back to indexADHD & How Anyone Can Improve Their Focus | Huberman Lab Podcast #37
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Welcome to the Huberman Lab Podcast,
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where we discuss science and science-based tools
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for everyday life.
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I'm Andrew Huberman, and I'm a professor of neurobiology
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and ophthalmology at Stanford School of Medicine.
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Today, we are going to talk all about
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attention deficit hyperactivity disorder, or ADHD.
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We are also going to talk about normal levels of focus,
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what are normal levels of focus,
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and how all of us, whether or not we have ADHD or not,
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can improve our ability to focus,
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our ability to rule out distraction,
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turns out those are two separate things,
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as well as remember information better.
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We are also going to talk about
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how we can learn to relax while focusing,
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which turns out to be a critical component
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of learning new information
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and for coming up with new creative ideas.
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So whether or not you have ADHD or know someone who does,
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or if you're somebody who feels that they do not have ADHD,
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but would simply like to improve their ability to focus
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or to be more creative,
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this episode is definitely for you as well.
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We are going to talk about drug-based tools
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that are out there.
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We are going to talk about behavioral tools.
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We will talk about the role of diet and supplementation,
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and we will talk about
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new emerging brain machine interface devices
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things like transcranial magnetic stimulation.
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If you don't know what that is, don't worry.
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I will explain it to you.
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These are non-invasive methods for rewiring your brain
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in order to make focusing more natural for you
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and to teach you how to increase your depth of focus.
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Now, just a quick reminder
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that anytime we discuss a psychiatric disorder,
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it's important that we remember
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that all of us have the temptation to self-diagnose
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or to diagnose others.
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So as I list off some of the symptomology of ADHD,
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some of that symptomology might resonate with you.
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You might think, oh, maybe I have ADHD,
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or you might decide that someone you know
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definitely has ADHD.
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However, it is very important that you don't self-diagnose
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or diagnose somebody else.
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The clear and real diagnosis of ADHD
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really should be carried out by a psychiatrist, a physician,
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or a very well-trained clinical psychologist.
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There are clear criteria for what constitutes full-blown ADHD.
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However, many of us have constellations of symptoms
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that make us somewhat like somebody with ADHD.
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And if you're struggling with focus nowadays,
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as a lot of people are, because of stress,
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because of smartphone use,
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which turns out can induce adult ADHD, we'll talk about that,
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well, then pay attention to the symptomology.
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You may actually require professional treatment.
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Equally important is to remember that some of the terms
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that we cover like impulse control and attention
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and concentration are somewhat subjective
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and they can change over time.
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Sometimes we have a better level of attention than others.
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Maybe it depends on how we slept
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or other events going on in our life,
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or something that we're entirely unaware of.
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The important thing to remember
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is that we can all improve our attentional capacity.
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We can all rewire the circuits
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that make heightened levels of focus more accessible to us.
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We can do that through multiple types of interventions
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and we are going to cover all those interventions today.
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Before we march into the material,
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I'd like to remind that this podcast is separate
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from my teaching and research roles at Stanford.
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It is, however, part of my desire and effort
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to bring zero cost to consumer information about science
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and science-related tools to the general public.
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In keeping with that theme,
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I'd like to thank the sponsors of today's podcast.
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Our first sponsor is Roca.
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Roca makes eyeglasses and sunglasses
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that are of the utmost quality.
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I've spent a lifetime working on the visual system
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and I can tell you that there are many features
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built into our visual system
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that allows us to see things clearly,
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whether or not we are in shade or bright sunlight, et cetera.
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A lot of sunglasses have the problem
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that you have to constantly take them off
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and put them back on again
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because of changes in background luminance, as we call it.
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Roca sunglasses have solved this problem.
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It doesn't matter if you're standing in tree shade
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or a bright light or what have you,
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you can always see things with perfect clarity.
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And that shows that they really understand
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the way that the visual system works
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and their eyeglasses are built accordingly.
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I wear readers at night.
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So I wear eyeglasses to read at night
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or when I drive at night
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and their readers and eyeglasses are terrific as well.
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One thing I like so much about their eyeglasses
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and their sunglasses is that
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despite being quote unquote performance glasses,
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meaning you can wear them while running
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or swimming or biking, they don't fall off your face
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even if you get sweaty, they're very lightweight,
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you don't even notice that they're on,
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is that the aesthetic is really good.
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A lot of performance glasses,
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they look kind of ridiculous, frankly,
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they make people look like cyborgs,
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but their aesthetics are terrific.
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They have a lot of different styles you can select from.
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The company was founded by two All-American swimmers
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from Stanford and everything about their sunglasses
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and eyeglasses were designed with optical clarity
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and performance in mind.
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If you'd like to try Roca, you can go to roca.com,
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that's R-O-K-A.com, and enter the code Huberman
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to save 20% off your first order.
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Today's episode is also brought to us by Belcampo.
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Belcampo is a regenerative farm in Northern California
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that raises organic grass-fed
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and finished certified humane meat.
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I tend to eat meat about once a day.
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So typically I'll fast until about noon or one,
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and then my lunch consists of a small piece of steak
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or chicken and some salad,
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and then I tend to eat my carbohydrates in the evening
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before I go to sleep.
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Sometimes, and especially lately,
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I'm eating my protein earlier in the day
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because I'm playing around with some of the findings
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related to protein intake early in the day.
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But regardless, I'm eating meat about once a day.
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For me, it's extremely important that any meat
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and that the meat be of the very highest quality.
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for brain health, for mood, et cetera.
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first-time customers can get 20% off
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by going to belcampo.com slash Huberman
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and using the code Huberman at checkout.
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Today's episode is also brought to us by Helix Sleep.
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Helix Sleep makes mattresses and pillows
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that are absolutely second to none.
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I started sleeping on a Helix mattress
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about eight, nine months ago,
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and I've never slept better in my life.
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If you go to the Helix site,
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they have a short two-minute quiz,
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and that quiz asks you questions like,
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do you sleep on your back?
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and they actually have an option to select I don't know.
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This turns out to be really important.
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So let's talk about ADHD,
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attention deficit hyperactivity disorder.
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Let's also talk about focus and attention
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and everybody's ability to focus and attend,
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not just people with ADHD.
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We are also going to talk about tools
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that would allow anyone, whether or not they have ADHD or not
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to enhance their level of concentration and focus.
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Now, ADHD used to be called ADD,
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attention deficit disorder.
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We have record of ADD in the medical literature
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dating back to as early as 1904.
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Now, there's nothing special about 1904.
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That's just the first time that it showed up
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in the standard medical literature.
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We have to believe that ADD, which we now call ADHD,
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existed before 1904 and probably long before 1904.
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Well, because it has a strong genetic component.
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If you have a close relative that has ADHD,
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there's a much higher probability that you will have ADHD.
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And that probability goes up depending on how closely
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related to that person you happen to be.
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So for instance, if you're an identical twin
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and your twin has ADHD,
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there's a very high concordance, as we say,
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a very high probability that you will have ADHD,
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If you have a fraternal twin with ADHD,
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that number goes down a bit in the 50 to 60% range
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If you have a parent with ADHD,
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that number ranges anywhere from 10 to 25% likelihood
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that you will have ADHD if you have two parents
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and so on and so on.
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Okay, so there's a genetic component.
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That genetic component, it turns out,
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relates directly to how specific neural circuits
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in the brain wire up, the chemicals they use
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and the way they use those chemicals,
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a topic that we are going to discuss in depth today.
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Now, if you have a close relative with ADHD,
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that does not mean that you are fated to have ADHD.
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And if you happen to have ADHD,
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there are ways to overcome those symptoms
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of lack of attention, impulsivity, and so on.
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Another important point about ADHD
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is that it has nothing to do with intelligence.
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Whether or not we're talking about intelligence
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measured by a standard IQ test,
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a rather controversial issue as many of you probably know,
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there are lots of forms of intelligence
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that a standard IQ test just wouldn't pick up.
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Emotional intelligence, musical intelligence,
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spatial intelligence, all sorts of intelligences.
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None of them are related to ADHD.
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Being very high functioning doesn't make you more likely
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And being ADHD doesn't necessarily mean
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that you have a low IQ.
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So there are people with ADHD who have low IQs,
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people with ADHD with high IQs,
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people with ADHD with high emotional IQ
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or with low IQ in the emotional scale.
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It's all over the place.
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The important point is that your ability to attend and focus
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does not relate to how smart you are
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or your IQ of any type, not just a standard IQ.
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The renaming of ADD to ADHD
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took place in the mid to late 1980s
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when the psychiatric community
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and the psychological community
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started taking better notice of the fact
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that so-called hyperactive kids also had attentional issues.
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This might seem obvious,
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but there's been extensive and ongoing revision
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of the criteria for designating a psychiatric disorder.
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And this is still an ongoing process, even today.
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So in the mid 80s, we started hearing about ADHD
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and then gradually that term ADD has been dropped away.
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However, just the renaming of ADD to ADHD
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has led to much better diagnosis and detection of ADHD.
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So right now, the current estimates
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are that about one in 10 children
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and probably more have ADHD.
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The current estimates are anywhere from 10%,
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one in 10, to as high as 12%.
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Now, fortunately, about half of those
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will resolve with proper treatment,
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but the other half typically don't.
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The other thing that we are seeing a lot nowadays
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is increased levels of ADHD in adults.
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And there's some question
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as to whether or not those adults had ADHD
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that went undetected during their childhood
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or whether or not ADHD is now cropping up in adulthood
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due to the way that we are interacting with the world.
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In particular, smartphone use,
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the combination of email, text, real world interactions,
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multiple apps and streams of media and social media
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all coming in at once, trying to manage life,
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all of the things that are going on
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are creating a kind of cloud of pulls on our attention.
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And so there is this question
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to whether or not we are creating ADHD in adults
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that never had ADHD prior to being an adult.
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So let's talk about attention.
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And first, let's just define what we mean by attention.
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Out there in the scientific literature
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and in discussions about ADHD,
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we will hear things like attention and focus
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and concentration and impulse control.
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For sake of today's discussion,
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attention, focus and concentration
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are essentially the same thing, okay?
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We could split hairs and the scientific literature
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does split hairs about these,
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but if we want to understand the biology
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and we want to have a straightforward conversation
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about ADHD, if I say attention or focus,
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I'm basically referring to the same thing
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unless I specify otherwise, okay?
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So people with ADHD have trouble holding their attention.
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What is attention?
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Well, attention is perception.
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It's how we are perceiving the sensory world.
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So just a little bit of neurobiology 101,
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we are sensing things all the time.
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There's information coming into our nervous system
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For instance, right now, you're hearing sound waves,
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you are seeing things,
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you are sensing things against your skin,
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but you are only paying attention to some of those.
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And the ones that you're paying attention to
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are your perceptions.
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So if you hear my voice, you are perceiving my voice.
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You are not paying attention to your other senses
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at the moment, okay?
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You might even be outside in a breeze.
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And until I said that,
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you might not be perceiving that breeze,
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but your body was sensing it all along.
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So attention and focus are more or less the same thing,
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but impulse control is something separate
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because impulse control requires pushing out
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or putting the blinders on
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to sensory events in our environment.
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It means lack of perception.
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Impulse control is about limiting our perception.
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Because people with ADHD have poor attention
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and they have high levels of impulsivity.
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They are easily distractible.
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But the way that shows up is very surprising.
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You might think that people with ADHD
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just simply can't attend to anything.
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They really can't focus even if they really want to,
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but that's simply not the case.
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People with ADHD, yes, they are distractible.
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Yes, they are impulsive.
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Yes, they are easily annoyed
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by things happening in the room.
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They sometimes have a high level of emotionality as well.
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Not always, but often.
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However, people with ADHD can have a hyper-focus,
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an incredible ability to focus
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on things that they really enjoy or are intrigued by.
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Now, this is a very important point
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because typically we think of somebody with ADHD
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as being really wild and hyperactive
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or having no ability whatsoever to sit still and attend.
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And while that phenotype, as we call it,
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that contour of behavior and cognition can exist,
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many people, if not all people with ADHD,
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if you give them something they really love,
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like if the child loves video games
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or if a child loves to draw
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or if an adult loves a particular type of movie
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or a person very much,
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they will obtain laser focus without any effort.
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So that tells us that people with ADHD
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have the capacity to attend,
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but they can't engage that attention
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for things that they don't really, really want to do.
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And as we all know, much of life,
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whether or not you're a child or an adult,
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involves doing a lot of things that we don't want to do.
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Much of our schooling involves doing things
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that we would prefer not to do
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and sort of forcing ourselves to do it,
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to attend even though we are not super interested
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in what we are attending to.
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There are a couple other things
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that people with ADHD display quite often.
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One is challenges with time perception.
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Now, time perception is a fascinating aspect
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of how our brain works.
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And later we're going to talk about time perception
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and how you can actually get better at time perception.
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It's very likely that right now you are doing things
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that get in the way of optimal time perception.
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And I will tell you how to adjust your ability
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to measure time with your brain.
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People with ADHD often run late.
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They often procrastinate.
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But what's interesting and surprising
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is that if they are given a deadline,
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they actually can perceive time very well.
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And they often can focus very well
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if the consequences of not completing a task
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or not attending are severe enough.
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It's a little bit like the way that people with ADHD
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can really focus if they like something.
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Well, if they're scared enough
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about the consequences of not attending,
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oftentimes, not always, but oftentimes they can attend.
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If they're not really concerned
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about a deadline or a consequence,
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well, then they tend to lose track of time
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and they tend to underestimate how long things will take.
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Now, many people do that, not just people with ADHD,
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but people with ADHD have challenges
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understanding how to line up the activities of their day
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in order to meet particular deadlines,
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even if it's just a simple thing
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like finishing one set of tasks before lunch.
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Oftentimes, they will remember that lunch starts at noon,
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but somehow they aren't able to fill the intervening time
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in a way that's productive.
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And they can obsess about the upcoming deadline,
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We will talk about how to remedy this.
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In addition, their spatial organization skills
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are often subpar, not always,
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but often you will find that somebody with ADHD
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uses what's called the pile system
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in order to organize things.
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They will take many belongings
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and this could be in the kitchen or in their bedroom
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or in their office or in any space,
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and they will start piling things up
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according to a categorization system
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that makes sense to them and only them.
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It doesn't really have any logical framework.
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Now, many people use the pile system
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and if you use the pile system,
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that doesn't mean that you have ADHD.
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In fact, if you're unpacking a house
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or you've moved recently
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or you've received a lot of presents recently,
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the pile system makes perfect sense to organize your space.
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But people with ADHD tend to organize things
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according to the pile system all the time
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and that pile system doesn't work for them.
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So that's the key distinction,
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that they use a filing system and it's not really files,
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they're piling things up in a way that makes sense to them,
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but then it doesn't work for them
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in terms of what task they actually need to perform.
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They can't find things or if anyone moves one thing,
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then it's very disruptive to their overall plan
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because their overall plan
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doesn't really work in the first place.
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So that's a common phenotype as we call it.
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A phenotype by the way is just an expression
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of a particular set of underlying genetic
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or psychological components, okay?
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So we see the phenotype.
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So a phenotype could be brown hair and green eyes,
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like for me, a phenotype could also be
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that somebody uses the piling system, okay?
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The other thing that people with ADHD have real trouble with
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is so-called working memory.
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Now you might think that people with ADHD
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would have really poor memories,
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but in fact, that's not the case.
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People with ADHD often can have a terrific memory
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they can remember upcoming events quite well,
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their memory is clearly working.
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However, one aspect of memory in particular
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that we call working memory is often disrupted.
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Working memory is the ability
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to keep specific information online,
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to recycle it in your brain over and over again
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so that you can use it in the immediate or short term.
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A good example of this would be you meet somebody,
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they tell you their name,
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they give you their phone number verbally,
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and you have to walk back to your phone
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and enter it into your phone.
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People without ADHD might have to put some effort into it,
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it might feel like a bit of a struggle,
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but typically they would be able to recite
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that phone number in their mind over and over
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and then put it into their phone.
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People with ADHD tend to lose the ability
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or lack the ability to remember things
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that they just need to keep online
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for anywhere from 10 seconds to a minute or two, okay?
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So a string of numbers like six, four, three, seven, eight,
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one for most people would be pretty easy.
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Six, four, three, seven, eight, one,
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six, four, three, seven, eight, one,
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you could probably remember that a minute from now
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without writing it down.
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But if you add one more number
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to that six, four, three, seven, eight, one, three,
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it gets tougher, okay?
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So there's a reason why phone numbers
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typically have seven digits in them.
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Of course, there's an area code,
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but remembering information that strings out longer
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than seven numbers or a sentence or two,
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that's challenging for most people.
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People with ADHD have severe challenges
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even with much smaller batches of information
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over even much smaller batches of time.
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Deficits in working memory are also something
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that we see in people who have frontotemporal dementia,
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so damage to the frontal lobes,
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or age-related cognitive decline.
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And so it will come as no surprise
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that later when we discuss treatments, supplements,
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and other tools for ADHD,
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that many of those treatments, supplements,
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and tools for ADHD are similar to the ones
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that work for age-related cognitive decline.
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Okay, so we've more or less established
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the kind of menu of items
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that people with ADHD tend to have.
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Some have all of them, some have just a subset of them.
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Their severity can range from very intense to mild,
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but in general, it's challenges with attention and focus,
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challenges with impulse control,
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they get annoyed easily, they have kind of an impulsivity,
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they can't stay on task, time perception can be off,
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they use the piling system or a system
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that doesn't work well for them
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in order to organize their things in physical space,
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and they have a hard time with anything that's mundane
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that they're not really interested in.
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But again, I just want to highlight
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that people with ADHD are able
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to obtain heightened levels of focus,
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even hyper-focus for things that are exciting to them
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and that they really want to engage in.
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So now you have the contour of what ADHD is.
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And if you're somebody who doesn't have ADHD,
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you should also be asking yourself
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which aspects of ADHD are similar to things
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I've experienced before,
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because what we know about the healthy brain
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is that there's also a range of abilities to focus.
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Some people focus very well on any task.
link |
You give them a task, they can just laser in on that task.
link |
Other people, they have to kind of fight an internal battle.
link |
They have to convince themselves
link |
that it's important or interesting.
link |
They have to kind of incentivize themselves internally.
link |
Other people, doesn't matter.
link |
They could be bored to tears with the information,
link |
but they can do it just because they are,
link |
quote unquote, very disciplined people.
link |
We tend to admire those people,
link |
but as you'll see a little bit later,
link |
it's not clear that that's the best way
link |
to run your attentional system.
link |
There might be something to this business
link |
of having heightened levels of attention
link |
for the things that you are most interested or excited by.
link |
So let's drill into this issue
link |
of why people with ADHD actually can focus very intensely
link |
on things that they enjoy and are curious about.
link |
Now, enjoyment and curiosity are psychological terms.
link |
They're not even really psychological terms.
link |
They're just the way that we describe our human experience
link |
of liking things, wanting to know more about them.
link |
But from a neurobiological perspective,
link |
they have a very clear identity and signature,
link |
and that's dopamine.
link |
Dopamine is released from neurons.
link |
It's what we call a neuromodulator.
link |
And as a neuromodulator,
link |
it changes the activity of the circuits in the brain
link |
such that certain circuits are more active than others.
link |
And in particular, dopamine creates
link |
a heightened state of focus.
link |
It tends to contract our visual world,
link |
and it tends to make us pay attention
link |
to things that are outside
link |
and beyond the confines of our skin.
link |
It's what we call exteroception.
link |
Dopamine also tends to put us in a state of motivation
link |
and wanting things outside the confines of our skin.
link |
So whether or not we're pursuing something physical
link |
in our world, or whether or not we're pursuing information
link |
in our outside world, dopamine is largely responsible
link |
for our ability and our drive to do that.
link |
But dopamine as a neuromodulator is also involved
link |
in changing the way that we perceive the world.
link |
So as I mentioned earlier,
link |
you have all these senses coming in
link |
and you can only perceive some of them
link |
because you're only paying attention to some of them.
link |
Dopamine, when it's released in our brain,
link |
tends to turn on areas of our brain
link |
that narrow our visual focus and our auditory focus.
link |
So it creates a cone of auditory attention
link |
that's very narrow,
link |
creates a tunnel of visual attention that's very narrow.
link |
Whereas when we have less dopamine,
link |
we tend to view the entire world.
link |
We tend to see the whole scene that we are in.
link |
We tend to hear everything all at once.
link |
So as I describe this,
link |
hopefully you're already starting to see and understand
link |
how having dopamine release can allow a person,
link |
whether or not they have ADHD or not,
link |
to direct their attention to particular things
link |
in their environment, right?
link |
So now what we're doing is we're moving away from attention
link |
as this kind of vague, ambiguous term,
link |
and we're giving it a neurochemical identity, dopamine,
link |
and we are giving it a neural circuit identity.
link |
And just to put a little bit of flavor and detail
link |
on which neurocircuits those are,
link |
I wanted to discuss two general types of neural circuits
link |
that dopamine tends to enhance.
link |
So let's talk neural circuits.
link |
And for those of you that love hearing
link |
neuroscience nomenclature, you're going to eat this part up.
link |
And for those of you that don't like a lot of names
link |
of brain areas, I invite you to tune out
link |
or just try and grab the top contour of this.
link |
I will describe it in pretty general terms,
link |
but I will give some detail,
link |
because I know there are some of you out there
link |
who really want to dig deeper into what the exact structures
link |
and connectivity is are, okay?
link |
So there are two main types of circuits
link |
that we need to think about with respect to ADHD,
link |
attention and dopamine.
link |
The first one is called the default mode network.
link |
The default mode network is the network of brain areas
link |
in your brain and my brain and in everybody's brain
link |
that is active when we're not doing anything,
link |
when we're just sitting there idle at rest.
link |
Now, it's very hard to not think about anything,
link |
but when you're not engaged in any type of specific task,
link |
so you're not driving, you're not playing a video game,
link |
you're not trying to study, you're not trying to listen,
link |
you're just sitting there,
link |
letting your brain kind of go wherever it wants to go,
link |
your default mode network underlies that state of mind.
link |
The other set of circuits that we're going to think about
link |
and talk about with respect to ADHD are the task networks.
link |
The networks of the brain that make you goal-oriented
link |
or that are at least trying to make you goal-oriented.
link |
And those are a completely different set of brain areas.
link |
However, the default mode network and these task networks
link |
are communicating with one another,
link |
and they're doing that in very interesting ways.
link |
So first I want to describe how these two sets
link |
of brain areas, the default mode network
link |
and the task networks normally interact, okay?
link |
So little bit of naming here.
link |
Again, feel free to ignore it
link |
if you don't want this level of detail,
link |
but the default mode network includes an area
link |
called the dorsolateral prefrontal cortex.
link |
Frontal cortex, no surprises in the front,
link |
and you have a dorsal, the top, and side lateral part,
link |
dorsolateral prefrontal cortex.
link |
You got one on each side of your brain, right?
link |
And then you have a brain area
link |
called the posterior cingulate cortex.
link |
And then you have an area called the lateral parietal lobe.
link |
Again, you don't need to remember these names,
link |
but these are three brain areas that normally
link |
are synchronized in their activity.
link |
So when one of these areas is active in a typical person,
link |
the other areas would be active as well.
link |
So it's a little bit like a symphony or a band,
link |
like a three-piece band.
link |
It's like drums, guitar, and bass.
link |
They're playing together, okay?
link |
That's how it is in a typical person,
link |
in a person with ADHD,
link |
or even a person who has subclinical ADHD,
link |
or in any human being who hasn't slept well,
link |
what you find is the default mode network
link |
is not synchronized.
link |
These brain areas are just not playing well together.
link |
Now, the task networks include
link |
a different set of structures.
link |
It still involves the prefrontal cortex,
link |
but it's a different part of the prefrontal cortex, okay?
link |
Tends to be the medial prefrontal cortex.
link |
And there are some other brain areas
link |
that the medial prefrontal cortex
link |
is communicating to all the time,
link |
mainly to suppress impulses.
link |
It's shutting down the desire to stand up
link |
or to scratch the side of your cheek or your nose
link |
if you're trying not to do that.
link |
Anytime you're restricting your behavior,
link |
these task-directed networks are very active, okay?
link |
Now, normally, in a person without ADHD,
link |
the task networks and the default mode networks
link |
are going in kind of seesaw fashion.
link |
They are actually what we call anti-correlated.
link |
So it's not just that they are not correlated.
link |
They are actually opposing one another.
link |
They are anti-correlated.
link |
In a person with ADHD, the default mode networks
link |
and the task networks are actually more coordinated.
link |
That might come as surprising.
link |
I think that we all have this tendency
link |
to kind of jump to conclusion
link |
and assume that somebody who doesn't have
link |
an easy time paying attention or has ADHD,
link |
that their brain must be completely incoherent,
link |
that it's not working well
link |
because everything's out of whack.
link |
But there's something interesting about people with ADHD
link |
whereby the task networks and the default mode networks
link |
are actually working together in a way that's correlated,
link |
and that is what's abnormal.
link |
So this would be like the guitar, bass, and the drums
link |
playing together in a way
link |
where the bass isn't keeping the backbeat
link |
and the drums aren't keeping the backbeat,
link |
that they're playing together,
link |
they're all playing the melodies and harmonies
link |
in a way that just doesn't sound right.
link |
That's what's going on in the brain of somebody with ADHD.
link |
And we can now confidently say,
link |
based on brain imaging studies,
link |
that when somebody gets better
link |
when they're treated for ADHD
link |
or when they age out of ADHD, as sometimes is the case,
link |
that the default mode networks and the task networks
link |
tend to become anti-correlated again, okay?
link |
So that's the underlying neurobiology,
link |
but you'll notice that I didn't mention dopamine at all.
link |
What dopamine is doing in this context
link |
is dopamine is acting like a conductor.
link |
Dopamine is saying this circuit should be active,
link |
then that circuit should be active.
link |
It should be default mode network,
link |
and then when the default mode network is not active,
link |
then it should be the task network.
link |
So it's really acting as a conductor saying,
link |
you go, now you go, now you go, now you go.
link |
And in ADHD, there's something about the dopamine system
link |
that is not allowing it to conduct these networks
link |
and make sure that they stay what the engineers
link |
or physicists or mathematicians would say out of phase
link |
to be anti-correlated, okay?
link |
Out of phase and anti-correlated,
link |
essentially the same thing,
link |
at least for purposes of this discussion.
link |
So that raises two questions.
link |
Could it be that dopamine is not at sufficiently high levels
link |
or could it be that dopamine is just doing it all wrong?
link |
In other words, is there no conductor
link |
or is the conductor playing with little tiny toothpicks
link |
and so the instruments can't see what they're supposed to do
link |
they can't get the instruction
link |
because it's just not loud enough, so to speak,
link |
or could it be that the information is getting out
link |
but the information that's getting out is wrong.
link |
The conductor is there
link |
but the conductor isn't very good at conducting.
link |
Now we can gain insight into how this system works and fails
link |
and how to treat it by looking at some of the current
link |
and previous treatments for ADHD,
link |
as well as some of the recreational drugs
link |
that people with ADHD tend to pursue and like.
link |
Now I'm certainly not a proponent of people with ADHD
link |
taking drugs recreationally, that's not what this is about.
link |
But if you look at their drug seeking behavior
link |
and you couple that drug seeking behavior
link |
to their desire to remedy their attention deficit,
link |
you start getting some really interesting insight
link |
into how dopamine is regulating these circuits
link |
in normal circumstances and in people with ADHD.
link |
So what exactly is going on with the dopamine system
link |
in people with ADHD?
link |
And what's going on with the dopamine system
link |
in people that have terrific levels of attention
link |
Well, in the year 2015, an important paper came out,
link |
the first author is Spencer
link |
and it came out in a journal called Biological Psychiatry
link |
and it formalized the so-called low dopamine hypothesis
link |
The idea that dopamine was somehow involved
link |
or not at the appropriate levels in people with ADHD
link |
had been around for a pretty long time,
link |
but a formal proposition of the low dopamine hypothesis
link |
led to some really important experiments and understanding
link |
of what goes wrong in ADHD.
link |
It turns out that if dopamine levels are too low
link |
in particular circuits in the brain,
link |
that it leads to unnecessary firing of neurons in the brain
link |
that are unrelated to the task that one is trying to do
link |
and that is unrelated to the information
link |
that one is trying to focus on.
link |
So if you think back before,
link |
you've got this default mode network
link |
and a task-related network and they need to be
link |
in this kind of concert of anti-correlation and an ADHD,
link |
they're firing together.
link |
Well, the problem seems to be that when dopamine is low,
link |
certain neurons are firing when they shouldn't be.
link |
This is like a band, right?
link |
We'll go back to our band, that's a guitar, a bass
link |
and a person playing the drums.
link |
And it's as if one of those or several of those instruments
link |
are playing notes when they shouldn't be playing, right?
link |
The pauses in music are just as important
link |
as the actual playing of notes.
link |
When dopamine is too low, neurons fire more than they should
link |
in these networks that govern attention.
link |
This is the so-called low dopamine hypothesis.
link |
And if you start looking anecdotally
link |
at what people with ADHD have done for decades,
link |
not just recently since the low dopamine hypothesis
link |
has been proposed, but what they were doing in the 1950s
link |
and in the 1940s and the 1960s,
link |
what you find is that they tend to use recreational drugs
link |
or they tend to indulge in non-drug stimulants.
link |
So things like drinking six cups of coffee
link |
or quadruple espressos, or when it was more prominent,
link |
smoking a half a pack of cigarettes
link |
and drinking four cups of coffee a day.
link |
Or if the person had access to it,
link |
using cocaine as a recreational drug
link |
or amphetamine as a recreational drug,
link |
all of those substances that I just described,
link |
in particular cocaine and amphetamine,
link |
but also coffee and cigarettes,
link |
increased levels of multiple neurotransmitters,
link |
but all have the quality of increasing levels of dopamine
link |
in the brain and in particular in the regions of the brain
link |
that regulate attention and these task-related
link |
and default mode networks, okay?
link |
Now, young children fortunately don't have access
link |
to those kinds of stimulants.
link |
And those stimulants all have high potential
link |
for abuse in adults.
link |
So we will talk about the potential for abuse
link |
But if you look at children,
link |
even very young children with ADHD,
link |
they show things like preference for sugary foods,
link |
which also act as dopamine inducing stimulants.
link |
Now, of course, once they get access to soda pop
link |
and coffee and tea, they start to indulge in those
link |
more than other people.
link |
For a long time, it was thought that children with ADHD
link |
consumed too many sugary foods or drank too much soda,
link |
or adults with ADHD would take recreational drugs
link |
like methamphetamine or cocaine,
link |
or would drink coffee to excess
link |
or smoke cigarettes to excess
link |
because they had poor levels of attention
link |
and because they couldn't make good decisions,
link |
they were too impulsive and so forth.
link |
And while that certainly could be the case,
link |
knowing what we now know about dopamine
link |
and the fact that having enough dopamine is required
link |
in order to coordinate these neural circuits
link |
that allow for focus and quality decision-making,
link |
an equally valid idea is that these children
link |
and these adults are actually trying to self-medicate
link |
by pursuing these compounds, right?
link |
Things like cocaine lead to huge increases in dopamine.
link |
Well, what happens when somebody with ADHD takes that drug?
link |
It turns out they actually obtain heightened levels
link |
of focus, their ability to focus on things
link |
other than things they absolutely care intensely about
link |
Likewise, children who consume anything
link |
that increases their levels of dopamine,
link |
if those children have ADHD, they tend to be calmer.
link |
They tend to be able to focus more.
link |
Now, this is very different than children
link |
who do not have ADHD.
link |
When they consume too much sugar,
link |
they tend to become super hyperactive.
link |
When they consume any kind of stimulant,
link |
they tend to go wild and run around like crazy.
link |
I actually have an anecdote about this
link |
just to illustrate it.
link |
I have a friend, he has two children
link |
that are now in their teens and 20s,
link |
but when they were little,
link |
one time I brought them some chocolate just as a gift
link |
when I showed up at their house.
link |
And within 30 minutes,
link |
the kids were running around like crazy.
link |
I mean, they were pretty high energy kids,
link |
but they were going bonkers.
link |
And that's actually when the mother,
link |
my friend at the time, unfortunately still now,
link |
looked at the chocolate
link |
and realized that it was chocolate with espresso beans
link |
and it was like dark chocolate espresso beans.
link |
So I was really at fault there.
link |
You don't want to give kids
link |
dark chocolate with espresso beans,
link |
but what you're really seeing in that hyperactivity,
link |
that is dopamine, okay?
link |
It's the sugar combined with the caffeine in this case,
link |
combined with a few other compounds that exist in chocolate
link |
that really increase our levels of alertness
link |
and our tendency to want to move around a lot.
link |
Okay, so dopamine and low levels of dopamine
link |
apparently are what's wrong in people with ADHD.
link |
That dopamine hypothesis is what led to the idea
link |
that treating people, children and adults included,
link |
with dopaminergic compounds
link |
would somehow increase their ability to focus.
link |
And if you look at the major drugs that were developed
link |
and now marketed by pharmaceutical companies
link |
for the treatment of ADHD,
link |
those drugs have names like Ritalin.
link |
Nowadays, it's typically things like Adderall,
link |
Modafinil, and some of the other derivatives,
link |
they all serve to increase levels of dopamine,
link |
in particular dopamine in the networks
link |
that control task-directed behavior
link |
and that coordinate the default mode network
link |
and these task-related networks.
link |
So many of you have probably heard of Ritalin.
link |
Ritalin is a prescription stimulant
link |
that is prescribed for ADHD as well as for narcolepsy.
link |
Narcolepsy is a condition
link |
in which people tend to fall asleep during the daytime
link |
quite a lot, excessive daytime sleepiness,
link |
not due to lack of sleep at night,
link |
but also tend to fall asleep when they get excited.
link |
If they're really emotionally excited or about to eat
link |
or any other kind of activity
link |
that would normally get somebody really aroused and alert,
link |
people with narcolepsy tend to fall asleep
link |
or they tend to become what's called cataplectic.
link |
They tend to just sort of go limp in the muscles.
link |
So it's this invasion of sleep into the daytime.
link |
It's dysregulated by emotion.
link |
You can imagine why a stimulant,
link |
something that would wake you up,
link |
make you very alert, focused, and motivated
link |
would be a good treatment for narcolepsy.
link |
Adderall also is used to treat ADHD
link |
and to treat narcolepsy.
link |
Things like modafinil also used to treat ADHD
link |
So you're sensing a theme here.
link |
So what are the differences and similarities
link |
between these drugs?
link |
And what can that tell us about ADHD?
link |
Well, Ritalin was one of the first-generation drugs
link |
that was prescribed for ADHD
link |
in order to deal head-on with this dopamine hypothesis,
link |
this idea that in ADHD, dopamine levels are too low.
link |
Nowadays, Adderall is the more typically prescribed drug
link |
That has to do with some of the so-called pharmacokinetics,
link |
the rate at which those drugs enter the system
link |
and how long they last in the system.
link |
So for instance, Ritalin was a drug that was packaged
link |
into various time-release formulas,
link |
whereas initially Adderall was only released in a form
link |
that had a very short life,
link |
so meaning that it wasn't in the bloodstream very long
link |
and didn't affect the brain for very long.
link |
And so the dosages could be controlled
link |
in a more typical way
link |
without going into a lot of tangential detail.
link |
As you all know, at different times of day,
link |
you tend to be more or less alert.
link |
So a long sustained release drug
link |
while that might sound like a really terrific thing,
link |
if that drug is having an effect of making you more alert
link |
and it's released across very many hours of your day,
link |
there might be periods of your day when you feel too alert,
link |
periods of your day when you feel just right
link |
and periods of your day
link |
when you wished that you were more alert.
link |
These are some of the pharmacokinetics,
link |
kinetics meaning movement of the different compounds
link |
within the bloodstream and brain that could,
link |
you could imagine in a very real way would impact
link |
whether or not someone would feel really good
link |
on one of these drugs
link |
or whether or not they would feel too anxious
link |
or too sleepy and so on.
link |
Let's take a step back for a second
link |
and just ask what are these drugs?
link |
We know they increase dopamine, but what are they really?
link |
Well, Ritalin also called methylphenidate
link |
is very similar to amphetamine, speed
link |
or what's typically called speed
link |
in the street drug nomenclature.
link |
Adderall, which goes by various other names, okay?
link |
So Adderall, Adderall XR, Midacis, things like that.
link |
Adderall is basically a combination of amphetamine
link |
and dextro amphetamine.
link |
Now, some of you probably realize this
link |
that Adderall is amphetamine,
link |
but I'm guessing that there are a good number
link |
of you out there, perhaps even parents and kids
link |
that don't realize that these drugs like cocaine
link |
and amphetamine, methamphetamine,
link |
which are incredibly dangerous
link |
and incredibly habit forming
link |
and have high potential for abuse.
link |
Well, the pharmaceutical versions of those
link |
are exactly what are used to treat ADHD.
link |
Now, they're not exactly like cocaine or methamphetamine,
link |
but they are structurally and chemically very similar
link |
and their net effect in the brain and body
link |
is essentially the same,
link |
which is to increase dopamine primarily,
link |
but also to increase levels of a neuromodulator
link |
called epinephrine or norepinephrine,
link |
also called noradrenaline and adrenaline.
link |
Those names are the same.
link |
And to some extent, to increase levels of serotonin
link |
in the brain and blood, but not so much serotonin,
link |
that's just kind of a small smidgen of effect, okay?
link |
So dopamine way up, norepinephrine and adrenaline way up.
link |
So that's motivation, drive, focus, and energy.
link |
And to some extent, a little bit of serotonin,
link |
which is really more about feeling calm and relaxed.
link |
And you could imagine why
link |
that would be a good balancing effect
link |
for dopamine and norepinephrine.
link |
So what I'm essentially saying
link |
is that the drugs that are used to treat ADHD are stimulants
link |
and they look very much like, in fact,
link |
nearly identical to some of the so-called
link |
street drug stimulants that we all hear are so terrible.
link |
However, I do want to emphasize
link |
that at the appropriate dosages
link |
and working with a quality psychiatrist
link |
or neurologist or family physician,
link |
it does have to be a board certified MD
link |
that prescribes these things,
link |
many people with ADHD achieve excellent relief
link |
with these drugs, not all of them, but many of them do,
link |
especially if these treatments are started early in life.
link |
So now knowing what these drugs are,
link |
I want to raise the question of why prescribe these drugs?
link |
I mean, everyone has to make a decision for themselves
link |
or for their child as to whether or not
link |
they're going to take these things or not.
link |
I also want to acknowledge that many people out there,
link |
many, many people out there are taking these drugs
link |
even though they have not been clinically diagnosed
link |
And when I say these drugs,
link |
I'm specifically referring to Ritalin and Adderall
link |
and Modafinil, but more typically it's Adderall, okay?
link |
People using cocaine and amphetamine
link |
for recreational purposes,
link |
that's a completely different beast
link |
and it is indeed a beast
link |
and it's something that I strongly discourage.
link |
However, I am aware that up to 25% of college students
link |
and perhaps as many as 35% of all individuals
link |
between the ages of 17 and 30 are taking Adderall
link |
on a regular or semi-regular basis in order to work,
link |
in order to study and in order to function
link |
and focus in their daily life,
link |
even though they have not been diagnosed with ADHD.
link |
There's a whole black market for this,
link |
they're getting it from people with prescriptions.
link |
I'm not here to pass judgment,
link |
I just want to emphasize how these drugs work,
link |
some of the things that they do to enhance cognition
link |
and focus that actually serve the brain well
link |
in certain individuals
link |
and how they can be very detrimental in other individuals.
link |
I sort of blew right past it,
link |
but the fact that in upwards of 25% of young people
link |
are taking things like Adderall,
link |
despite not having a clinical diagnosis of ADHD,
link |
well, that's a ridiculously high number.
link |
it was estimated that Adderall use and Ritalin use
link |
without diagnosis of ADHD
link |
was second in incident only to cannabis,
link |
but actually now the consumption of Adderall
link |
without prescription is higher than the consumption
link |
of cannabis in that age group.
link |
So what that means is that there's a lot of stimulant use
link |
in that age group.
link |
And there are a lot of adults also
link |
using and abusing stimulants in order to gain focus.
link |
Then we could have a whole discussion
link |
about whether or not life is becoming more demanding,
link |
whether or not the need for focus is excessive
link |
and that's why people are doing that.
link |
Frankly, it's an interesting discussion,
link |
but it's not one that would deliver us to any answers.
link |
Rather, I'd like to focus on the ways that people now
link |
and people have always been self-medicating
link |
to increase focus, right?
link |
Caffeine, which I indulge some, I don't think to access,
link |
has long been used as a stimulant to increase dopamine,
link |
increase norepinephrine, increase focus and energy.
link |
And in addition to that,
link |
it works through the so-called cyclic AMP,
link |
phosphodiesterase pathway.
link |
Remember, anytime you hear an ASE, that's an enzyme.
link |
Phosphodiesterase is involved in the conversion
link |
of things like cyclic AMP into energy for cells and so forth.
link |
Basically, coffee gives you energy, it makes you feel good.
link |
And it increases focus because of the circuits
link |
that it engages in the brain.
link |
People have been taking caffeine
link |
and continue to take caffeine for ages.
link |
People also used to smoke cigarettes, nicotine,
link |
in order to gain focus.
link |
Nowadays, that's less common because of the concerns,
link |
quite valid concerns about lung cancer from smoking,
link |
but there's a lot of vaping out there.
link |
There are a lot of people now consuming nicotine,
link |
which is the active substance in cigarettes
link |
and in most nicotine vapes,
link |
that stimulates the brain to be more focused and more alert.
link |
So the idea of taking stimulants,
link |
of consuming things or smoking things
link |
in order to increase alertness is not a new idea.
link |
It's just that in ADHD,
link |
it's surprising that these things would work, right?
link |
I mean, if the problem is attention deficit
link |
hyperactivity disorder,
link |
what we're really talking about here
link |
or children that are prescribed a drug
link |
that ought to be a stimulant,
link |
it ought to make them hyper hyperactive.
link |
And rather than doing that,
link |
it actually somehow serves to calm them a bit
link |
or at least allow them to focus.
link |
Here's the reason.
link |
Children have a brain that's very plastic,
link |
meaning it can remodel itself and change in response
link |
to experience very, very quickly compared to adults.
link |
Taking stimulants as a child,
link |
if you are a child diagnosed with ADHD,
link |
allows that forebrain task-related network
link |
to come online, to be active at the appropriate times.
link |
And because those children are young,
link |
it allows those children to learn what focus is
link |
and to sort of follow or enter that tunnel of focus.
link |
Now, by taking a drug, it's creating focus artificially.
link |
It's not creating focus
link |
because they're super interested in something.
link |
It's chemically inducing a state of focus.
link |
And let's face it, a lot of childhood and school
link |
and becoming a functional adult
link |
is about learning how to focus
link |
even though you don't want to do something.
link |
In fact, when I was in college,
link |
I had this little trick that may or may not work
link |
for some of you, which is if I couldn't focus
link |
on the material I was trying to learn,
link |
I would delude myself into thinking
link |
that it was the most interesting thing in the world.
link |
I would just kind of lie to myself and tell myself,
link |
okay, this, I won't mention the subjects.
link |
I absolutely love this.
link |
I would just, I would tell myself that I loved it.
link |
And I noticed that just that selective
link |
or deliberate engagement of that desire to know circuit,
link |
whatever that is in my brain, no doubt involves dopamine,
link |
allowed me to focus and remember the information.
link |
And somewhat surprisingly, or perhaps not surprisingly,
link |
I would often fall in love with the information.
link |
I find that that was my favorite class.
link |
It was what I wanted to learn the most.
link |
So that's one way you can do it artificially,
link |
but kids with ADHD, they can't do that, right?
link |
They're told to sit still
link |
and they end up getting up 11 times.
link |
You know, they are told that they can't speak out in class
link |
or that they have to remain in their seats for 10 minutes.
link |
And they just, despite their best effort,
link |
they simply cannot do it.
link |
They're highly distractible.
link |
So what are we to make of this whole picture
link |
that we need more dopamine, but these kids with ADHD,
link |
they're getting their dopamine by way of a drug,
link |
which is for all the world, amphetamines, right?
link |
That's really what it is.
link |
What are the long-term consequences?
link |
What are the short-term consequences?
link |
And what should we make of people taking these drugs
link |
without a clinical need?
link |
What are the consequences there?
link |
Well, in order to get to some of those answers,
link |
I went to one of my colleagues.
link |
This is a colleague that I've actually known
link |
for a very long time.
link |
I was their teaching assistant
link |
when they were an undergraduate.
link |
They went on to get an MD, a medical degree,
link |
as well as a PhD and have become a pediatric neurologist
link |
that specializes in the treatment of epilepsy
link |
and ADHD in kids of all ages, from age three to 21.
link |
That's the age range, pretty broad age range,
link |
and has extensive knowledge in this.
link |
And what makes them particularly interesting
link |
for sake of this discussion is that they have a child,
link |
a young boy, who's now showing signs of ADHD,
link |
and they are on the threshold of trying to decide
link |
whether or not they will prescribe Adderall
link |
or something similar.
link |
So we had a discussion about this.
link |
And prior to learning that their child may have ADHD,
link |
I asked the following questions.
link |
First of all, I asked,
link |
what do you think about giving young kids amphetamine?
link |
And their answer was, you know, on the face of it,
link |
but provided that the lowest possible dose is used
link |
and that that dosage is modulated as they grow older
link |
and develop those powers of attention,
link |
their observation was that they've seen more kids benefit
link |
than not benefit from that.
link |
Now, I'm certainly not saying what people should do.
link |
You obviously have to go to a doctor,
link |
because as I always say, I'm not a doctor.
link |
I don't prescribe anything.
link |
I'm a professor, so I profess things.
link |
And here I'm professing that you talk to your doctor
link |
if you're considering giving Ritalin or Adderall
link |
or any type of stimulant to your child, of course.
link |
What could be more important than the health of your child?
link |
But it was a very interesting answer
link |
because typically we hear, yes, medicate or don't medicate.
link |
Rarely do we hear that the medication should be adjusted
link |
across the lifespan and in any particular kind of way.
link |
Now, the fact that this person,
link |
this now friend of mine and colleague of mine
link |
has so much expertise in the way that the brain works
link |
and is considering putting their child on such medication,
link |
why wouldn't you wait until your kid reaches puberty?
link |
I mean, we know that in boys and in girls,
link |
there are increases in testosterone and estrogen
link |
during puberty that dramatically change
link |
the way that the body appears,
link |
but also that dramatically changed the way
link |
that the brain functions.
link |
In particular, we know this,
link |
that puberty triggers the activation
link |
of so-called frontotemporal task-related
link |
executive functioning.
link |
That's just fancy science speak for being able to focus,
link |
being able to direct your attention,
link |
being able to control your impulses.
link |
Look at a small child or look at a puppy
link |
and then look at an older child
link |
or look at a dog, very different levels,
link |
patterns of spontaneous behavior.
link |
Young children move around a lot.
link |
They're, I don't want to say shifty
link |
because that makes it sound like
link |
they're up to something bad, which they might be,
link |
but they don't have to be up to something bad.
link |
They fidget a lot, so do puppies.
link |
Everything's a stimulus.
link |
As animals and humans get older,
link |
they learn how to control their behavior and sit still,
link |
listen and focus, even if they don't want to.
link |
So giving a drug that allows a child
link |
to access that stillness early on,
link |
it's thought will allow them to maintain
link |
that ability as time goes on.
link |
But I decided to push a little bit further.
link |
I said, well, why would you do it now
link |
as opposed to during puberty or after puberty?
link |
And their answer was very specific
link |
and I think very important.
link |
What they said was, look,
link |
neuroplasticity is greatest in childhood
link |
and tapers off after about age 25,
link |
but neuroplasticity from age three
link |
until age 12 or 13 is exceedingly high.
link |
And they're right.
link |
When you sit back and you look
link |
at the literature on neuroplasticity,
link |
you'd say childhood plasticity and young adult plasticity
link |
is much greater than adult plasticity,
link |
but that early childhood plasticity is far and away
link |
the period in which you can reshape the brain
link |
at an accelerated rate.
link |
So this lines up really well with the clinical literature.
link |
Not surprisingly, they're a clinician.
link |
That early treatment is key.
link |
If you have the opportunity to work with a quality physician
link |
and treat these things early,
link |
these drugs can allow these frontal circuits,
link |
these task-related circuits,
link |
to achieve their appropriate levels of functioning
link |
and for kids to learn how to focus
link |
in a variety of different contexts.
link |
Now, is that the only thing that they should be doing?
link |
So the next question I asked was,
link |
what should we make of all this diet-related stuff, right?
link |
I've heard before that the so-called elimination diet
link |
or ingesting no sugars or no dairy or no gluten,
link |
that all of these things have been purported
link |
to improve symptoms of ADHD.
link |
And people and parents with ADHD go to fanatic lengths
link |
to try and find the exact foods that are causing problems
link |
and the exact foods that the kids can eat
link |
in order to try and get their brain wired up right
link |
and correctly and to avoid lifelong ADHD.
link |
And their answer was really interesting.
link |
But before I tell you their answer,
link |
I want to tell you the studies and the data
link |
related to this question of whether or not food
link |
and the constellation of foods that one avoids and will eat
link |
has anything to do with our levels of attention,
link |
and in particular, whether or not that can be used
link |
as a leverage point to treat ADHD.
link |
So you can imagine the challenges of exploring the role
link |
of diet and nutrition in any study,
link |
but especially in a study on ADHD.
link |
Well, because as I mentioned before,
link |
children with ADHD and it turns out adults with ADHD
link |
tend to pursue sugary foods or any types of food
link |
that increase their levels of dopamine.
link |
They are naturally drawn to those foods,
link |
whether or not they realize it or not,
link |
presumably as a way to try and treat
link |
their lack of focus and impulsivity.
link |
So in this study that I'm about to share with you,
link |
there was no drug treatment.
link |
It was just a study manipulating diet
link |
and involved a hundred children,
link |
50 in the so-called elimination diet group,
link |
the special diet where certain foods were eliminated
link |
and 50 in the so-called control group.
link |
However, being a well-designed randomized controlled trial,
link |
the study also included a crossover,
link |
meaning where the kids would serve as their own control
link |
or control group at a certain portion of the studies.
link |
They would be in one group
link |
where they eliminated certain foods.
link |
And then after a period of time in the study,
link |
they would swap to the other group.
link |
This is a powerful way to design a study
link |
for reasons that you can imagine
link |
because you start to eliminate changes and effects
link |
due to individual differences.
link |
In any case, a hundred children total,
link |
50 in each group at any one period in time.
link |
And the effects that they observed were extremely dramatic.
link |
In the world of statistics and analysis of scientific data,
link |
we talk about P values, probability values.
link |
What's the likelihood that something could happen
link |
according to chance?
link |
And typically the cutoff would be
link |
something like P less than 0.05.
link |
That's less than 0.05 chance essentially
link |
of the effect being due to chance.
link |
However, in this study,
link |
every single one of the effects is P less than 0.0001.
link |
Very, very infinitesimally small probability
link |
that the effect observed could be due to chance.
link |
So what were these effects?
link |
These effects were enhanced ability to focus,
link |
less impulsivity, even less tendency to move
link |
when trying to sit still.
link |
So everything from mental focus
link |
to the ability to control their bodies improved
link |
when they were in the elimination diet group.
link |
What was eliminated?
link |
Well, the elimination diet in this particular study
link |
was a so-called oligoantigenic diet.
link |
It was a diet in which each kid took a test
link |
to determine which foods they had antibodies for,
link |
meaning that they were mildly allergic to.
link |
Now, in this study, it was very important
link |
that the kids not be extremely allergic to any food
link |
because as I mentioned before,
link |
they actually served as a control at one point in the study
link |
where they were eating all sorts of foods,
link |
including foods that they had mild allergies to.
link |
So basically what this study said
link |
was that eliminating foods to which children have allergies
link |
can dramatically improve their symptoms of ADHD.
link |
And this study, not surprisingly,
link |
because it was published in such a high quality journal,
link |
Lancet, et cetera, large number of subjects,
link |
set the world on fire.
link |
People were extremely excited about these results
link |
because here in the absence of any drug treatment,
link |
there was a significant improvement
link |
in ADHD symptoms observed.
link |
And then came the criticisms.
link |
So many papers were published after this,
link |
specifically dealing with reanalysis of these data.
link |
And I want to be fair in saying that
link |
the data in the paper look good,
link |
but there are criticisms of the overall
link |
structural design in the study.
link |
I don't want to go into all the details exactly
link |
because it gets really nuanced about some of the statistics
link |
and the way that one examines these types of data,
link |
but there was skepticism.
link |
And in science, skepticism is healthy,
link |
especially when making decisions about
link |
whether or not to treat or feed children one food or another
link |
or give them one drug or another.
link |
Now I want to return to the story of my friend
link |
who is a pediatric neurologist and treats ADHD
link |
and has a child who is on the precipice
link |
of perhaps starting to take drugs
link |
for the treatment of ADHD.
link |
I asked the simple question,
link |
do you see an effect of diet?
link |
Meaning when parents control the diet of their children,
link |
does it make a positive or negative or no difference
link |
in terms of the way that the kids respond to ADHD drugs
link |
like Ritalin and Adderall,
link |
or whether or not it can help them avoid
link |
treating with those drugs entirely?
link |
And her response was very straightforward.
link |
She said, elimination of simple sugars
link |
has a dramatic and positive effect.
link |
She's observed that over and over and over again
link |
in many dozens, if not hundreds of patients, okay?
link |
Now that's not a peer reviewed study.
link |
That's a statement that I'm conveying to you anecdotally,
link |
but it's a highly, highly informed one.
link |
I said, what about these elimination diets?
link |
She said, and I found other sources to support this,
link |
that these oligo-antigenic diets are controversial.
link |
There are many people who really believe
link |
in identifying all the things that you're allergic to
link |
and making sure that you and especially your kids
link |
avoid those foods.
link |
However, there's another camp that's starting to emerge
link |
in the peer reviewed scientific literature
link |
showing that when kids are not exposed to certain foods,
link |
in particular nuts and things of that sort,
link |
they develop allergies to those foods.
link |
And then when exposed to them later,
link |
they cause real problems.
link |
So there's a whole galaxy of discussion and controversy
link |
and outright fighting about allergies in kids
link |
and whether or not the oligo-antigenic diet is the one.
link |
However, out of the four neurologists and psychiatrists
link |
that I spoke to about ADHD in preparation for this,
link |
every single one said,
link |
children with ADHD as much as possible
link |
should be encouraged to avoid high sugar
link |
and simple sugar foods of most kinds.
link |
And if they can find particular foods
link |
that exacerbate their symptoms,
link |
obviously eliminating those foods is beneficial.
link |
And the foods that exacerbate their symptoms
link |
So I don't like giving a complicated answer,
link |
but I also don't like giving an incomplete answer.
link |
What this tells me is that children,
link |
and especially young children who have ADHD
link |
should probably not eat much sugar,
link |
in particular simple sugars.
link |
In addition to that,
link |
exploring whether or not they have existing allergies
link |
to foods they already consume
link |
might be a good idea.
link |
At least that's what this paper,
link |
the Pelser et al. Lancet paper seems to speak to.
link |
And I should mention that that paper was published in 2011.
link |
Since then, there have been many dozens of studies
link |
exploring the same thing,
link |
as well as meta-analyses of all those data.
link |
And it does appear that diet can have
link |
a highly significant role in eliminating
link |
or at least reducing the symptoms of ADHD.
link |
So much so that some of the children
link |
are able to not take medication at all
link |
or eventually wean themselves off medication
link |
as young adults and as adults.
link |
One interesting question is whether or not adults
link |
should modify their diet
link |
in order to increase their levels of focus
link |
if they're already having normal levels of focus,
link |
but would like more,
link |
or would like to reduce existing adult ADHD.
link |
That's an interesting and even more controversial topic.
link |
It brings us right into the realm
link |
of what are called omega-3 fatty acids.
link |
I've talked many times on this podcast
link |
about the known benefits of omega-3 fatty acids,
link |
in particular, getting one gram, 1,000 milligrams or more,
link |
even as much as 2,000 milligrams each day
link |
of the so-called EPA component of omega-3 fatty acids,
link |
known to have antidepressant effects,
link |
mood elevating effects,
link |
known to have important effects
link |
protecting the cardiovascular system.
link |
I think it's now clear
link |
that the immune system also benefits
link |
that omega-3 fatty acids
link |
that include a gram or more of EPAs are very beneficial.
link |
Typically, that's done through fish oil.
link |
Liquid fish oil is going to be the most cost efficient,
link |
but there are capsule forms.
link |
For those of you that don't like fish oil,
link |
you can ingest this through other means.
link |
You can get it from certain algaes or krill, et cetera.
link |
You have to make it compatible with your particular diet,
link |
whether or not you're vegan or vegetarian
link |
or omnivore, et cetera.
link |
Omega-3s have been shown
link |
to have all these positive health benefits.
link |
Do they have positive effects on focus and attention?
link |
And the answer is,
link |
you can find studies that support that statement,
link |
and the effects are significant,
link |
but the effects are modest.
link |
You can also find studies that show no effect.
link |
However, much like with omega-3s and antidepressants,
link |
whereby ingestion of omega-3 fatty acids
link |
of a gram or more of EPA per day
link |
allows people with major depression
link |
to get away with taking lower doses
link |
of antidepressant medication,
link |
it does seem that ingestion of omega-3 fatty acids
link |
in adults that include EPAs of 1,000 milligrams or more
link |
can allow adults with ADHD
link |
or mild attention deficit issues
link |
to function well on lower doses of medication,
link |
and in rare cases to eliminate medication entirely.
link |
So what this says is once again
link |
that the omega-3 fatty acids are beneficial.
link |
Will they cure or eliminate ADHD?
link |
I think it's safe to say no.
link |
They are playing a supportive
link |
or what we call a modulatory role.
link |
Just like good sleep plays a supportive and modulatory role
link |
for essentially everything,
link |
your immune system, your ability to think,
link |
your ability to regulate your emotion,
link |
it's modulating that process.
link |
This component of modulation
link |
is extremely important to highlight.
link |
And I think I want to spend a moment on it
link |
because this is especially important
link |
in the context of ADHD
link |
and all the information that's out there.
link |
There are biological processes that are mediated
link |
by particular compounds like dopamine.
link |
So for instance, the ability to feel motivated
link |
to attend, to focus,
link |
is mediated by the circuits in the brain
link |
that release dopamine.
link |
However, attention is also modulated by how rested you are.
link |
If you want to eliminate your ability to think well at all,
link |
just stay up for two nights and don't sleep at all, right?
link |
If you do that, you will have modulated the circuits
link |
in your brain that respond to various things
link |
and you will be highly distractible.
link |
You will be highly emotional.
link |
You will feel like garbage,
link |
but that doesn't mean that sleep mediates focus
link |
and attention, it modulates it indirectly.
link |
Likewise, I think these omega-3 fatty acids,
link |
in particular the EPAs,
link |
which are so beneficial for mood
link |
and apparently also for attention,
link |
they don't directly mediate attention and mood.
link |
What they do is they modulate those circuits.
link |
They make dopamine more available.
link |
They make whatever dopamine is available
link |
more likely to bind to the various receptors
link |
that are present on neurons and so forth.
link |
And I think this is very important
link |
because likewise diet and any discussion about nutrition
link |
has to include this framework of is the diet,
link |
the elimination diet,
link |
or whether or not it's some other diet
link |
or esoteric diet, ketogenic diet,
link |
is it modulating or mediating a process?
link |
And most likely in the context of ADHD,
link |
it's modulating that process.
link |
So if the ADHD is mild or if it's caught early enough,
link |
or if it's in conjunction with pharmacology
link |
with a prescription treatment,
link |
well, then it might help guide the child or adult
link |
to a better place of being able to focus.
link |
But it's not going to be the switch that flips everything.
link |
Now, that does not mean that consuming the wrong foods,
link |
sugary foods or foods that you happen to be allergic to
link |
It will still be detrimental.
link |
So I hope that conceptual framework helps
link |
because if you go online,
link |
if you're somebody with ADHD or not,
link |
you are going to be bombarded with the ADHD diet,
link |
the oligoantigenic diet, the elimination,
link |
this supplement, that EPA.
link |
And I think it's very important to understand
link |
whether or not you're talking about
link |
something mediating a process or modulating a process.
link |
Now, drugs like Ritalin, drugs like Adderall,
link |
they are tapping into the circuitries
link |
and the neurochemistries that mediate attention and focus.
link |
They are not the only alternatives
link |
or the only choices rather for treatment of these circuits
link |
and enhancement of the circuits for focus.
link |
I'm going to talk about other alternatives
link |
and some behavioral alternatives
link |
that are not very well known,
link |
but are very, very effective in a few minutes.
link |
But I really want to make this clear distinction
link |
between modulation and mediation
link |
because it's vital for anyone that's trying to modulate
link |
or mediate anything within their own brain.
link |
If any of you are interested in this oligoantigenic diet
link |
as it relates to ADHD,
link |
and you want to explore a more recent study
link |
besides that classic 2011 Lancet study
link |
that's rather controversial,
link |
there's a paper that was published
link |
in Frontiers in Psychiatry just last year, 2020.
link |
The title of the paper is oligoantigenic diet
link |
improves children's ADHD rating scale scores reliably
link |
in added video rating.
link |
The added video rating is just that they're using
link |
an additional measure of focus and attention.
link |
Again, that's Frontiers in Psychiatry 2020.
link |
I'll put a link to it in the caption,
link |
and that's a more recent study for you to peruse.
link |
So we've talked about the neural circuits of focus
link |
and the chemistry of focus,
link |
but we haven't talked yet about
link |
what would make us better at focusing
link |
and what focusing better really is.
link |
So let's take a step back and think about how we focus
link |
and how to get better at focus.
link |
And I'm going to share with you a tool
link |
for which there are terrific research data
link |
that will allow you in a single session
link |
to enhance your ability to focus in theory forever.
link |
What I'm about to read you is from an excellent book
link |
that I recommend if any of you are interested in neuroscience
link |
and things like meditation and default mode networks
link |
and things of that sort.
link |
The book is called Altered Traits.
link |
Science reveals how meditation changes
link |
your mind, brain, and body.
link |
And no, I'm not going to try and convince you to meditate.
link |
I'm going to share with you a small passage in the book
link |
that relates some research data related to focus
link |
that are very important.
link |
If you want to meditate, that's your choice.
link |
That's a separate matter.
link |
This is a book by Daniel Goleman and Richard Davidson.
link |
And I should just mention that Goleman is a well-known author
link |
has written books on emotional intelligence and so forth.
link |
Richard Davidson is also a PhD.
link |
He's a professor of psychology and psychiatry,
link |
and he's at a University of Wisconsin, Madison.
link |
He's done terrific work on brain states
link |
and modulation of brain states and so forth.
link |
What we're about to talk about is when attention works
link |
and when attention falters.
link |
And what we are specifically going to talk about
link |
are what are called attentional blinks,
link |
not actual eye blinks.
link |
We're going to talk about that in a few minutes,
link |
but we're going to talk about attentional blinks.
link |
I'm paraphrasing here because Goleman and Davidson
link |
wrote about this so beautifully.
link |
I'd rather paraphrase from them
link |
than try and just make up a new way to say it
link |
that is less interesting or less good,
link |
but I want to credit them.
link |
Attentional blinks are really easy to understand
link |
if you think about a where's Waldo task.
link |
You know this task, where's Waldo,
link |
where there are a bunch of people
link |
and objects and things in a picture,
link |
and somewhere in there is Waldo
link |
with the striped hat and the glasses
link |
and kind of a skinny dude,
link |
and you have to find Waldo.
link |
And so it's a visual search,
link |
and it's visual search for an object
link |
that has distinct features,
link |
but is embedded in this ocean of other things
link |
that could easily be confused as Waldo.
link |
So you tend to look, look, look, look, look, look, look, look.
link |
And then you find Waldo.
link |
They enjoy doing this.
link |
Adults may or may not enjoy it, but they can do it too.
link |
When you find Waldo,
link |
or when you search for a target
link |
in some other visual search task,
link |
at that moment, your nervous system celebrates a little bit,
link |
and it celebrates through the release of neurochemicals
link |
that make you feel good.
link |
You found it, and you pause.
link |
Now, the pause is interesting,
link |
because when you pause,
link |
what we know from many experiments
link |
is that in that moment of pause and mild celebration,
link |
you are not able to see another Waldo
link |
sitting right next to it.
link |
So what this means is in attending to something,
link |
in searching, and in identifying a visual target,
link |
your attention blinked.
link |
It shut off for a second.
link |
And there's a more formal and more laboratory type way
link |
that we look at this.
link |
The more typical way to do this
link |
is to give someone a string of letters
link |
or a string of numbers.
link |
And beforehand, you tell them,
link |
be on the lookout for the letters R and Z.
link |
You're just going to watch this string of numbers go by,
link |
and there will be a letter R in there,
link |
and there will be a letter Z in there,
link |
and try and spot them both.
link |
And what you find is
link |
when you present that string of numbers,
link |
and then they see the R,
link |
they register it consciously,
link |
and they tend to miss the Z,
link |
just like in the Waldo type example.
link |
Now, of course, the numbers are going by pretty quickly,
link |
but they can spot the R.
link |
They could also spot the Z if you told them beforehand,
link |
And the numbers are moving through at the same rate
link |
in both conditions.
link |
So what that means is that in every case,
link |
you are capable of seeing the R or the Z.
link |
It's when you try and see both
link |
that seeing the first one prevents you
link |
from seeing the second one.
link |
It's what we call an attentional blink.
link |
We do this all the time,
link |
and people with ADHD tend to have
link |
many more attentional blinks than people that don't.
link |
And this is true for children and for adults.
link |
This is an important point,
link |
so important that I want to emphasize it twice
link |
in case you attentionally blinked.
link |
If you see something that you're looking for,
link |
or you're very interested in something,
link |
you are definitely missing other information,
link |
in part because you're over-focusing on something.
link |
And this leads to a very interesting hypothesis
link |
about what might go wrong in ADHD,
link |
where we've always thought that they cannot focus,
link |
and yet we know they can focus on things
link |
they care very much about.
link |
Well, maybe, just maybe,
link |
they are experiencing more attentional blinks
link |
than people who do not have ADHD.
link |
And indeed, there are data now to support the possibility
link |
that that's actually what's happening.
link |
And that should be exciting to anyone that has ADHD.
link |
It should also be exciting to anyone
link |
that cares about increasing their focus
link |
and their ability to attend.
link |
What this is saying is that these circuits
link |
that underlie focus and our ability to attend
link |
and our ability to eliminate distraction,
link |
they aren't just failing to focus.
link |
That's just a semantic way of describing the outcome.
link |
They are over-focusing on certain things
link |
and thereby missing other things.
link |
And so our distractibility or the distractibility
link |
of somebody with ADHD could exist
link |
because they are over-focusing on certain elements
link |
and they are therefore missing other elements
link |
that they should be attending to.
link |
So what they really need is this property
link |
that we call open monitoring.
link |
Now, open monitoring is something
link |
that's described in the book that I just referred to
link |
and that typically is associated with people
link |
who have done a lot of meditation,
link |
so-called vipassana meditation, or have spent a lot of time
link |
learning how to do what's called open gaze visual analysis
link |
and open gaze thinking, but there's a simpler version
link |
of this that allows us to bypass all that.
link |
your visual system has two modes of processing.
link |
It can be highly focused, a soda straw view,
link |
so looking for the R in this string of numbers
link |
in the example that I just gave,
link |
or if you're very excited about something,
link |
you're in that soda straw view of the world
link |
and you're missing other things, okay?
link |
That's high levels of attention.
link |
However, there's also a property of your visual system
link |
that allows you to dilate your gaze
link |
to be in so-called panoramic vision.
link |
Panoramic vision is something you can do right now
link |
no matter where you are, and I can do it right now.
link |
You won't know that I'm doing it,
link |
but even though I'm still looking directly at you,
link |
I'm consciously dilating my gaze
link |
so that I can see the ceiling, the floor,
link |
and the walls all around me.
link |
That panoramic vision is actually mediated
link |
by a separate stream or set of neural circuits
link |
going from the eye into the brain,
link |
and it's a stream or set of circuits
link |
that isn't just wide angle view.
link |
It also is better at processing things in time.
link |
Its frame rate is higher.
link |
So you've seen slow motion video
link |
and you've seen standard video.
link |
Slow motion video gives you that slow motion look
link |
because it's a higher frame rate,
link |
your thin slicing time, okay?
link |
So you can use panoramic vision
link |
to access the state that we call open monitoring.
link |
When people do that, they are able to attend to
link |
and recognize multiple targets
link |
within this string of numbers.
link |
They can see the R and they can see the Z
link |
and they can see additional things.
link |
So this is something that can be trained up
link |
and people can practice whether or not
link |
they have ADHD or not.
link |
What it involves is learning
link |
how to dilate your gaze consciously.
link |
That's actually quite easy for most people.
link |
Whether or not you wear corrective lenses
link |
or contacts or not,
link |
you can consciously go into open gaze
link |
and then you can contract your field of view as well.
link |
There have also been studies done
link |
where people were taught to think in a particular way
link |
for a very short period of time
link |
and that forever changed their ability
link |
to limit or reduce the number of these attentional blinks.
link |
There are now published accounts in the literature
link |
of a simple practice done for about 15 minutes
link |
where subjects were asked to just sit quietly,
link |
eyes closed and do what is sort of akin to meditation
link |
but to not direct their mind
link |
into any particular state or place
link |
but simply to think about their breathing
link |
and to focus on their so-called interoception,
link |
focus on how their body feels,
link |
their mind drifted to bring it back.
link |
Okay, so it's basically meditation for about 15 minutes.
link |
That might not seem like a significant or unusual practice
link |
or that it would have any impact at all
link |
but remarkably, just doing that once for 17 minutes
link |
significantly reduced the number of attentional blinks
link |
that people would carry out.
link |
In other words, their focus got better
link |
in a near permanent way without any additional training.
link |
There's something about that practice
link |
of reducing the amount of visual information coming in
link |
and learning to pay attention to one's internal state,
link |
what we call interoception,
link |
that allowed them an awareness
link |
such that when they needed to look for visual targets,
link |
when they need to focus on multiple things in sequence,
link |
they didn't experience the same number
link |
of attentional blinks.
link |
And I should mention, not incidentally,
link |
as people age and their working memory gets worse
link |
and their ability to focus gets worse,
link |
the number of attentional blinks
link |
that they carry out goes up.
link |
And there are now studies exploring
link |
whether or not this simple meditation-like practice
link |
of 15 to 20 minutes or so of sitting
link |
and just quietly resting and paying attention
link |
to one's breathing and internal state
link |
can also offset some of that age-related,
link |
what is called cognitive decline.
link |
So what these data tell me is that regardless
link |
of whether or not you're a child or you're an adult,
link |
whether or not you have ADHD or not,
link |
whether or not you're experiencing
link |
age-related cognitive decline,
link |
or you would simply like to avoid
link |
age-related cognitive decline,
link |
a simple practice of taking 17 minutes,
link |
sitting and paying attention to your internal state,
link |
just interocepting, registering your breathing,
link |
registering the contact of your skin
link |
with whatever surface you're on,
link |
can forever rewire your brain to be able to attend better
link |
and possibly even offset
link |
some of that age-related attentional drift.
link |
Now, I don't expect anyone to start meditating regularly.
link |
I don't expect anyone to do anything they don't want to do,
link |
but I think most of us could handle one meditation session
link |
of 17 minutes or so.
link |
And so if ever there was a tool that stood
link |
to rewire our attentional circuitry in a powerful way,
link |
this seems to be it.
link |
And in addition, the ability to engage in panoramic vision,
link |
to dilate our gaze, the so-called open monitoring
link |
that allows the brain to function in a way
link |
that it can detect more information faster,
link |
that's a powerful tool as well.
link |
And the beauty of that tool is that it works the first time
link |
and it works every time.
link |
Now, how exactly it works is a little bit unclear.
link |
Is it, for instance, orchestrating this synchrony
link |
or asynchrony between the default mode network
link |
and the task-related networks?
link |
Those studies have not yet been carried out.
link |
Nonetheless, the effects are significant,
link |
they are long lasting,
link |
and they appear to exist after just one session
link |
of this quiet 17-minute interoception,
link |
which to me makes it seem like a very worthwhile thing
link |
to do for everybody.
link |
So we just talked about attentional blinks,
link |
which are essentially blinks of thinking.
link |
It's your mind shutting off for a moment
link |
and missing information.
link |
Now let's talk about actual blinks,
link |
the sort that you do with your eyelids.
link |
Now, this might come across as somewhat obvious,
link |
but you can do fast, what are called spontaneous blinks,
link |
and they are always coordinated between the two eyes.
link |
Or you can do long blinks,
link |
like when you go to sleep at night,
link |
you do one very long blink and I'm not being facetious.
link |
When you go to sleep at night,
link |
you are shutting your eyelids
link |
and you are limiting the amount of information coming in
link |
and your perception of time starts to drift
link |
as you go into sleep.
link |
Your perception of time changes from very fast
link |
at one moment to very slow,
link |
meaning the frame rate
link |
at which you are analyzing information,
link |
dreaming, et cetera, is variable when you are in sleep.
link |
Sometimes it's very fast,
link |
meaning you experience things in slow motion.
link |
Sometimes it's very fast.
link |
In waking too, your experience of time
link |
can sometimes be very fast, sometimes be very slow.
link |
Typically, the more alert you are,
link |
the higher the frame rate,
link |
your thin slicing your experience.
link |
You've probably had this happen.
link |
If you're ever very stressed
link |
and you're waiting for something or somebody,
link |
it seems like it takes forever
link |
because your frame rate is higher.
link |
You're analyzing time more finely.
link |
Conversely, if you are very relaxed or even sleepy,
link |
you wake up and you have to think about all the things
link |
it will seem like the world is going by very, very fast
link |
and that you are moving very slow.
link |
Time is going at the same rate,
link |
but your perception of time is what's changed.
link |
Believe it or not,
link |
your perception of time is also changed on a rapid basis,
link |
moment to moment basis by how often you blink.
link |
This is a well-established literature
link |
in the world of neuroscience
link |
that unlike the literature and claims about blinking
link |
and sociopathy, which have no basis,
link |
the science of blinking as it relates to time perception
link |
has some very good data to support it.
link |
I want to just emphasize one study in particular,
link |
which is quite appropriately titled
link |
Time Dilates After Spontaneous Blinking.
link |
This is a paper that was published in Current Biology.
link |
The first author is Terhune, T-E-R-H-U-N-E.
link |
It's a wonderful paper.
link |
They examined the relationship between fluctuations
link |
in timing and blinking.
link |
And to make a long story short,
link |
what they found is that right after blinks,
link |
we reset our perception of time, okay?
link |
So blinks in that sense are a little bit like
link |
the curtain coming down on a scene between scenes in a play
link |
or takes in a movie, you know, when they clap,
link |
the clap thing, they start it, take, you know,
link |
And then at the end, they do the thing
link |
and they click it down and they say, it's a take.
link |
When you blink, it's a take, okay?
link |
Now what's interesting and will immediately make sense to you
link |
as to why this is important
link |
is that the rate of blinking is controlled by dopamine.
link |
So what this means is that dopamine is controlling attention,
link |
blinks relate to attention and focus,
link |
and therefore the dopamine and blinking system
link |
is one way that you constantly modulate
link |
and update your perception of time.
link |
And fortunately, it's also one that you can control.
link |
So the basic takeaway of this study
link |
was that blinking controls time perception,
link |
but also that levels of dopamine
link |
can alter your sense of time and, stay with me here,
link |
and that blinking and dopamine are inextricably linked.
link |
They are working together to control your attention.
link |
When dopamine levels go up,
link |
people tend to overestimate how long something lasted.
link |
Because they are processing time more finely.
link |
It's slow motion mode.
link |
When dopamine levels are lower,
link |
they tend to underestimate time intervals.
link |
Let's remember back to the very beginning of the episode,
link |
what's going on in people with ADHD?
link |
They are not good at managing their time.
link |
They tend to run late or they are disorganized.
link |
They are not just disorganized in space,
link |
meaning in the physical space around them,
link |
they are disorganized in time.
link |
Their dopamine is low.
link |
We know that as well.
link |
And so they are underestimating time intervals.
link |
And so it makes perfect sense that they would be late.
link |
It makes perfect sense that they would lose track of time
link |
or the ability to focus.
link |
This is really exciting
link |
because what it means is that children with ADHD,
link |
adults with ADHD, or people with normal levels of focus
link |
that want to improve their ability to focus
link |
can do so through a training
link |
that involves learning how often to blink and when,
link |
and how to keep their visual focus on a given target.
link |
And it turns out this study has actually been done.
link |
There's a study again, I'll link to this study,
link |
entitled Improvement of Attention
link |
in Elementary School Students
link |
Through Fixation-Focused Training Activity.
link |
I won't go through all the details,
link |
but what they found was a short period
link |
of focusing on a visual target
link |
allowed these school children to greatly enhance
link |
their ability to focus on other types of information.
link |
And a significant component of the effect
link |
was due to the way that they were controlling the shutters
link |
on their eyes, their eyelids, and controlling their blinks.
link |
So what they did in the study is they had these kids
link |
focus their visual attention on some object
link |
that was relatively close, like their hand,
link |
for a minute or so, which actually takes some effort
link |
if you try and do that.
link |
They were allowed to blink.
link |
However, it's known from other work
link |
that if people can consciously override the desire to blink,
link |
at least to the point where they feel like they have to
link |
or else their eyes would dry out,
link |
that actually can increase attention even further.
link |
And they had conditions where they would look
link |
at a point further across the room
link |
and even further across the room.
link |
It only took a few minutes each day to do this,
link |
30 seconds in one condition or maybe a minute,
link |
and then at another station
link |
of looking a little bit further out
link |
and a little bit further out.
link |
However, there was an important feature of this study
link |
that is definitely worth mentioning,
link |
which is before they did this visual focus task or training,
link |
they did a series of physical movements with the kids
link |
so that the kids could sort of eliminate
link |
or move out some of their desire to move
link |
and would thereby enhance their ability to sit still.
link |
Now, it's long been known that kids need a recess.
link |
They need time to run around and play and roll around,
link |
do whatever it is that they do
link |
in order to be able to sit still at all.
link |
Adults probably need this too, frankly,
link |
but kids need it more because the circuits in the brain
link |
that control reflexive movements
link |
and as we say, kind of rhythmic undulating behavior
link |
and things like that, that's an active suppression.
link |
And kids have less of that circuitry built up
link |
until they hit about age 15 or 16.
link |
So they had the kids move around a bit
link |
and then do this focus training.
link |
That brings me to another treatment
link |
that's actively used nowadays in schools
link |
for kids with ADHD, but also it's starting to be used
link |
by many kids and by parents
link |
in order to keep their kids focusing
link |
and not going crazy in the car or not acting out in general.
link |
And that's the prevalence of these so-called fidgeter toys
link |
or things that kids can do actively and repetitively
link |
in order to move out some of their
link |
underlying reverberatory activity in their nervous system.
link |
So what you will find is that some kids with ADHD
link |
are now given a rubber band on their desk,
link |
literally a rubber band that's attached to their desk
link |
and they're able to pull on it,
link |
even snap it against the desk.
link |
If I had done that when I was a kid,
link |
I think my teachers would have thrown me out of class,
link |
but I think it's great that they're allowing them
link |
to do this now as a way of moving
link |
some of their physical energy out
link |
or engage their physical energy rather,
link |
as opposed to trying to sit,
link |
statue still all the time and attend.
link |
And it turns out that does enhance
link |
these children's ability to focus mentally
link |
when they have some physical activity to attend to.
link |
And it turns out it also can work for adults.
link |
I'll share with you a related anecdote
link |
because it illustrates the underlying mechanism.
link |
I've had the great privilege
link |
of being able to do a number of surgeries,
link |
brain surgeries during my career.
link |
So one thing you find when you do brain surgeries
link |
is that the brain's pretty small,
link |
regardless of the species that you're working on
link |
and you're in there and you're trying
link |
to do something very specific.
link |
And the more you try and hold your hands really steady,
link |
the more they want to shake, all right?
link |
So it's not natural for any of our limbs
link |
to sit perfectly still.
link |
Depending on how much coffee you've had,
link |
how well rested you are,
link |
and your sort of baseline level of autonomic arousal,
link |
some of you may find that you can hold out your hand
link |
it absolutely rock solid.
link |
Others will shake a little bit more.
link |
Doesn't mean you're nervous if you're shaking,
link |
doesn't mean you're calm if you're still.
link |
What it relates to is the amount
link |
of what we call pre-motor activity,
link |
the number of commands to move
link |
that are being sent through the system.
link |
And that's what I mean by reverberatory activity.
link |
And it does seem that kids with ADHD and adults with ADHD
link |
have a lot of reverberatory activity
link |
in their nervous system.
link |
And so that's that constant desire to move.
link |
It's hard for them to sit still
link |
and therefore it's hard for them to attend,
link |
to harness their attention.
link |
When you do a surgery and you find
link |
that your hands are shaking,
link |
what you learn from your mentors, which I did,
link |
and what works extremely well,
link |
whether or not you're doing a surgery or not,
link |
is that you simply tap your foot
link |
or you bounce your knee a little bit,
link |
which you might think would make your hand shake even more,
link |
but provided that it's subtle,
link |
what it does is it actually shuttles some of the activity
link |
from those pre-motor circuits to elsewhere in the body.
link |
And then you're able to sit much more still with your hand.
link |
You're able to perform the surgery with much more precision.
link |
You are able to write with much better handwriting.
link |
And for those of you who engage in public speaking,
link |
if you're ever too nervous,
link |
that's why pacing while you public speak
link |
helps if you're nervous.
link |
That's why bouncing your knee behind the podium
link |
That's why nodding your head and gesticulating can help.
link |
It's not a matter of quote unquote moving energy
link |
out of the body that doesn't actually happen.
link |
What it is is you're engaging those pre-motor circuits
link |
that are sending through commands.
link |
It's like trying to stuff a bunch of stuff through a funnel
link |
and it creates this tension.
link |
So you're giving it an outlet for the neural circuitry
link |
to be able to move something
link |
so that you can keep other components of your body
link |
and your mental attention engaged
link |
and locked onto something, what we call focus.
link |
One thing related to this whole business
link |
of blinking and focus and training yourself to focus
link |
and not blinking, et cetera,
link |
is that most all of the drugs, Ritalin, Adderall,
link |
and recreational drugs that increase dopamine,
link |
even coffee and tea and other forms of caffeine,
link |
they tend to make us blink less.
link |
And when we get tired, we tend to blink more.
link |
Now, this is sort of a duh, right?
link |
But being wide-eyed with excitement or fear
link |
or with your eyes barely being able to keep them open,
link |
now it should make perfect sense
link |
that these shutters on the front of your eyes,
link |
they aren't just there for winking
link |
and they aren't just there for cosmetic purposes.
link |
They are there to regulate the amount of information
link |
going into your nervous system.
link |
And they're there to regulate how long
link |
you are bringing information into your nervous system
link |
and in what bins, how widely or finely you are binning time
link |
is set by how often you blink and how widely
link |
or specifically you are grabbing attention
link |
from the visual world is set by whether or not
link |
you're viewing things very specifically,
link |
like a crosshair or through a soda straw view like this,
link |
or whether or not you were in this panoramic
link |
sort of whole environment mode,
link |
this kind of fisheye lens or wide angle lens mode.
link |
And in fairness to the pharmacology and the circuitry,
link |
while dopamine and heightened levels of alertness
link |
and excitement tend to make us blink less and attend more,
link |
there's actually a study that's looked
link |
at the other neurochemical systems and drugs
link |
and how those relate to blinking.
link |
And so this will all be obvious by the title of the paper
link |
I'm about to share with you.
link |
This is a paper entitled
link |
Decreased Spontaneous Eye Blink Rates
link |
in Chronic Cannabis Users,
link |
Evidence for Striatal Cannabinoid Dopamine Interactions.
link |
Okay, I'm not going to go into all the details here,
link |
but one thing that is somewhat surprising
link |
is that many people with ADHD use or abuse cannabis.
link |
You might think, well, why would they do that?
link |
Because I thought that a increase in dopamine
link |
is actually what's going to lead
link |
to heightened levels of attention,
link |
and that's what these people and children crave.
link |
Well, it turns out that cannabis
link |
also increases dopamine transmission in the brain,
link |
but because of the other chemicals it increases,
link |
namely serotonin and some components
link |
of the cannabinoid and opioid system.
link |
It creates that kind of alert, but mellow feel.
link |
And again, here, I'm not a proponent of this.
link |
I personally am not a THC or cannabis user.
link |
It's just not my thing.
link |
And obviously it's illegal some places,
link |
and so you have to determine that for yourself.
link |
It does have medical purposes,
link |
and in some places it is legal,
link |
but THC increases dopamine and increases neurochemicals
link |
that can also create a state of calm.
link |
So it's that sort of middle ground.
link |
And this paper has a beautiful demonstration whereby
link |
not just while people are using cannabis,
link |
but depending on how long they've been using cannabis
link |
across their lifespan, the rates of eye blinking change.
link |
So if you look at the number of years
link |
that people have been using cannabis on a regular basis,
link |
either daily or up to, excuse me, weekly or up to daily,
link |
what you find is that for people
link |
that have not been using cannabis at all
link |
or have only been using it for about two years,
link |
their rates of eye blinks are much higher
link |
than people who have been using it chronically for 10 years.
link |
In other words, people who've been using cannabis
link |
for 10 years don't blink very often at all.
link |
Now, cannabis has well-known effects in depleting memory,
link |
but it does seem to engage the focus and blinking system
link |
in a way that increases focus.
link |
So basically what I'm saying is
link |
marijuana seems to increase people's focus,
link |
but then they can't remember what they were focusing on.
link |
Something I'd like to discuss just briefly
link |
is the so-called interoceptive awareness
link |
that's present in people with ADHD,
link |
both children and adults.
link |
Interoceptive awareness is one sense
link |
of one's own internal state, heartbeat, breathing,
link |
contact of skin with a given surface, et cetera.
link |
For a long time, there was this hypothesis,
link |
this idea that people with ADHD
link |
were just not in touch with how they felt,
link |
that somehow they weren't registering
link |
all the stuff that was going on inside them,
link |
changes in heart rate and so forth.
link |
And so they were behaving in a way that was dysregulated
link |
or appear dysregulated.
link |
And that if they could just learn to attend
link |
to their internal state better,
link |
that somehow they would function better in the world.
link |
Now, before we described a process,
link |
literally a 17 minute interoceptive exercise
link |
that does seem to lead to improvements
link |
in one's ability to focus for a longer period of time.
link |
However, it's very unlikely that that was due
link |
to increasing interoceptive awareness per se.
link |
It probably wasn't because people gain a much heightened
link |
or improved ability to understand what's going on internally.
link |
In fact, you can imagine how that might actually
link |
prevent one's ability to pay attention to things
link |
in the outside world.
link |
So while there is benefit to just sitting there
link |
and being in stillness, as they say,
link |
or focusing on one's breathing and internal state
link |
for sake of then accessing information
link |
in the external world,
link |
a really nice study called Interoceptive Awareness
link |
in Attention Deficit Hyperactivity Disorder
link |
explored whether or not interoceptive awareness
link |
was different in people with ADHD or did not have ADHD.
link |
And the findings were essentially that there's no difference
link |
that people with ADHD, children and adults,
link |
they are aware of what's going on inside them
link |
just as much as anyone else is.
link |
And the typical measure of interoceptive awareness
link |
is one's ability to count their own heartbeats.
link |
This is actually challenging for some individuals
link |
and very easy for other individuals,
link |
regardless of their attentional capacity.
link |
Some people just can really feel their heartbeat
link |
without taking their pulse, other people cannot.
link |
And these studies are pretty straightforward to do.
link |
You ask people to sit there and to count their heartbeats
link |
and then you are monitoring their heartbeats
link |
and you get to gauge how accurate they are.
link |
So it's important to understand that people with ADHD
link |
are in touch with how they feel.
link |
It's really a question of whether or not
link |
they can take the demands that are placed upon them
link |
and enter a cognitive state, a mental state
link |
that allows them to access the information
link |
they need to access.
link |
In other words, whether or not they can focus.
link |
But it is absolutely wrong to think that the child
link |
that's getting up 11 times during a short six minute
link |
interaction at the table, or whether or not a child
link |
who somehow has to venture off every moment
link |
or a coworker of yours who's an adult,
link |
who's constantly fidgeting or moving things around
link |
that somehow they are unaware that they are oblivious.
link |
They're not oblivious to how they feel.
link |
Chances are they are very challenged in the situations
link |
that they're in and they're doing everything they can
link |
to try and regulate their attention.
link |
So I think it's an important study to highlight
link |
because it really underscores the fact that
link |
something else is going on and that something else
link |
has everything to do with this ability
link |
to coordinate these task-directed networks
link |
and to coordinate that in the proper way
link |
with that default mode network.
link |
And that is a process, as you now know,
link |
that's regulated exquisitely by certain neurochemicals
link |
and in particular, the neurochemicals dopamine,
link |
norepinephrine, and serotonin.
link |
And a fourth one I'd like to throw into the mix,
link |
which is acetylcholine, which is very vital
link |
for cognitive focus.
link |
So now I want to switch back to talking about
link |
some of the drugs that are typically used
link |
to access those systems, prescription drugs.
link |
And I want to talk about some of the new and emerging
link |
non-prescription approaches to increasing the levels
link |
of dopamine, acetylcholine, and serotonin in the brain
link |
using various supplement type compounds
link |
because several of them are showing
link |
really remarkable efficacy
link |
in excellent peer-reviewed studies.
link |
So before moving to some of the newer atypical compounds
link |
and things sold over the counter,
link |
I'd like to just briefly return to the classic drugs
link |
that are used to treat ADHD.
link |
These are the ones I mentioned earlier,
link |
methylphenidate, also called Ritalin,
link |
modafinil, armodafinil is another one, and Adderall.
link |
Again, all of these work by increasing levels of dopamine
link |
and norepinephrine.
link |
Typically, they are taken orally in pill form
link |
or sometimes in capsule form.
link |
The dosages that are appropriate
link |
vary according to severity of the condition
link |
for a given person and the age of the person.
link |
This is a complicated landscape for each individual.
link |
They have to figure out the pharmacology
link |
that's best for them.
link |
Some individuals are even layering long
link |
or time to release Ritalin with Adderall in smaller doses.
link |
It can get quite complex
link |
or it can be quite straightforward.
link |
If you are really interested in these drugs
link |
and how they work, and you'd like to get a glance
link |
at a table of all the results from all the studies
link |
of which there are now hundreds,
link |
there's an excellent review about these drugs
link |
and their use and their comparison
link |
to similarly structured drugs,
link |
in particular MDMA and cocaine and amphetamine,
link |
meaning street amphetamine,
link |
to really illustrate the similarities of action
link |
and some of the problems associated with long-term use.
link |
I don't expect you to read this article in full.
link |
I'm here so that you don't have to go read these articles,
link |
but in case you want a ton of information,
link |
the paper is Esposito et al, Frontiers in Biosciences.
link |
It's an excellent, excellent review
link |
of the entire literature.
link |
I can put a link to that study in our caption.
link |
And it essentially describes all the studies
link |
that have been done, peer reviewed and published.
link |
And it refers to these drugs in an interesting way.
link |
It doesn't just refer these drugs as for treatment of ADHD.
link |
It actually refers to them using language
link |
that ordinarily I'm not very fond of,
link |
but I'll agree to here,
link |
which is so-called smart drugs or nootropics.
link |
It also covers caffeine, which again,
link |
as I mentioned earlier, increases dopamine, norepinephrine,
link |
and to some extent serotonin.
link |
But what I like about this review so much
link |
is that in putting these drugs of abuse,
link |
methamphetamine and cocaine,
link |
right alongside these drugs like Ritalin and Adderall
link |
and also caffeine,
link |
we start to realize that the distinction
link |
between drugs of abuse and the distinction between drugs
link |
of treatment is actually a very fine
link |
and sometimes even a blurry line.
link |
And in thinking about whether or not
link |
one wants to use these prescription,
link |
I want to emphasize prescription, not drugs of abuse,
link |
but prescription drugs for treatment
link |
of one's own attentional capacity,
link |
I think it is important to understand the extent
link |
to which they all carry more or less the same side effects.
link |
The one exception being caffeine.
link |
Caffeine side effects can be anxiety
link |
if you ingest too much of it, insomnia,
link |
if you drink it too late in the day,
link |
but typically it will not cause the major side effects
link |
of the other drugs,
link |
such as high propensity for addiction and abuse,
link |
amphetamines of any kind,
link |
as well as cocaine can cause sexual side effects
link |
because they're vasoconstrictors.
link |
So, you know, men have trouble achieving erection.
link |
There can often be the intense desire or libido for sex,
link |
but an inability to actually perform.
link |
So that's an issue with any kind of stimulant.
link |
So these drugs are not without their consequences.
link |
In addition, and here I'd lump caffeine back into the mix.
link |
In addition, they almost all carry cardiac effects, right?
link |
They increase heart rate,
link |
but they also have effects on constriction of blood vessels
link |
and arteries and veins and so forth
link |
in ways that can create cardiovascular problems.
link |
Now, caffeine is a bit of a complicated one.
link |
I talked about this on a podcast long ago,
link |
but I'll just remind you that it turns out
link |
that if you are caffeine adapted,
link |
in other words, if you are used to drinking caffeine,
link |
then the ingestion of caffeine
link |
most often will cause vasodilation.
link |
It will actually allow more blood flow through.
link |
However, if you are not caffeine adapted,
link |
it will cause vasoconstriction
link |
due to an increased stress response.
link |
So if you're familiar with caffeine,
link |
caffeine can actually have a little bit more
link |
of a relaxation response,
link |
although if you drink enough of it,
link |
it will make you amped up.
link |
These other drugs almost always lead to vasoconstriction,
link |
increased heart rate, dilation of the pupils,
link |
less blinking, heightened levels of attention,
link |
which looks very much like stress,
link |
and at its extremes looks very much like
link |
the effects of street drugs like cocaine and amphetamine.
link |
Because of the large amounts of dopamine
link |
that are released in the brain,
link |
people tend to crave that state over and over,
link |
and yet with each subsequent use
link |
are able to get less and less of that euphoric feeling
link |
or that really, really focused feeling.
link |
So one thing that's being explored quite extensively now
link |
in the treatment of ADHD are drug schedules,
link |
whether or not people should take Adderall every day
link |
or every other day,
link |
whether or not they should take it
link |
only every once in a while,
link |
whether or not young children can take it just a few times
link |
and engage in behavioral training of the sort
link |
that I talked about before where they're doing,
link |
maybe it's a 17 minute meditation type exercise,
link |
but more likely it would be the movement
link |
followed by the visual focusing,
link |
because that's only done for 20 or 30 or 60 seconds.
link |
Why would you do that?
link |
Well, in a chemically enhanced state,
link |
your brain is more plastic.
link |
The circuits are able to modify and learn better.
link |
That's the optimal time to engage in focus
link |
in a very deliberate way.
link |
So just taking a drug and expecting focus
link |
to just work at any point
link |
and being able to turn focus on and off at will,
link |
that's an unrealistic expectation, right?
link |
More likely the best use of things like Adderall,
link |
modafinil, armodafinil, and Ritalin
link |
is going to be to combine those treatments
link |
with behavioral exercises that actively engage
link |
the very circuits that you're trying to train up and enhance
link |
and then perhaps, I want to highlight perhaps,
link |
tapering off those drugs
link |
so that then one can use those circuits
link |
without any need for chemical intervention.
link |
So despite any controversy that might be out there,
link |
I think it's fair to say that the consumption
link |
of omega-3 fatty acids can positively modulate
link |
the systems for attention and focus.
link |
So then the question becomes how much EPA,
link |
how much DHA does that differ
link |
for what's helpful for depression, et cetera?
link |
And actually it does differ.
link |
In reviewing the studies for this,
link |
it appears that a threshold level of 300 milligrams of DHA
link |
turns out to be an important inflection point.
link |
So typically fish oils or other sources of omega-3s
link |
will have DHA and EPA.
link |
And typically it's the EPA that's harder to get
link |
at sufficient levels,
link |
meaning you have to take quite a lot of fish oil
link |
in order to get above that 1000 milligram
link |
or 2000 milligram threshold to improve mood
link |
and other functions.
link |
But for sake of attention,
link |
there are 10 studies that have explored this in detail.
link |
And while the EPA component is important,
link |
the most convincing studies point to the fact
link |
that getting above 300 milligrams per day of DHA
link |
is really where you start to see the attentional effects.
link |
Now, fortunately, if you're getting sufficient EPA
link |
for sake of mood and other biological functions,
link |
almost without question,
link |
you're getting 300 milligrams or more of DHA.
link |
So that usually checks that box just fine.
link |
What's interesting is that there's another compound,
link |
phosphatidylsterine that has been explored
link |
for its capacity to improve the symptoms of ADHD.
link |
Again, I don't think this is any direct way,
link |
but rather in a modulatory way.
link |
But it appears that phosphatidylsterine taken for two months
link |
for 200 milligrams per day
link |
was able to reduce the symptoms of ADHD in children.
link |
It has not been looked at in adults yet,
link |
at least as far as I know,
link |
but that this effect was greatly enhanced
link |
by the consumption of omega-3 fatty acids.
link |
So now we're starting to see synergistic effects
link |
of omega-3 fatty acids and phosphatidylsterine.
link |
Again, that was 200 milligrams per day.
link |
This is something that sold over the counter
link |
in capsule form, at least in the US.
link |
There were two studies, both were double blind studies
link |
carried out for anywhere from one to six months
link |
on both boys and girls.
link |
And it really was boys and girls, not men and women.
link |
This was kids age one to six or seven to 12.
link |
And it was a fairly large number of subjects.
link |
So 147 subjects in one case and 36 in the other.
link |
The takeaway is that getting sufficient levels of EPAs,
link |
in particular this 300 milligram threshold of DHA,
link |
plus if you are interested in it and it's right for you,
link |
200 milligrams of phosphatidylsterine
link |
can be an important augment
link |
for improving the symptoms of ADHD.
link |
You'll also find literature out there
link |
and many claims about so-called ginkgo bilboa,
link |
which has been shown to have minor effects
link |
in improving the symptoms of ADHD.
link |
Not nearly as effective as Ritalin and Adderall.
link |
Ginkgo bilboa is not appropriate for many people.
link |
I am one such person.
link |
I don't have ADHD, but when I've taken ginkgo,
link |
even at very low doses,
link |
I get absolutely splitting headaches.
link |
Some people do not experience those headaches,
link |
but it's known to have very potent vasoconstrictive
link |
and vasodilating properties that vary
link |
depending on when you took the compound.
link |
So for those of you that are exploring ginkgo bilboa,
link |
and you will see a lot of claims about ginkgo bilboa
link |
for attention in ADHD,
link |
definitely take the vasodilation, vasoconstriction headache
link |
issue into consideration.
link |
So I'd like to talk about the drug modafinil
link |
and the closely related drug armodafinil,
link |
that's AR modafinil,
link |
because modafinil and armodafinil
link |
are gaining popularity out there,
link |
both for treatment of ADHD and narcolepsy,
link |
but also for communities of people
link |
that are trying to stay awake long periods of time.
link |
So it's actively used in the military by first responders.
link |
It's gaining popularity on college campuses,
link |
and people are using it more and more as an alternative
link |
to Adderall and Ritalin and excessive amounts of coffee.
link |
It does increase focus and to a dramatic extent.
link |
Modafinil typically was very expensive.
link |
I don't know if it's still this expensive,
link |
but when one has a prescription for it,
link |
it could still cost as much as eight or $900
link |
or even a thousand dollars a month.
link |
R-modafinil is a far less expensive version
link |
that's chemically slightly different than modafinil.
link |
Regardless of price,
link |
people are taking modafinil and R-modafinil.
link |
Want to emphasize that unlike Ritalin and Adderall,
link |
modafinil and R-modafinil
link |
are weak dopamine reuptake inhibitors,
link |
and that's how they lead to increases in dopamine.
link |
So whereas Ritalin and Adderall, amphetamine and cocaine
link |
lead to big increases in dopamine,
link |
also through reuptake mechanisms and so forth,
link |
modafinil is a weaker dopamine reuptake stimulator.
link |
And so what that means is that it leaves more dopamine
link |
around to be active at the synapse,
link |
the gaps between neurons.
link |
However, it also activates other systems.
link |
It acts on the orexin system,
link |
which is actually a peptide that we talked about
link |
in the episode on hunger,
link |
because it regulates hunger and appetite,
link |
and it regulates sleepiness and feelings of sleepiness.
link |
In fact, the orexin, also called hypocretin system,
link |
the orexin hypocretin system
link |
is what's disrupted in narcolepsy.
link |
That was the important discovery of my colleagues,
link |
Emmanuel Mignon and Seiji Nishino
link |
at Stanford some years ago,
link |
they identified the biological basis of narcolepsy,
link |
and it's a disruption in the orexin hypocretin system,
link |
and modafinil is one of the primary treatments
link |
It also has these other effects on the dopamine system
link |
and on the norepinephrine system.
link |
Even though it doesn't lead to quite as intense levels
link |
of dopamine and arousal and focus,
link |
it does have the property
link |
of raising levels of attention and focus,
link |
and that's why people are using it.
link |
So it's a somewhat milder form of Adderall.
link |
R-modafinil, for some people, works as well as modafinil,
link |
and as I mentioned before, it's much lower cost.
link |
For other people, it doesn't.
link |
I have an experience, meaning I do have an experience
link |
that I'll share with you with R-modafinil.
link |
A few years ago, I was suffering from jet lag
link |
really terribly, and I was traveling overseas.
link |
I went to a meeting to give a talk.
link |
I took half of the prescribed dose of R-modafinil.
link |
It was prescribed to me.
link |
I took that half dose, and I gave my lecture,
link |
and then I stayed around to answer questions,
link |
and then four hours later, a friend of mine came up to me
link |
and said, you know, you've been talking
link |
for four and a half hours,
link |
and there are only a few people still here.
link |
Luckily, there were still a few people.
link |
It'd be a lot weirder if the room was completely empty
link |
since it wasn't being recorded.
link |
So I have firsthand knowledge
link |
of the sorts of cognitive effects that it can create.
link |
I personally would not want to be in that state
link |
for sake of studying or learning
link |
or for doing this podcast, for instance,
link |
and I can honestly say that today,
link |
all I've ingested is some coffee
link |
and some yerba mate tea and some water.
link |
I'm not on any of the compounds that I've described
link |
during the course of today's episode.
link |
You might ask why I took half the recommended dose
link |
of R-modafinil, and the reason is that I'm somebody
link |
who's fairly hypersensitive to medication of any kind.
link |
What you find if you look in the literature
link |
is that about 5% of people
link |
are hyper hypersensitive to medication.
link |
They require far lower doses of any medication
link |
than other people in order to experience the same effects.
link |
I'm somebody that I think is sort of modest hyper,
link |
if that sort of oxymoronic statement,
link |
but a modest hypersensitivity to medication,
link |
so I've almost always been able to get by
link |
on taking less of whatever was prescribed for me
link |
and feel just fine,
link |
or in this case to feel like it was still too much.
link |
It turned out that the right dose of R-modafinil for me
link |
was zero milligrams.
link |
Now you may notice that I haven't talked much
link |
about acetylcholine.
link |
Acetylcholine is a neurotransmitter
link |
that at the neuron to muscle connections,
link |
the so-called neuromuscular junctions,
link |
is involved in generating muscular contractions
link |
of all kinds for all movements.
link |
Acetylcholine is also released from two sites in the brain.
link |
So a little bit of nomenclature here.
link |
Again, feel free to ignore the nomenclature,
link |
but there is a collection of neurons in your brainstem
link |
that send projections forward,
link |
kind of like a sprinkler system that's very diffuse
link |
to release acetylcholine.
link |
And those neurons reside in an area or a structure
link |
that's called the pedunculopontine nucleus, the PPN.
link |
And then there's a separate collection of neurons
link |
in the basal forebrain called unimaginatively
link |
nucleus basalis, the nucleus at the base.
link |
And they also hose the brain with acetylcholine,
link |
but in a much more specific way.
link |
So one is sort of like a sprinkler system,
link |
and the other one is more like a fire hose
link |
to a particular location.
link |
And those two sources of acetylcholine collaborate
link |
to activate particular locations in the brain
link |
and really bring about a tremendous degree of focus
link |
to whatever is happening at those particular synapses.
link |
So it could be a focus on visual information
link |
or auditory information.
link |
If you're listening closely to what I'm saying right now,
link |
or you just heard closely step out
link |
from the rest of my sentence,
link |
no doubt there was acetylcholine released at the sites
link |
in your brain where the neurons that represent
link |
your recognition of the word closely occurred, okay?
link |
So now you have an example and you have an understanding
link |
and hopefully a picture in your mind
link |
of how all this is working.
link |
Not surprisingly then, drugs that increase cholinergic
link |
or acetylcholine transmission
link |
will increase focus and cognition.
link |
One such compound is so-called alpha-GPC,
link |
which is a form of choline
link |
and increases acetylcholine transmission.
link |
Dosages as high as 1200 milligrams per day,
link |
which is a very high dosage spread out,
link |
typically it's 300 or 400 milligrams spread out
link |
throughout the day,
link |
have been shown to offset some of the effects
link |
of age-related cognitive decline,
link |
improve cognitive functioning.
link |
People that don't have age-related cognitive decline,
link |
that's a very high dose.
link |
Typically when people are using alpha-GPC to study
link |
or to enhance learning of any kind,
link |
they will take somewhere between 300 and 600 milligrams,
link |
that's more typical.
link |
Again, you have to check with your doctor,
link |
you have to decide if the safety margins
link |
are appropriate for you.
link |
Obviously you'll want to check that out,
link |
but alpha-GPC is effective in creating more focus
link |
by way of this cholinergic system.
link |
It stimulates acetylcholine release
link |
from both of those locations,
link |
the PPN in the back of the brain
link |
and nucleus basalis in the front of the brain.
link |
There are two other over-the-counter compounds
link |
that are in active use out there for treatment of ADHD
link |
and in use for simply trying to improve focus.
link |
And the first one is L-tyrosine.
link |
It's an amino acid that acts as a precursor
link |
to the neuromodulator dopamine.
link |
And now knowing everything you know about dopamine attention
link |
and the circuits involved,
link |
it should come as no surprise
link |
as to why people are exploring the use of L-tyrosine
link |
L-tyrosine does lead to increases in dopamine.
link |
They are fairly long-lived
link |
and L-tyrosine can improve one's ability to focus.
link |
However, the dosaging can be very tricky to dial in.
link |
Sometimes it makes people feel too euphoric
link |
or too jittery or too alert
link |
that they are then unable to focus well.
link |
So the dosage ranges are huge.
link |
You see evidence for 100 milligrams
link |
all the way up to 1200 milligrams.
link |
It's something that really should be approached
link |
with caution, especially for people
link |
that have any kind of underlying psychiatric
link |
because dysregulation of the dopamine system
link |
is central to many of the mood disorders,
link |
such as depression,
link |
but also especially mania,
link |
mania bipolar disorder,
link |
schizophrenia, things of that sort.
link |
So it's something that really should be approached
link |
Nonetheless, in exploring what's out there
link |
and even some studies online
link |
that were done either animal studies or human studies,
link |
it's clear that L-tyrosine is being explored
link |
as is PEA and phenylethylamine,
link |
which is essentially PEA,
link |
but some related compounds.
link |
So there's a whole class of dopaminergic
link |
or dopamine stimulating supplements
link |
that people are using to try
link |
and get their dopamine levels up.
link |
And again, it's kind of a fine line
link |
between too little enough and too much.
link |
If you want to get the literature on those two compounds,
link |
there I will refer you to this great website
link |
at examine.com, just as it sounds.
link |
And you can put in L-tyrosine or PEA
link |
and you can get the details on that.
link |
But I highly recommend also going to their section
link |
on ADHD to see how those particular compounds
link |
relate specifically to ADHD and cognitive focus.
link |
And last but not least,
link |
in terms of these different compounds,
link |
I do want to mention the racetams.
link |
These are somewhat esoteric
link |
and probably most of you haven't heard about them,
link |
but some of you probably know a lot about them
link |
and they are becoming more popular.
link |
They go by names like Nupept and things of that sort.
link |
The racetams are illegal in certain countries.
link |
They are gray market in other countries
link |
and they are sold over the counter
link |
in this country, in the US.
link |
So they have different margins for safety.
link |
You definitely need to consult your doctor,
link |
especially if you have ADHD.
link |
But Nupept has been shown when taken, you know,
link |
at 10 milligrams twice daily,
link |
can be more effective than some of the other racetams.
link |
Nupept taps into the cholinergic system,
link |
the acetylcholine system in ways very similar to alpha-GPC,
link |
but seems to have a slightly higher affinity
link |
for some of the receptors involved
link |
and can lead to those heightened states
link |
of cognitive capacity.
link |
And there are these studies, one in particular,
link |
comparative studies of Nupept and paracetam
link |
and the treatment of patients with mild cognitive disorders
link |
and brain diseases of vascular and traumatic origin.
link |
That's a mouthful.
link |
What this study basically points to
link |
is the fact that people who are experiencing
link |
some degree of inability to focus
link |
due to prior concussion or some vascular event,
link |
a stroke or ischemia of any kind,
link |
because neurons need blood,
link |
when the blood supply is cut off to neurons
link |
or when there's a bleed in the brain,
link |
subsequent to that,
link |
often there are challenges in maintaining focus.
link |
This is very common for people that have done sports
link |
where there's a lot of running into each other
link |
with your head, like rugby, football, hockey, and so forth,
link |
but also people who have experienced head blows
link |
or often overlooked is the fact that
link |
most traumatic head injury is not actually from sports,
link |
even football, it's from things like construction work,
link |
from high impact work of that kind.
link |
So there does seem to be some efficacy
link |
of Nupept and paracetam and things like it.
link |
It's an emerging area.
link |
And as I mentioned in the US,
link |
these things are sold over the counter.
link |
Again, you have to figure out if it's right for you,
link |
but they are beginning to show some promise
link |
and I'm intrigued by them
link |
because of the way that they tap into the cholinergic system
link |
which is both directly involved in focus
link |
and the ability to focus,
link |
but is also important for things related
link |
to age-related cognitive decline.
link |
So a decline in cholinergic transmission or acetylcholine
link |
as we call it in the brain
link |
is one of the things associated with cognitive decline.
link |
And it does seem that increasing cholinergic transmission
link |
can offset some of that cognitive decline
link |
and perhaps even more so in conditions
link |
such as vascular damage or concussion to the brain.
link |
If you're interested in atypical treatments for ADHD,
link |
compounds to improve focus and related themes
link |
and you like reading about this stuff,
link |
there's an excellent review article that I can refer you to.
link |
It's by Ann et al, AHN.
link |
It was published in 2016.
link |
So it's a little bit behind the times,
link |
although it's surprisingly comprehensive given that,
link |
which lines up all the various drugs that I've discussed,
link |
racetams and Adderall and Ritalin
link |
and various forms of dopaminergic agents
link |
and cholinergic agents spells out whether or not
link |
they are sold over the counter by prescription
link |
and really lines them up in all their effects,
link |
their drawbacks, et cetera.
link |
I'll refer you to that study.
link |
It's available in its full length form online for free.
link |
It's on et al, the journal is Neuroplasticity 2016.
link |
Should be very easy to find if you put those keywords in.
link |
And while it is a review, it is a very comprehensive review.
link |
And if you're really into this stuff
link |
and you also want to learn a thing or two
link |
about how these things interact with neurofeedback, et cetera,
link |
there's some information in there as well.
link |
I know I've already covered a lot of information,
link |
but there is one more category of technology
link |
for the treatment of ADHD and for enhancement of focus
link |
in anyone that I would like to emphasize.
link |
And that's transcranial magnetic stimulation.
link |
Transcranial magnetic stimulation, also called TMS,
link |
is achieving increasing popularity nowadays
link |
for the treatment of all sorts of neurologic conditions
link |
and psychiatric conditions.
link |
It is a non-invasive tool.
link |
It involves taking a coil, it's a device with a coil
link |
that's placed over particular locations in the brain
link |
and then sends magnetic stimulation into the brain.
link |
It can actually pass through the skull
link |
without having to drill through the skull.
link |
And nowadays can be used to both lower
link |
the amount of activity or increase the amount of activity
link |
in specific brain areas.
link |
Its spatial precision is not remarkable.
link |
That doesn't mean it's not of use,
link |
but it is not a super fine grain tool, okay?
link |
It's not a cannon, but it's also not a needle.
link |
It is somewhere in between.
link |
It can direct the activity of particular brain regions
link |
at particular depths.
link |
And as I mentioned, it can increase
link |
or decrease that activity.
link |
So for instance, I've had a TMS coil placed on my head,
link |
not for therapeutic purposes,
link |
even it was, I wouldn't tell you,
link |
but rather just for, well, I'm a neuroscientist
link |
and I worked in a lab with one
link |
for entertainment exploratory purposes.
link |
Please don't do this at home.
link |
It was placed over my motor cortex,
link |
which generates voluntary action.
link |
And it was a coil that at that time
link |
could only inhibit neurons.
link |
And so what I was doing is I was moving objects
link |
around on a table, just like I am now.
link |
It was actually a pencil, not a pen.
link |
And I was tapping the pencil
link |
and then the TMS coil was turned on.
link |
And for the life of me, I could not move that pencil, okay?
link |
Because it was inhibiting my upper motor neurons
link |
in the portion of my cortex
link |
that controls voluntary activity.
link |
As soon as the coil was turned off,
link |
I could return to tapping the pencil again.
link |
Nowadays, it's possible to stimulate motor cortex
link |
or any area of the brain with some degree of precision
link |
that could create the impulse to move
link |
without actually making the decision to move.
link |
So you can literally engage certain neural circuits
link |
and therefore behaviors and certain thought
link |
and emotional patterns
link |
by way of transcranial magnetic stimulation.
link |
This has far reaching and vast implications
link |
as you can probably imagine.
link |
In discussing ADHD with a colleague that uses TMS,
link |
what they are doing is they are taking the TMS coil
link |
to children and adults that have ADHD
link |
and they're using it to stimulate the portions
link |
of the prefrontal cortex that we talked about earlier
link |
that engage task-directed focused states.
link |
So rather than using a drug that generally increases dopamine
link |
and some of the other chemicals involved,
link |
they're using directed TMS stimulation of these circuits.
link |
And fortunately, I was quite relieved to hear this,
link |
they are combining that with a focused learning task.
link |
So they're literally teaching the brain to learn
link |
in a non-invasive way, no drug at all.
link |
And right now there are experiments,
link |
clinical trials going on comparing TMS of this sort
link |
to the drug treatments of the sort that we described earlier
link |
that engage these circuits through pharmacologic mechanisms.
link |
So very exciting times for TMS,
link |
very exciting times for pharmacology related to ADHD
link |
and for enhancing focus in general.
link |
And when I say very exciting times,
link |
I mean, no drug is perfect,
link |
but the constellation of drugs that's out there
link |
is getting much larger,
link |
but because they tap into different aspects
link |
of their circuitry,
link |
I do think that we are well on our way
link |
to identifying the ideal combinations of drug treatments,
link |
technological treatments and behavioral paradigms
link |
for increasing focus in both children and adults with ADHD.
link |
And as a final, final point,
link |
I also want to mention something about technologies
link |
that are making it harder for all of us to focus,
link |
regardless of whether or not
link |
we have preexisting ADHD or not.
link |
You can probably guess where this is going.
link |
Everybody nowadays seems to have a smartphone.
link |
I'm sure there are a few individuals out there
link |
that don't have a smartphone.
link |
Nonetheless, most people have them.
link |
Most kids want one as soon as they can get them
link |
and they are small.
link |
They grab our attention entirely,
link |
but within that small box of attention,
link |
there are millions of attentional windows scrolling by.
link |
So just because it's one device that we look at
link |
does not mean that we are focused.
link |
We are focused on our phone,
link |
but because of the way in which context
link |
switches up so fast within the phone,
link |
it's thought that the brain is struggling now
link |
to leave that rapid turnover of context.
link |
Many, many shows, many, many Instagram pages,
link |
many, many Twitter feeds, many, many websites,
link |
basically the whole world, at least in virtual format,
link |
is available within that small box.
link |
Unlike any other technology humans
link |
have ever dealt with before,
link |
even though there are trillions,
link |
infinite number of bits of information
link |
in the actual physical world,
link |
your attentional window, that aperture of constriction
link |
and dilating that visual window
link |
is the way in which you cope
link |
with all that overwhelming information typically.
link |
Well, within the phone,
link |
your visual aperture is set to a given width.
link |
It's about this big.
link |
Typically the phone seemed to be getting bigger,
link |
but nonetheless, it's about that big.
link |
And within there, your attentional window
link |
is grabbing a near infinite number of bits of information,
link |
If a picture is worth a thousand words,
link |
a movie is worth a billion pictures.
link |
The brain loves visual motion.
link |
And so the question is,
link |
does that sort of interaction on a regular basis
link |
lead to deficits in the types of attention that we need
link |
in order to perform well
link |
in work and school relationships, et cetera?
link |
And the short answer is yes, it does appear so.
link |
We are inducing a sort of ADHD.
link |
And while the studies on this are ongoing
link |
because prominent use of smartphones
link |
really took off right around 2010 and we're only in 2021,
link |
longstanding studies take time,
link |
which is essentially to say the same thing as longstanding.
link |
There are some studies and one in particular
link |
that I'd like to highlight.
link |
One was actually carried out pretty early in 2014.
link |
This is a study that explored smartphone use,
link |
at the time they called it mobile phone use,
link |
but smartphone use and inattention,
link |
difficulties in attending in 7,102 adolescents.
link |
So this is a huge study,
link |
a population-based cross-sectional study.
link |
And you will be probably surprised and somewhat dismayed
link |
to hear that in order to avoid this decrease
link |
in attentional capacity, adolescents needed
link |
to use their smartphone for less than 60 minutes per day
link |
in order to stay focused and centered on their other tasks.
link |
Otherwise they started to really run into significant issues.
link |
So 60 minutes is not much.
link |
I have a feeling that most young people
link |
are using their phone more than 60 minutes per day.
link |
I think for adults, the number is probably higher,
link |
meaning if you're an adult,
link |
I'm going to just extrapolate from what I read in this study.
link |
It seems that probably two hours a day on the phone
link |
would be the upper limit beyond which
link |
you would probably experience
link |
pretty severe attentional deficits.
link |
I'm a big fan of Cal Newport who wrote the book,
link |
He's also written the excellent book,
link |
"'A World Without Email.'"
link |
I've never met him, but I'm a huge admirer of his work.
link |
And I will paraphrase something that he said
link |
far more eloquently than I ever could,
link |
which is that the brain does not do well
link |
with constant context switching,
link |
meaning it can do it,
link |
but it diminishes our capacity to do meaningful work
link |
of any other kind.
link |
And so Cal, as I understand is very,
link |
he's a computer science professor at Georgetown, by the way,
link |
is very structured and very disciplined
link |
in his avoidance of cell phone use.
link |
I think we're all striving to do that.
link |
I'm not here to tell you what to do,
link |
but I think whether or not you have ADHD or not,
link |
if you're an adolescent,
link |
limiting your smartphone use to 60 minutes per day or less,
link |
and if you are an adult to two hours per day or less
link |
is going to be among the very best ways to maintain,
link |
just to maintain your ability to focus
link |
at whatever level you can now.
link |
And as I always say,
link |
most of the things that we get recognized for in life,
link |
success in life in every endeavor,
link |
whether or not it's school, relationships, sport,
link |
creative works of any kind are always proportional
link |
to the amount of focus that we can bring that activity.
link |
It is important to rest, of course, to get proper sleep,
link |
but I stand behind that statement.
link |
And I leave you with that study about attention
link |
and cell phones and how cell phones are indeed eroding
link |
our attentional capacities.
link |
So I realized I covered a lot of information about ADHD
link |
and the biology of focus and how to get better at focusing.
link |
We talked about the behavioral
link |
and psychological phenotypes of ADHD.
link |
We talked about the underlying neural circuitry.
link |
We also talked about the neurochemistry,
link |
and we talked about the various prescription drug treatments
link |
that are aimed at that neurochemistry
link |
and aimed at increasing focus
link |
in children and adults with ADHD.
link |
We also talked about over-the-counter compounds,
link |
the role of particular types of diets and elimination diets.
link |
And we talked about interactions
link |
between these various features in dictating outcomes
link |
for ADHD and enhancing focus in general.
link |
We also talked a little bit about emerging neurotechnologies
link |
and how certain technologies like the smartphone
link |
are no doubt hindering our ability to focus
link |
and put us at greater risk of developing ADHD at all ages.
link |
I do acknowledge the irony and somewhat the contradiction
link |
of doing a two-hour plus episode on ADHD
link |
if indeed people who are watching this
link |
have challenges with attention.
link |
I want to emphasize that this podcast,
link |
like all of our podcast episodes,
link |
are timestamped for a specific reason.
link |
They are designed to be digested
link |
in whatever batch one chooses, right?
link |
You don't have to watch or listen
link |
to the entire thing all at once.
link |
However, if you've gotten to this point in the podcast,
link |
I want to thank you.
link |
I do hope that you've learned a lot about this condition.
link |
I hope you've also learned a lot
link |
about your own capacity to focus
link |
and things that you can do to enhance your focus.
link |
We even talked about a tool that takes just one
link |
17-minute session to enhance your ability to focus
link |
thereafter, presumably forever.
link |
If you're enjoying this podcast and you're learning from it,
link |
please subscribe to our YouTube channel.
link |
That really helps us.
link |
In addition, in the comment section on YouTube,
link |
you can leave us suggestions for future podcast guests
link |
and suggestions for future podcast topics
link |
that we may have not covered
link |
or that you'd like to see covered in the future.
link |
In addition, please subscribe to the podcast
link |
on Apple and Spotify.
link |
And on Apple, you have the opportunity to leave us a comment
link |
and up to a five-star review.
link |
In addition, please check out the sponsors mentioned
link |
at the beginning of the podcast.
link |
That's a terrific way to support us.
link |
And for those of you that would like to support research
link |
on stress, neurobiology, and human performance,
link |
you can go to hubermanlab.stanford.edu,
link |
and there you can make a tax-deductible donation
link |
for research on neurobiology in my laboratory.
link |
In addition, we have a Patreon.
link |
It's patreon.com slash Andrew Huberman.
link |
There, you can support the podcast
link |
at any level that you like.
link |
During today's episode,
link |
we talked a lot about supplement-based compounds.
link |
If you're interested in supplements
link |
and you want to see the supplements that I personally take,
link |
you can go to Thorne.
link |
That's T-H-O-R-N-E slash the letter U slash Huberman.
link |
And you can see everything that I take,
link |
and you can get 20% off any of those supplements.
link |
Or if you navigate into the Thorne site through that portal,
link |
you can get 20% off any of the supplements
link |
that Thorne makes.
link |
Supplements aren't for everybody.
link |
You by no means have to take supplements,
link |
but if you are going to take supplements,
link |
it's important that you take supplements
link |
from a source that's reputable,
link |
in which the ingredients are very high quality,
link |
and in which the amount of the ingredients
link |
that listed on the bottle
link |
actually matches what's in the bottle.
link |
That's why we partnered with Thorne,
link |
because they have the highest levels of stringency
link |
in terms of quality and specificity of the ingredients.
link |
And finally, I want to thank you for your time
link |
and your attention.
link |
And as always, thank you for your interest in science.
link |
I'll see you next time.