what everyday life activities are problematic for the patient and for their families. So you prefer BASC and Barkley? Barkley? I like mine a lot. Oh, I'm sorry. But Russ Barkley's scales I think are excellent. The brief is widely used and deservedly so. What is yours called again? I missed it, I'm sorry. Brown Executive Function slash Attention Rating Skills. Thank you. Thank you. Next question, please. Yes, just real quick, Liz. I'm sure you've seen it as we see it. The series on Amazon is near to my heart. And all of the stars are neurodiverse. They're on the spectrum and it's hysterical. Okay, my question to you, because I actually asked Dr. Volkow about this a few years ago. How are the studies on L-DOPA going? Because I thought that would be brilliant, but I'm wondering how it's playing out. Okay, well, we're still in the middle of this RCT and COVID kind of put it on hold, even though we moved all of our groups to telehealth during COVID. You know, it's a medication trial, so you have to have people in person. I can only tell you anecdotally what we've noticed with L-DOPA. And there are times because the families don't know if they have L-DOPA or placebo, but at the end of the study, several families have been like, I don't know what this is, but you need to give me more of this. And I, so just anecdotally, like we're starting to like really notice that it seems to be working at least for some people, but the research is still, you know, ongoing, so. I'm glad you're doing it. Thank you, and I love the series. Yeah, as we see it, I was able to moderate a screening of that with Jason Kadams and the cast, and they were adorable. If you go to the Friends of the Semel Institute at UCLA, you can see like a whole screening with them, but it was very sweet. All of the cast members are on the spectrum and they're fantastic and it's a lovely series. We can take just two more brief questions. Thank you for the wonderful session. My name is Mohamed Selim. I'm from Egypt. I'm running a unit for children and adolescents over there. I have two quick questions. You said that psychometric tools are not very successful in diagnosing ADHD. You have to slow down a little bit. I'm having trouble hearing the last sentence. You said that psychometric tools are not very successful in diagnosing ADHD. Does this include the objective ones like the continuous performance test? What I was knocking was the neuropsychological testing. Those are, the neuropsychological test batteries are quite helpful for determining the damage from a stroke or brain damage. They are not effective for looking at the range of daily activities that are problematic for people with ADHD, so that's why I said I do not think they are useful tools for assessing and treating ADHD. Okay. And I have a question for Elizabeth. I have some younger teens and young adults that they are clearly on the spectrum, but they don't want to be involved in any training program. They will just come and say, I'm fine, I don't need people. I don't have to have friends. Yeah. And so how do you motivate them? Well, first of all, again, we only include youth that actually are motivated to be in the intervention. So if someone said, I don't want to do this, I would never force that onto somebody. But I would have a discussion about it because what I do find is that a lot of the young people we work with, they want to have friends, they just don't know how to have friends and they've often experienced a lot of rejection. And they've probably gone through social skills groups before and these are the groups that tell them to go up and say hi and go up and introduce yourself and they discover it doesn't work and they just sort of give up. And so I like to also share the difference between our program and other programs. I'll use examples of those ecologically valid skills. What have you been told to do before? That actually doesn't work. Did you find that? This is what we teach. So I do a little bit of psycho ed about how the program's different. But if they don't want to learn the skills, they don't have to. What you could do in that situation is work with people that are close to them, like family members and parents. Because the reality is that that individual is probably still getting some social coaching in their life. We just want to make sure it's good social coaching, right? So that the adults or whoever is around them, their therapist, whomever, they're giving good advice in these situations. Okay. Thank you. Thank you very much. Last question for Mo. Yeah, hey guys. I'm a child psychiatrist. I treat a lot of eight HD folks. I wanted to know, you know, obviously our diagnostic criteria are somewhat lacking. You know, in my view, the big thing they miss is a lot of the emotional content. There is nothing in our diagnostic criteria about the emotional content. Both the emotional regulation and how people with ADHD feel about all these problems. Yeah. Do you have any thoughts about what we can do as a community of practicing doctors to help try and like educate our peers and the committee about how to get the actual criteria fixed? I think we have a problem of lack of education in our field. Changing the DSM is like trying to get an act of Congress passed. Yep. But I think just sharing opportunities that we have to talk with one another and to write about it is about all we can do. The world is not everything we'd like it to be. I would like at this point to say thank you very much to Liz for your excellent presentation and to Ryan for your excellent presentation and to all of you for your participation. If anybody wants to get, you've already gotten information about how to get Liz's slides. If you'd like to get copies of my slides and Ryan's slides, I've got some of my business cards up here. You can just take one and email the office and they will be glad to send them to you. Thanks very much for being here. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

ADHD

autism

comorbid conditions

assessment

medication options

stimulants

non-stimulant medications

psychotropic medications

social challenges

PEERS intervention

social skills

communication

evidence-based interventions