ADHD & How Anyone Can Improve Their Focus

00:00:00.000 | - Welcome to the Huberman Lab Podcast,

00:00:02.260 | where we discuss science and science-based tools

00:00:04.900 | for everyday life.

00:00:05.900 | I'm Andrew Huberman,

00:00:10.460 | and I'm a professor of neurobiology and ophthalmology

00:00:13.180 | at Stanford School of Medicine.

00:00:15.300 | Today, we are going to talk all about

00:00:17.280 | attention deficit hyperactivity disorder, or ADHD.

00:00:21.660 | We are also going to talk about normal levels of focus,

00:00:25.300 | what are normal levels of focus,

00:00:27.380 | and how all of us, whether or not we have ADHD or not,

00:00:31.860 | can improve our ability to focus,

00:00:34.420 | our ability to rule out distraction,

00:00:36.580 | turns out those are two separate things,

00:00:39.000 | as well as remember information better.

00:00:42.180 | We are also going to talk about

00:00:43.700 | how we can learn to relax while focusing,

00:00:46.740 | which turns out to be a critical component

00:00:49.140 | of learning new information,

00:00:51.160 | and for coming up with new creative ideas.

00:00:54.840 | So whether or not you have ADHD or know someone who does,

00:00:59.100 | or if you're somebody who feels that they do not have ADHD,

00:01:02.620 | but would simply like to improve their ability to focus

00:01:05.940 | or to be more creative,

00:01:07.700 | this episode is definitely for you as well.

00:01:10.240 | We are going to talk about drug-based tools

00:01:13.920 | that are out there,

00:01:14.820 | we are going to talk about behavioral tools,

00:01:17.000 | we will talk about the role of diet and supplementation,

00:01:20.220 | and we will talk about

00:01:21.420 | new emerging brain machine interface devices

00:01:24.780 | things like transcranial magnetic stimulation.

00:01:27.520 | If you don't know what that is, don't worry,

00:01:29.080 | I will explain it to you.

00:01:30.600 | These are non-invasive methods for rewiring your brain

00:01:34.660 | in order to make focusing more natural for you,

00:01:38.540 | and to teach you how to increase your depth of focus.

00:01:41.860 | Now, just a quick reminder

00:01:43.340 | that anytime we discuss a psychiatric disorder,

00:01:47.080 | it's important that we remember

00:01:49.080 | that all of us have the temptation to self-diagnose

00:01:52.040 | or to diagnose others.

00:01:53.960 | So as I list off some of the symptomology of ADHD,

00:01:56.580 | some of that symptomology might resonate with you.

00:01:58.660 | You might think, oh, maybe I have ADHD,

00:02:00.860 | or you might decide that someone you know

00:02:02.800 | definitely has ADHD.

00:02:05.180 | However, it is very important that you don't self-diagnose

00:02:08.200 | or diagnose somebody else.

00:02:10.280 | The clear and real diagnosis of ADHD

00:02:14.420 | really should be carried out by a psychiatrist, a physician,

00:02:18.620 | or a very well-trained clinical psychologist.

00:02:21.540 | There are clear criteria for what constitutes full-blown ADHD.

00:02:26.540 | However, many of us have constellations of symptoms

00:02:31.040 | that make us somewhat like somebody with ADHD.

00:02:34.980 | And if you're struggling with focus nowadays,

00:02:36.840 | as a lot of people are,

00:02:39.040 | because of stress, because of smartphone use,

00:02:42.080 | which turns out can induce adult ADHD,

00:02:44.880 | we'll talk about that,

00:02:46.280 | well, then pay attention to the symptomology.

00:02:48.900 | You may actually require professional treatment.

00:02:51.180 | You might not.

00:02:52.300 | Equally important is to remember

00:02:53.560 | that some of the terms that we cover,

00:02:54.960 | like impulse control and attention and concentration,

00:02:58.740 | are somewhat subjective and they can change over time.

00:03:01.460 | Sometimes we have a better level of attention than others.

00:03:04.940 | Maybe it depends on how we slept

00:03:06.280 | or other events going on in our life,

00:03:08.000 | or something that we're entirely unaware of.

00:03:10.500 | The important thing to remember

00:03:11.940 | is that we can all improve our attentional capacity.

00:03:15.000 | We can all rewire the circuits

00:03:17.220 | that make heightened levels of focus more accessible to us.

00:03:21.140 | We can do that through multiple types of interventions,

00:03:24.020 | and we are going to cover all those interventions today.

00:03:27.640 | Before we march into the material,

00:03:29.080 | I'd like to remind that this podcast is separate

00:03:31.120 | from my teaching and research roles at Stanford.

00:03:33.320 | It is, however, part of my desire and effort

00:03:35.480 | to bring zero cost to consumer information about science

00:03:38.280 | and science-related tools to the general public.

00:03:41.240 | In keeping with that theme,

00:03:42.360 | I'd like to thank the sponsors of today's podcast.

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00:07:56.340 | So let's talk about ADHD,

00:07:58.220 | attention deficit hyperactivity disorder.

00:08:00.920 | Let's also talk about focus and attention

00:08:03.240 | and everybody's ability to focus and attend,

00:08:06.080 | not just people with ADHD.

00:08:08.520 | We are also going to talk about tools

00:08:10.120 | that would allow anyone,

00:08:11.800 | whether or not they have ADHD or not,

00:08:13.920 | to enhance their level of concentration and focus.

00:08:16.920 | Now, ADHD used to be called ADD,

00:08:21.640 | attention deficit disorder.

00:08:23.340 | We have record of ADD in the medical literature

00:08:27.880 | dating back to as early as 1904.

00:08:30.600 | Now, there's nothing special about 1904.

00:08:32.640 | That's just the first time that it showed up

00:08:34.080 | in the standard medical literature.

00:08:36.720 | We have to believe that ADD, which we now call ADHD,

00:08:41.580 | existed before 1904 and probably long before 1904.

00:08:46.440 | Why?

00:08:47.280 | Well, because it has a strong genetic component.

00:08:50.220 | If you have a close relative that has ADHD,

00:08:53.800 | there's a much higher probability that you will have ADHD.

00:08:57.240 | And that probability goes up depending on

00:08:59.320 | how closely related to that person you happen to be.

00:09:02.040 | So for instance, if you're an identical twin

00:09:04.460 | and your twin has ADHD,

00:09:06.760 | there's a very high concordance, as we say,

00:09:09.840 | a very high probability that you will have ADHD,

00:09:12.840 | up to 75% chance.

00:09:15.200 | If you have a fraternal twin with ADHD,

00:09:17.120 | that number goes down a bit in the 50 to 60% range

00:09:20.600 | and so on.

00:09:21.520 | If you have a parent with ADHD,

00:09:23.560 | that number ranges anywhere from 10 to 25% likelihood

00:09:26.820 | that you will have ADHD if you have two parents

00:09:28.700 | and so on and so on.

00:09:30.000 | Okay, so there's a genetic component.

00:09:31.720 | That genetic component, it turns out,

00:09:33.400 | relates directly to how specific neural circuits

00:09:36.280 | in the brain wire up, the chemicals they use,

00:09:39.280 | and the way they use those chemicals,

00:09:41.200 | a topic that we are going to discuss in depth today.

00:09:44.220 | Now, if you have a close relative with ADHD,

00:09:48.080 | that does not mean that you are fated to have ADHD.

00:09:51.460 | And if you happen to have ADHD,

00:09:53.800 | there are ways to overcome those symptoms

00:09:56.640 | of lack of attention, impulsivity, and so on.

00:10:00.100 | Another important point about ADHD

00:10:03.440 | is that it has nothing to do with intelligence.

00:10:06.420 | Whether or not we're talking about intelligence

00:10:08.100 | measured by a standard IQ test,

00:10:10.440 | a rather controversial issue, as many of you probably know,

00:10:13.020 | there are lots of forms of intelligence

00:10:15.340 | that a standard IQ test just wouldn't pick up.

00:10:18.380 | Emotional intelligence, musical intelligence,

00:10:20.180 | spatial intelligence, all sorts of intelligences,

00:10:23.260 | none of them are related to ADHD.

00:10:27.860 | Being very high functioning doesn't make you more likely

00:10:30.520 | to have ADHD, and being ADHD doesn't necessarily mean

00:10:34.360 | that you have a low IQ.

00:10:35.280 | So there are people with ADHD who have low IQs,

00:10:37.840 | people with ADHD with high IQs,

00:10:39.880 | people with ADHD with high emotional IQ,

00:10:42.280 | or with low IQ in the emotional scale,

00:10:45.440 | it's all over the place.

00:10:46.600 | The important point is that your ability to attend and focus

00:10:50.000 | does not relate to how smart you are,

00:10:52.600 | or your IQ of any type, not just a standard IQ.

00:10:57.000 | The renaming of ADD to ADHD

00:11:00.280 | took place in the mid to late 1980s,

00:11:03.280 | when the psychiatric community

00:11:05.020 | and the psychological community

00:11:06.880 | started taking better notice of the fact

00:11:10.080 | that so-called hyperactive kids also had attentional issues.

00:11:14.800 | This might seem obvious,

00:11:16.120 | but there's been extensive and ongoing revision

00:11:19.800 | of the criteria for designating a psychiatric disorder,

00:11:23.560 | and this is still an ongoing process, even today.

00:11:27.100 | So in the mid '80s, we started hearing about ADHD,

00:11:29.920 | and then gradually that term ADD has been dropped away.

00:11:33.100 | However, just the renaming of ADD to ADHD

00:11:37.660 | has led to much better diagnosis and detection of ADHD.

00:11:43.520 | So right now, the current estimates

00:11:46.420 | are that about one in 10 children,

00:11:49.340 | and probably more, have ADHD.

00:11:53.020 | The current estimates are anywhere from 10%, one in 10,

00:11:56.780 | to as high as 12%.

00:11:58.780 | Now, fortunately, about half of those

00:12:00.860 | will resolve with proper treatment,

00:12:03.700 | but the other half typically don't.

00:12:05.920 | The other thing that we are seeing a lot nowadays

00:12:08.660 | is increased levels of ADHD in adults,

00:12:13.340 | and there's some question

00:12:14.620 | as to whether or not those adults had ADHD

00:12:17.340 | that went undetected during their childhood,

00:12:19.940 | or whether or not ADHD is now cropping up in adulthood

00:12:24.020 | due to the way that we are interacting with the world.

00:12:27.540 | In particular, smartphone use,

00:12:30.080 | the combination of email, text, real-world interactions,

00:12:34.520 | multiple apps and streams of media and social media

00:12:39.620 | all coming in at once, trying to manage life,

00:12:42.060 | all of the things that are going on

00:12:44.540 | are creating a kind of cloud of pulls on our attention.

00:12:49.100 | And so there is this question

00:12:50.740 | to whether or not we are creating ADHD in adults

00:12:54.100 | that never had ADHD prior to being an adult.

00:12:58.100 | So let's talk about attention.

00:13:00.640 | And first, let's just define what we mean by attention.

00:13:04.220 | Out there in the scientific literature

00:13:05.980 | and in discussions about ADHD,

00:13:08.140 | we will hear things like attention, and focus,

00:13:10.780 | and concentration, and impulse control.

00:13:13.540 | For sake of today's discussion,

00:13:15.760 | attention, focus, and concentration

00:13:17.780 | are essentially the same thing, okay?

00:13:20.060 | We could split hairs and the scientific literature

00:13:22.180 | does split hairs about these,

00:13:23.920 | but if we want to understand the biology

00:13:25.700 | and we want to have a straightforward conversation

00:13:28.080 | about ADHD, if I say attention or focus,

00:13:31.420 | I'm basically referring to the same thing

00:13:33.620 | unless I specify otherwise, okay?

00:13:36.080 | So people with ADHD have trouble holding their attention.

00:13:41.080 | What is attention?

00:13:43.660 | Well, attention is perception.

00:13:46.580 | It's how we are perceiving the sensory world.

00:13:50.520 | So just a little bit of neurobiology 101,

00:13:52.620 | we are sensing things all the time.

00:13:54.620 | There's information coming into our nervous system

00:13:56.380 | all the time.

00:13:57.200 | For instance, right now, you're hearing sound waves,

00:13:59.700 | you are seeing things,

00:14:00.700 | you are sensing things against your skin,

00:14:02.700 | but you are only paying attention to some of those.

00:14:06.120 | And the ones that you're paying attention to

00:14:08.660 | are your perceptions.

00:14:09.780 | So if you hear my voice, you are perceiving my voice.

00:14:12.860 | You are not paying attention to your other senses

00:14:15.820 | at the moment, okay?

00:14:17.020 | You might even be outside in a breeze.

00:14:18.820 | And until I said that,

00:14:19.860 | you might not be perceiving that breeze,

00:14:21.940 | but your body was sensing it all along.

00:14:23.900 | So attention and focus are more or less the same thing,

00:14:28.320 | but impulse control is something separate

00:14:31.000 | because impulse control requires pushing out

00:14:34.040 | or putting the blinders on

00:14:35.860 | to sensory events in our environment.

00:14:38.340 | It means lack of perception.

00:14:40.120 | Impulse control is about limiting our perception.

00:14:44.180 | People with ADHD have poor attention

00:14:47.580 | and they have high levels of impulsivity.

00:14:50.000 | They are easily distractible.

00:14:52.500 | But the way that shows up is very surprising.

00:14:55.700 | You might think that people with ADHD

00:14:58.280 | just simply can't attend to anything.

00:15:00.300 | They really can't focus even if they really want to,

00:15:03.060 | but that's simply not the case.

00:15:05.440 | People with ADHD, yes, they are distractible.

00:15:09.620 | Yes, they are impulsive.

00:15:12.000 | Yes, they are easily annoyed by things happening in the room.

00:15:15.460 | They sometimes have a high level of emotionality as well,

00:15:18.240 | not always, but often.

00:15:19.960 | However, people with ADHD can have a hyper-focus,

00:15:24.280 | an incredible ability to focus

00:15:27.040 | on things that they really enjoy or are intrigued by.

00:15:31.780 | Now, this is a very important point

00:15:33.560 | because typically we think of somebody with ADHD

00:15:37.320 | as being really wild and hyperactive

00:15:40.080 | or having no ability whatsoever to sit still and attend.

00:15:44.240 | And while that phenotype, as we call it,

00:15:46.760 | that contour of behavior and cognition can exist,

00:15:51.540 | many people, if not all people with ADHD,

00:15:55.320 | if you give them something they really love,

00:15:57.680 | like if the child loves video games

00:15:59.480 | or if a child loves to draw,

00:16:01.300 | or if an adult loves a particular type of movie

00:16:05.440 | or a person very much, they will obtain laser focus

00:16:09.960 | without any effort.

00:16:11.640 | So that tells us that people with ADHD

00:16:14.040 | have the capacity to attend,

00:16:16.240 | but they can't engage that attention

00:16:19.200 | for things that they don't really, really want to do.

00:16:22.520 | And as we all know, much of life,

00:16:24.680 | whether or not you're a child or an adult,

00:16:26.560 | involves doing a lot of things that we don't want to do.

00:16:28.680 | Much of our schooling involves doing things

00:16:30.320 | that we would prefer not to do

00:16:32.400 | and sort of forcing ourselves to do it,

00:16:34.520 | to attend even though we are not super interested

00:16:37.360 | in what we are attending to.

00:16:39.280 | There are a couple of other things

00:16:40.560 | that people with ADHD display quite often.

00:16:43.720 | One is challenges with time perception.

00:16:47.560 | Now, time perception is a fascinating aspect

00:16:50.060 | of how our brain works.

00:16:51.040 | And later we're going to talk about time perception

00:16:53.000 | and how you can actually get better at time perception.

00:16:56.200 | It's very likely that right now you are doing things

00:16:58.920 | that get in the way of optimal time perception.

00:17:01.960 | And I will tell you how to adjust your ability

00:17:05.000 | to measure time with your brain.

00:17:08.960 | People with ADHD often run late.

00:17:12.040 | They often procrastinate.

00:17:13.980 | But what's interesting and surprising

00:17:15.660 | is that if they are given a deadline,

00:17:17.920 | they actually can perceive time very well.

00:17:20.900 | And they often can focus very well

00:17:23.420 | if the consequences of not completing a task

00:17:26.160 | or not attending are severe enough.

00:17:28.480 | It's a little bit like the way that people with ADHD

00:17:31.920 | can really focus if they like something.

00:17:34.280 | Well, if they're scared enough about the consequences

00:17:36.780 | of not attending, oftentimes, not always,

00:17:39.440 | but oftentimes they can attend.

00:17:41.040 | If they're not really concerned

00:17:44.100 | about a deadline or a consequence,

00:17:46.780 | well, then they tend to lose track of time

00:17:48.740 | and they tend to underestimate how long things will take.

00:17:52.200 | Now, many people do that, not just people with ADHD,

00:17:55.140 | but people with ADHD have challenges

00:17:58.800 | understanding how to line up the activities of their day

00:18:02.540 | in order to meet particular deadlines.

00:18:04.640 | Even if it's just a simple thing like finishing

00:18:07.400 | one set of tasks before lunch.

00:18:10.260 | Oftentimes they will remember that lunch starts at noon,

00:18:13.780 | but somehow they aren't able to fill the intervening time

00:18:16.940 | in a way that's productive.

00:18:19.120 | And they can obsess about the upcoming deadline,

00:18:21.660 | for instance.

00:18:22.720 | We will talk about how to remedy this.

00:18:25.040 | In addition, their spatial organization skills

00:18:27.960 | are often subpar, not always,

00:18:31.600 | but often you will find that somebody with ADHD

00:18:34.840 | uses what's called the pile system

00:18:37.120 | in order to organize things.

00:18:39.220 | They will take many belongings,

00:18:41.220 | and this could be in the kitchen or in their bedroom

00:18:43.420 | or in their office or in any space,

00:18:46.560 | and they will start piling things up

00:18:48.160 | according to a categorization system

00:18:50.020 | that makes sense to them and only them.

00:18:52.380 | It doesn't really have any logical framework.

00:18:55.620 | Now, many people use the pile system,

00:18:57.300 | and if you use the pile system,

00:18:58.380 | that doesn't mean that you have ADHD.

00:18:59.900 | In fact, if you're unpacking a house

00:19:01.540 | or you've moved recently,

00:19:03.180 | or you've received a lot of presents recently,

00:19:05.700 | the pile system makes perfect sense to organize your space.

00:19:09.440 | But people with ADHD tend to organize things

00:19:12.180 | according to the pile system all the time,

00:19:14.660 | and that pile system doesn't work for them.

00:19:17.660 | Okay, so that's the key distinction,

00:19:18.940 | that they use a filing system, and it's not really files,

00:19:21.400 | they're piling things up in a way that makes sense to them,

00:19:24.200 | but then it doesn't work for them

00:19:25.760 | in terms of what tasks they actually need to perform.

00:19:29.040 | They can't find things,

00:19:30.520 | or if anyone moves one thing,

00:19:32.360 | then it's very disruptive to their overall plan

00:19:34.840 | because their overall plan

00:19:35.680 | doesn't really work in the first place.

00:19:38.080 | So that's a common phenotype, as we call it.

00:19:41.840 | A phenotype, by the way, is just an expression

00:19:44.300 | of a particular set of underlying genetic

00:19:48.360 | or psychological components, okay?

00:19:51.400 | So we say the phenotype.

00:19:52.520 | So a phenotype could be brown hair and green eyes.

00:19:55.420 | Like for me, a phenotype could also be

00:19:57.420 | that somebody uses the piling system, okay?

00:20:00.580 | The other thing that people with ADHD have real trouble with

00:20:04.740 | is so-called working memory.

00:20:06.900 | Now, you might think that people with ADHD

00:20:08.440 | would have really poor memories,

00:20:09.860 | but in fact, that's not the case.

00:20:11.380 | People with ADHD often can have a terrific memory

00:20:14.840 | for past events.

00:20:16.140 | They can remember upcoming events quite well.

00:20:19.120 | Their memory is clearly working.

00:20:21.140 | However, one aspect of memory in particular

00:20:23.240 | that we call working memory is often disrupted.

00:20:26.740 | Working memory is the ability to keep specific information

00:20:30.100 | online to recycle it in your brain over and over again

00:20:33.180 | so that you can use it in the immediate or short term.

00:20:36.580 | A good example of this would be you meet somebody,

00:20:39.020 | they tell you their name,

00:20:40.400 | they give you their phone number verbally,

00:20:42.200 | and you have to walk back to your phone

00:20:43.860 | and enter it into your phone.

00:20:46.020 | People without ADHD might have to put some effort into it.

00:20:49.400 | It might feel like a bit of a struggle,

00:20:50.720 | but typically they would be able to recite that phone number

00:20:53.060 | in their mind over and over and then put it into their phone.

00:20:55.740 | People with ADHD tend to lose the ability

00:20:58.640 | or lack the ability to remember things

00:21:01.860 | that they just need to keep online

00:21:03.340 | for anywhere from 10 seconds to a minute or two, okay?

00:21:07.120 | So a string of numbers like 6, 4, 3, 7, 8, 1

00:21:10.340 | for most people would be pretty easy.

00:21:12.520 | 6, 4, 3, 7, 8, 1, 6, 4, 3, 7, 8, 1.

00:21:14.820 | You could probably remember that a minute from now

00:21:17.140 | without writing it down.

00:21:18.780 | But if you add one more number to that 6, 4, 3, 7, 8, 1, 3,

00:21:23.220 | it gets tougher, okay?

00:21:25.060 | So there's a reason why phone numbers

00:21:27.260 | typically have seven digits in them.

00:21:29.800 | Of course, there's an area code,

00:21:30.980 | but remembering information that strings out longer

00:21:35.500 | than seven numbers or a sentence or two,

00:21:39.420 | that's challenging for most people.

00:21:41.060 | People with ADHD have severe challenges

00:21:43.180 | even with much smaller batches of information

00:21:46.060 | over even much smaller batches of time.

00:21:49.420 | Deficits in working memory are also something

00:21:51.400 | that we see in people who have frontotemporal dementia,

00:21:54.420 | so damage to the frontal lobes,

00:21:56.080 | or age-related cognitive decline.

00:21:59.360 | And so it will come as no surprise

00:22:01.020 | that later when we discuss treatments, supplements,

00:22:04.860 | and other tools for ADHD,

00:22:07.140 | that many of those treatments, supplements,

00:22:09.040 | and tools for ADHD are similar to the ones

00:22:11.940 | that work for age-related cognitive decline.

00:22:14.740 | Okay, so we've more or less established

00:22:19.300 | the kind of menu of items that people with ADHD tend to have.

00:22:23.120 | Some have all of them, some have just a subset of them.

00:22:26.180 | Their severity can range from very intense to mild,

00:22:31.060 | but in general, it's challenges with attention and focus,

00:22:35.180 | challenges with impulse control.

00:22:36.980 | They get annoyed easily.

00:22:38.380 | They have kind of an impulsivity.

00:22:39.760 | They can't stay on task.

00:22:41.140 | Time perception can be off.

00:22:43.680 | They use the piling system or a system

00:22:46.720 | that doesn't work well for them

00:22:48.720 | in order to organize their things in physical space.

00:22:52.160 | And they have a hard time with anything that's mundane

00:22:54.580 | that they're not really interested in.

00:22:56.860 | But again, I just want to highlight

00:22:58.380 | that people with ADHD are able

00:23:00.580 | to obtain heightened levels of focus,

00:23:02.380 | even hyper-focus for things that are exciting to them

00:23:05.460 | and that they really want to engage in.

00:23:07.660 | So now you have the contour of what ADHD is.

00:23:10.340 | And if you're somebody who doesn't have ADHD,

00:23:12.720 | you should also be asking yourself

00:23:14.580 | which aspects of ADHD are similar

00:23:18.420 | to things I've experienced before,

00:23:20.600 | because what we know about the healthy brain

00:23:24.080 | is that there's also a range of abilities to focus.

00:23:27.420 | Some people focus very well on any task.

00:23:30.140 | You give them a task, they can just laser in on that task.

00:23:33.700 | Other people, they have to kind of fight an internal battle.

00:23:36.640 | They have to convince themselves

00:23:37.860 | that it's important or interesting.

00:23:39.180 | They have to kind of incentivize themselves internally.

00:23:42.860 | Other people, doesn't matter.

00:23:45.620 | They could be bored to tears with the information,

00:23:47.900 | but they can do it just because they are quote unquote,

00:23:50.060 | very disciplined people.

00:23:51.580 | We tend to admire those people,

00:23:53.000 | but as you'll see a little bit later,

00:23:54.660 | it's not clear that that's the best way

00:23:56.000 | to run your attentional system.

00:23:57.700 | There might be something to this business

00:23:59.900 | of having heightened levels of attention

00:24:02.020 | for the things that you are most interested or excited by.

00:24:05.280 | So let's drill into this issue of why people with ADHD

00:24:10.720 | actually can focus very intensely

00:24:12.860 | on things that they enjoy and are curious about.

00:24:16.660 | Now, enjoyment and curiosity are psychological terms.

00:24:21.320 | They're not even really psychological terms.

00:24:22.900 | They're just the way that we describe our human experience

00:24:25.520 | of liking things, wanting to know more about them.

00:24:28.780 | But from a neurobiological perspective,

00:24:31.500 | they have a very clear identity and signature,

00:24:34.780 | and that's dopamine.

00:24:36.240 | Dopamine is released from neurons.

00:24:38.940 | It's what we call a neuromodulator.

00:24:41.140 | And as a neuromodulator,

00:24:43.220 | it changes the activity of the circuits in the brain

00:24:45.820 | such that certain circuits are more active than others.

00:24:49.380 | And in particular, dopamine creates

00:24:52.500 | a heightened state of focus.

00:24:54.820 | It tends to contract our visual world,

00:24:57.540 | and it tends to make us pay attention to things

00:24:59.980 | that are outside and beyond the confines of our skin.

00:25:04.060 | It's what we call exteroception.

00:25:06.420 | Dopamine also tends to put us in a state of motivation

00:25:10.680 | and wanting things outside the confines of our skin.

00:25:14.180 | So whether or not we're pursuing something physical

00:25:16.540 | in our world, or whether or not we're pursuing information

00:25:20.180 | in our outside world, dopamine is largely responsible

00:25:23.620 | for our ability and our drive to do that.

00:25:26.520 | But dopamine as a neuromodulator is also involved

00:25:30.780 | in changing the way that we perceive the world.

00:25:34.120 | So as I mentioned earlier,

00:25:35.180 | you have all these senses coming in,

00:25:37.180 | and you can only perceive some of them

00:25:39.140 | because you're only paying attention to some of them.

00:25:42.260 | Dopamine, when it's released in our brain,

00:25:45.580 | tends to turn on areas of our brain

00:25:47.860 | that narrow our visual focus and our auditory focus.

00:25:51.740 | So it creates a cone of auditory attention

00:25:54.320 | that's very narrow, creates a tunnel of visual attention

00:25:57.580 | that's very narrow, whereas when we have less dopamine,

00:26:00.680 | we tend to view the entire world.

00:26:02.780 | We tend to see the whole scene that we are in.

00:26:04.900 | We tend to hear everything all at once.

00:26:07.420 | So as I describe this,

00:26:09.380 | hopefully you're already starting to see

00:26:11.700 | and understand how having dopamine release

00:26:15.540 | can allow a person, whether or not they have ADHD or not,

00:26:20.020 | to direct their attention to particular things

00:26:22.820 | in their environment, right?

00:26:24.460 | So now what we're doing is we're moving away from attention

00:26:27.700 | as this kind of vague, ambiguous term,

00:26:30.340 | and we're giving it a neurochemical identity, dopamine,

00:26:33.540 | and we are giving it a neural circuit identity.

00:26:36.520 | And just to put a little bit of flavor and detail

00:26:39.800 | on which neural circuits those are,

00:26:41.580 | I wanted to discuss two general types of neural circuits

00:26:44.540 | that dopamine tends to enhance.

00:26:46.960 | So let's talk neural circuits.

00:26:48.500 | And for those of you that love hearing

00:26:50.580 | neuroscience nomenclature, you're going to eat this part up.

00:26:54.140 | And for those of you that don't like a lot of names

00:26:56.300 | of brain areas, I invite you to tune out

00:26:59.200 | or just try and grab the top contour of this.

00:27:01.900 | I will describe it in pretty general terms,

00:27:03.780 | but I will give some detail

00:27:04.920 | because I know there are some of you out there

00:27:07.100 | who really want to dig deeper into what the exact structures

00:27:10.260 | and connectivities are, okay?

00:27:12.360 | So there are two main types of circuits

00:27:14.820 | that we need to think about with respect to ADHD,

00:27:17.500 | attention and dopamine.

00:27:19.020 | The first one is called the default mode network.

00:27:22.100 | The default mode network is the network of brain areas

00:27:25.700 | in your brain, in my brain, and in everybody's brain

00:27:28.500 | that is active when we're not doing anything,

00:27:31.820 | when we're just sitting there idle at rest.

00:27:34.260 | Now, it's very hard to not think about anything,

00:27:36.520 | but when you're not engaged in any type of specific task,

00:27:39.740 | so you're not driving, you're not playing a video game,

00:27:42.140 | you're not trying to study, you're not trying to listen,

00:27:44.540 | you're just sitting there,

00:27:45.460 | letting your brain kind of go wherever it wants to go,

00:27:48.700 | your default mode network underlies that state of mind.

00:27:53.040 | The other set of circuits that we're going to think about

00:27:56.900 | and talk about with respect to ADHD are the task networks,

00:28:01.600 | the networks of the brain that make you goal-oriented

00:28:04.900 | or that are at least trying to make you goal-oriented.

00:28:08.380 | And those are a completely different set of brain areas.

00:28:11.300 | However, the default mode network and these task networks

00:28:16.300 | are communicating with one another,

00:28:18.460 | and they're doing that in very interesting ways.

00:28:21.200 | So first, I want to describe how these two sets

00:28:24.160 | of brain areas, the default mode network

00:28:26.060 | and the task networks normally interact, okay?

00:28:29.540 | So little bit of naming here.

00:28:30.960 | Again, feel free to ignore it

00:28:32.260 | if you don't want this level of detail,

00:28:34.340 | but the default mode network includes an area called

00:28:38.580 | the dorsolateral prefrontal cortex.

00:28:41.300 | Frontal cortex, no surprises in the front,

00:28:43.500 | and you have a dorsal, the top, and side lateral part,

00:28:46.660 | dorsolateral prefrontal cortex.

00:28:49.020 | You got one on each side of your brain, right?

00:28:51.460 | And then you have a brain area

00:28:52.480 | called the posterior cingulate cortex.

00:28:54.780 | And then you have an area called the lateral parietal lobe.

00:28:57.180 | Again, you don't need to remember these names,

00:28:58.860 | but these are three brain areas

00:29:00.260 | that normally are synchronized in their activity.

00:29:03.180 | So when one of these areas is active in a typical person,

00:29:06.460 | the other areas would be active as well.

00:29:08.580 | So it's a little bit like a symphony

00:29:10.220 | or a band, like a three-piece band.

00:29:11.780 | It's like drums, guitar, and bass.

00:29:13.740 | They're playing together, okay?

00:29:16.120 | That's how it is in a typical person,

00:29:17.860 | in a person with ADHD,

00:29:19.780 | or even a person who has subclinical ADHD,

00:29:22.500 | or in any human being who hasn't slept well,

00:29:25.980 | what you find is the default mode network is not synchronized.

00:29:28.960 | These brain areas are just not playing well together.

00:29:32.820 | Now, the task networks

00:29:34.620 | include a different set of structures.

00:29:37.640 | It still involves the prefrontal cortex,

00:29:39.660 | but it's a different part of the prefrontal cortex, okay?

00:29:42.940 | Tends to be the medial prefrontal cortex.

00:29:45.660 | And there are some other brain areas

00:29:47.240 | that the medial prefrontal cortex

00:29:48.700 | is communicating to all the time,

00:29:50.900 | mainly to suppress impulses.

00:29:53.220 | It's shutting down the desire to stand up

00:29:56.300 | or to scratch the side of your cheek or your nose

00:29:58.580 | if you're trying not to do that.

00:29:59.900 | Anytime you're restricting your behavior,

00:30:01.860 | these task-directed networks are very active, okay?

00:30:05.600 | Now, normally, in a person without ADHD,

00:30:10.220 | the task networks and the default mode networks

00:30:14.020 | are going in kind of seesaw fashion.

00:30:15.940 | They are actually what we call anti-correlated.

00:30:18.760 | So it's not just that they are not correlated.

00:30:20.720 | They are actually opposing one another.

00:30:22.820 | They are anti-correlated.

00:30:24.300 | In a person with ADHD, the default mode networks

00:30:28.340 | and the task networks are actually more coordinated.

00:30:31.820 | That might come as surprising.

00:30:33.060 | I think that we all have this tendency

00:30:35.900 | to kind of jump to conclusion and assume that somebody

00:30:38.960 | who doesn't have an easy time paying attention or has ADHD,

00:30:42.780 | that their brain must be completely incoherent,

00:30:45.500 | that it's not working well because everything's out of whack.

00:30:48.940 | But there's something interesting about people with ADHD

00:30:51.580 | whereby the task networks and the default mode networks

00:30:56.320 | are actually working together in a way that's correlated,

00:30:59.380 | and that is what's abnormal.

00:31:01.740 | So this would be like the guitar, bass, and the drums

00:31:05.080 | playing together in a way where the bass

00:31:08.060 | isn't keeping the backbeat

00:31:09.460 | and the drums aren't keeping the backbeat,

00:31:12.100 | that they're playing together.

00:31:13.300 | They're all playing the melodies and harmonies

00:31:14.940 | in a way that just doesn't sound right.

00:31:17.100 | That's what's going on in the brain of somebody with ADHD.

00:31:21.500 | And we can now confidently say,

00:31:23.300 | based on brain imaging studies,

00:31:24.900 | that when somebody gets better

00:31:26.820 | when they're treated for ADHD or when they age out of ADHD,

00:31:30.540 | as sometimes is the case,

00:31:32.300 | that the default mode networks and the task networks

00:31:35.720 | tend to become anti-correlated again, okay?

00:31:38.660 | So that's the underlying neurobiology,

00:31:41.420 | but you'll notice that I didn't mention dopamine at all.

00:31:45.220 | What dopamine is doing in this context

00:31:47.380 | is dopamine is acting like a conductor.

00:31:50.540 | Dopamine is saying this circuit should be active,

00:31:52.840 | then that circuit should be active.

00:31:54.000 | It should be default mode network,

00:31:55.480 | and then when the default mode network is not active,

00:31:57.880 | then it should be the task network.

00:31:59.300 | So it's really acting as a conductor saying,

00:32:01.140 | you go, now you go, now you go, now you go.

00:32:03.300 | And in ADHD, there's something about the dopamine system

00:32:07.040 | that is not allowing it to conduct these networks

00:32:10.740 | and make sure that they stay what, you know,

00:32:13.340 | the engineers or physicists or mathematicians

00:32:15.260 | would say out of phase to be anti-correlated, okay?

00:32:18.700 | Out of phase and anti-correlated,

00:32:19.780 | essentially the same thing,

00:32:20.980 | at least for purposes of this discussion.

00:32:23.460 | So that raises two questions.

00:32:25.700 | Could it be that dopamine is not at sufficiently high levels

00:32:30.460 | or could it be that dopamine is just doing it all wrong?

00:32:33.180 | In other words, is there no conductor

00:32:35.140 | or is the conductor playing with like little tiny toothpicks

00:32:37.540 | and so the instruments can't see what they're supposed to do?

00:32:40.980 | They can't get the instruction

00:32:42.600 | 'cause it's just not loud enough, so to speak,

00:32:45.040 | or could it be that the information is getting out

00:32:47.060 | but the information that's getting out is wrong?

00:32:49.100 | The conductor is there

00:32:49.980 | but the conductor isn't very good at conducting.

00:32:54.140 | Now we can gain insight into how this system works and fails

00:32:58.900 | and how to treat it by looking at some of the current

00:33:01.820 | and previous treatments for ADHD,

00:33:04.260 | as well as some of the recreational drugs

00:33:06.300 | that people with ADHD tend to pursue and like.

00:33:09.840 | Now I'm certainly not a proponent of people with ADHD

00:33:12.560 | taking drugs recreationally, that's not what this is about,

00:33:15.500 | but if you look at their drug seeking behavior

00:33:18.260 | and you couple that drug seeking behavior

00:33:21.500 | to their desire to remedy their attention deficit,

00:33:25.500 | you start getting some really interesting insight

00:33:28.240 | into how dopamine is regulating these circuits

00:33:31.620 | in normal circumstances and in people with ADHD.

00:33:35.900 | So what exactly is going on with the dopamine system

00:33:38.400 | in people with ADHD?

00:33:40.220 | And what's going on with the dopamine system

00:33:41.980 | in people that have terrific levels of attention

00:33:44.940 | for any task?

00:33:46.500 | Well, in the year 2015, an important paper came out,

00:33:50.960 | the first author is Spencer

00:33:52.780 | and it came out in a journal called "Biological Psychiatry"

00:33:55.860 | and it formalized the so-called low dopamine hypothesis

00:33:59.940 | of ADHD.

00:34:01.860 | The idea that dopamine was somehow involved

00:34:04.080 | or not at the appropriate levels in people with ADHD

00:34:07.300 | had been around for a pretty long time

00:34:09.820 | but a formal proposition of the low dopamine hypothesis

00:34:14.780 | led to some really important experiments and understanding

00:34:17.660 | of what goes wrong in ADHD.

00:34:20.740 | It turns out that if dopamine levels are too low

00:34:24.340 | in particular circuits in the brain,

00:34:27.120 | that it leads to unnecessary firing of neurons in the brain

00:34:31.220 | that are unrelated to the task that one is trying to do

00:34:35.340 | and that is unrelated to the information

00:34:37.920 | that one is trying to focus on.

00:34:39.880 | So if you think back before,

00:34:41.060 | you've got this default mode network

00:34:42.800 | and a task-related network

00:34:44.220 | and they need to be in this kind of concert

00:34:46.800 | of anti-correlation and in ADHD, they're firing together.

00:34:50.720 | Well, the problem seems to be that when dopamine is low,

00:34:54.120 | certain neurons are firing when they shouldn't be.

00:34:57.660 | This is like a band, right?

00:34:59.100 | We'll go back to our band.

00:35:00.020 | That's a guitar, a bass and a person playing the drums

00:35:03.300 | and it's as if one of those or several of those instruments

00:35:06.620 | are playing notes when they shouldn't be playing, right?

00:35:09.460 | The pauses in music are just as important

00:35:12.000 | as the actual playing of notes.

00:35:14.500 | When dopamine is too low,

00:35:17.940 | neurons fire more than they should in these networks

00:35:20.880 | that govern attention.

00:35:22.000 | This is the so-called low dopamine hypothesis.

00:35:26.260 | And if you start looking anecdotally

00:35:29.500 | at what people with ADHD have done for decades,

00:35:33.640 | not just recently since the low dopamine hypothesis

00:35:36.620 | has been proposed,

00:35:38.280 | but what they were doing in the 1950s

00:35:40.200 | and then the 1940s and the 1960s,

00:35:42.500 | what you find is that they tend to use recreational drugs

00:35:48.060 | or they tend to indulge in non-drug stimulants.

00:35:53.060 | So things like drinking six cups of coffee

00:35:57.140 | or quadruple espressos,

00:35:59.220 | or when it was more prominent,

00:36:01.100 | smoking a half a pack of cigarettes

00:36:02.980 | and drinking four cups of coffee a day.

00:36:05.460 | Or if the person had access to it,

00:36:07.980 | using cocaine as a recreational drug

00:36:10.060 | or amphetamine as a recreational drug.

00:36:12.580 | All of those substances that I just described,

00:36:15.860 | in particular cocaine and amphetamine,

00:36:17.740 | but also coffee and cigarettes,

00:36:20.500 | increased levels of multiple neurotransmitters,

00:36:23.600 | but all have the quality of increasing levels

00:36:26.260 | of dopamine in the brain.

00:36:27.580 | And in particular,

00:36:29.100 | in the regions of the brain that regulate attention

00:36:31.840 | and these task-related and default mode networks, okay?

00:36:35.780 | Now, young children fortunately don't have access

00:36:38.100 | to those kinds of stimulants most of the time.

00:36:41.180 | And those stimulants all have high potential for abuse

00:36:45.660 | in adults.

00:36:46.500 | So we will talk about the potential for abuse

00:36:48.300 | in a few minutes.

00:36:49.340 | But if you look at children,

00:36:51.540 | even very young children with ADHD,

00:36:54.500 | they show things like preference for sugary foods,

00:36:57.620 | which also act as dopamine inducing stimulants.

00:37:01.760 | Now, of course, once they get access to soda pop

00:37:05.860 | and coffee and tea,

00:37:07.740 | they start to indulge in those more than other people.

00:37:10.100 | For a long time it was thought that children with ADHD

00:37:12.380 | consumed too many sugary foods or drank too much soda.

00:37:15.620 | Or adults with ADHD would take recreational drugs

00:37:19.820 | like methamphetamine or cocaine,

00:37:21.840 | or would drink coffee to excess

00:37:24.040 | or smoke cigarettes to excess

00:37:25.860 | because they had poor levels of attention.

00:37:28.220 | And because they couldn't make good decisions,

00:37:31.180 | they were too impulsive and so forth.

00:37:33.340 | And while that certainly could be the case,

00:37:35.620 | knowing what we now know about dopamine

00:37:37.900 | and the fact that having enough dopamine is required

00:37:41.900 | in order to coordinate these neural circuits

00:37:43.580 | that allow for focus and quality decision-making,

00:37:46.580 | an equally valid idea is that these children

00:37:51.140 | and these adults are actually trying to self-medicate

00:37:53.840 | by pursuing these compounds, right?

00:37:56.140 | Things like cocaine lead to huge increases in dopamine.

00:37:59.060 | Well, what happens when somebody with ADHD takes that drug?

00:38:03.260 | It turns out they actually obtain heightened levels of focus.

00:38:07.080 | Their ability to focus on things other than things

00:38:09.420 | they absolutely care intensely about goes up.

00:38:13.640 | Likewise, children who consume anything

00:38:16.480 | that increases their levels of dopamine,

00:38:19.020 | if those children have ADHD, they tend to be calmer.

00:38:23.700 | They tend to be able to focus more.

00:38:25.780 | Now, this is very different

00:38:27.460 | than children who do not have ADHD.

00:38:29.780 | When they consume too much sugar,

00:38:30.900 | they tend to become super hyperactive.

00:38:33.180 | When they consume any kind of stimulant,

00:38:34.880 | they tend to go wild and run around like crazy.

00:38:37.260 | I actually have an anecdote about this

00:38:38.660 | just to illustrate it.

00:38:40.340 | I have a friend, he has two children

00:38:42.520 | that are now in their teens and 20s,

00:38:44.420 | but when they were little,

00:38:45.700 | one time I brought them some chocolate just as a gift

00:38:48.220 | when I showed up at their house.

00:38:49.740 | And within 30 minutes,

00:38:51.660 | the kids were running around like crazy.

00:38:53.700 | I mean, they were pretty high energy kids,

00:38:56.080 | but they were going bonkers.

00:38:57.740 | And that's actually when the mother,

00:38:59.800 | my friend at the time, unfortunately still now,

00:39:02.140 | looked at the chocolate

00:39:02.980 | and realized that it was chocolate with espresso beans in it.

00:39:06.100 | It was like dark chocolate espresso beans.

00:39:07.520 | So I was really at fault there.

00:39:09.140 | You don't want to give kids dark chocolate

00:39:10.820 | with espresso beans,

00:39:11.660 | but what you're really seeing in that hyperactivity,

00:39:14.220 | that is dopamine, okay?

00:39:15.740 | It's the sugar combined with the caffeine in this case,

00:39:18.680 | combined with a few other compounds that exist in chocolate

00:39:21.340 | that really increase our levels of alertness

00:39:23.420 | and our tendency to want to move around a lot.

00:39:25.880 | Okay, so dopamine and low levels of dopamine

00:39:31.200 | apparently are what's wrong in people with ADHD.

00:39:34.940 | That dopamine hypothesis is what led to the idea

00:39:38.060 | that treating people, children and adults included,

00:39:41.700 | with dopaminergic compounds

00:39:44.440 | would somehow increase their ability to focus.

00:39:48.400 | And if you look at the major drugs that were developed

00:39:51.380 | and now marketed by pharmaceutical companies

00:39:53.960 | for the treatment of ADHD,

00:39:55.760 | those drugs have names like Ritalin.

00:39:59.800 | Nowadays, it's typically things like Adderall,

00:40:03.580 | Modafinil and some of the other derivatives,

00:40:06.140 | they all serve to increase levels of dopamine,

00:40:09.200 | in particular dopamine in the networks

00:40:11.300 | that control task-directed behavior

00:40:13.620 | and that coordinate the default mode network

00:40:16.700 | and these task-related networks.

00:40:18.800 | So many of you have probably heard of Ritalin.

00:40:20.860 | Ritalin is a prescription stimulant

00:40:23.500 | that is prescribed for ADHD as well as for narcolepsy.

00:40:28.220 | Narcolepsy is a condition in which people tend to fall asleep

00:40:32.020 | during the daytime quite a lot.

00:40:33.260 | It's excessive daytime sleepiness,

00:40:35.020 | not due to lack of sleep at night,

00:40:37.200 | but also tend to fall asleep when they get excited.

00:40:39.820 | If they're really emotionally excited or about to eat

00:40:42.860 | or any other kind of activity

00:40:44.260 | that would normally get somebody really aroused and alert,

00:40:47.420 | people with narcolepsy tend to fall asleep

00:40:49.380 | or they tend to become what's called cataplectic.

00:40:51.900 | They tend to just sort of go limp in the muscles.

00:40:54.460 | So it's this invasion of sleep into the daytime.

00:40:57.100 | It's dysregulated by emotion.

00:40:59.000 | You can imagine why a stimulant,

00:41:00.840 | something that would wake you up,

00:41:02.220 | make you very alert, focused, and motivated

00:41:04.180 | would be a good treatment for narcolepsy.

00:41:07.380 | Adderall also is used to treat ADHD and to treat narcolepsy.

00:41:12.380 | Things like modafinil also used to treat ADHD and narcolepsy.

00:41:18.140 | So you're sensing a theme here.

00:41:19.760 | So what are the differences and similarities

00:41:21.980 | between these drugs and what can that tell us about ADHD?

00:41:25.020 | Well, Ritalin was one of the first-generation drugs

00:41:29.380 | that was prescribed for ADHD in order to deal head-on

00:41:34.140 | with this dopamine hypothesis,

00:41:36.140 | this idea that in ADHD, dopamine levels are too low.

00:41:40.300 | Nowadays, Adderall is the more typically prescribed drug

00:41:43.440 | for ADHD.

00:41:45.180 | That has to do with some of the so-called pharmacokinetics,

00:41:47.780 | the rate at which those drugs enter the system

00:41:50.740 | and how long they last in the system.

00:41:52.780 | So for instance, Ritalin was a drug that was packaged

00:41:56.100 | into various time-release formulas,

00:41:58.300 | whereas initially Adderall was only released in a form

00:42:02.120 | that had a very short life.

00:42:03.600 | So meaning that it wasn't in the bloodstream very long

00:42:07.300 | and didn't affect the brain for very long.

00:42:08.940 | And so the dosages could be controlled

00:42:11.460 | in a more typical way

00:42:13.000 | without going into a lot of tangential detail.

00:42:15.900 | As you all know, at different times of day,

00:42:17.980 | you tend to be more or less alert.

00:42:19.860 | So a long sustained release drug,

00:42:22.620 | while that might sound like a really terrific thing,

00:42:24.920 | if that drug is having an effect of making you more alert

00:42:27.820 | and it's released across very many hours of your day,

00:42:31.140 | there might be periods of your day when you feel too alert,

00:42:34.360 | periods of your day when you feel just right,

00:42:36.240 | and periods of your day

00:42:37.080 | when you wished that you were more alert.

00:42:39.220 | These are some of the pharmacokinetics,

00:42:41.580 | kinetics meaning movement of the different compounds

00:42:44.400 | within the bloodstream and brain that could,

00:42:46.700 | you could imagine in a very real way would impact

00:42:49.140 | whether or not someone would feel really good

00:42:50.740 | on one of these drugs or whether or not

00:42:52.460 | they would feel too anxious or too sleepy and so on.

00:42:56.260 | Let's take a step back for a second and just ask,

00:42:57.940 | what are these drugs?

00:42:59.340 | We know they increase dopamine, but what are they really?

00:43:03.180 | Well, Ritalin, also called methylphenidate,

00:43:07.660 | is very similar to amphetamine, speed,

00:43:11.280 | or what's typically called speed

00:43:13.040 | in the street drug nomenclature.

00:43:16.340 | Adderall, which goes by various other names, okay?

00:43:20.940 | So Adderall, Adderall XR, Midiasis,

00:43:25.940 | things like that.

00:43:26.920 | Adderall is basically a combination of amphetamine

00:43:30.980 | and dextro amphetamine.

00:43:33.260 | Now, some of you probably realize this,

00:43:35.220 | that Adderall is amphetamine,

00:43:37.020 | but I'm guessing that there are a good number of you

00:43:39.200 | out there, perhaps even parents and kids

00:43:41.220 | that don't realize that these drugs

00:43:43.380 | like cocaine and amphetamine, methamphetamine,

00:43:45.700 | which are incredibly dangerous and incredibly habit forming

00:43:50.700 | and have high potential for abuse.

00:43:53.580 | Well, the pharmaceutical versions of those

00:43:56.180 | are exactly what are used to treat ADHD.

00:43:59.640 | Now, they're not exactly like cocaine or methamphetamine,

00:44:01.900 | but they are structurally and chemically very similar,

00:44:05.080 | and their net effect in the brain and body

00:44:07.860 | is essentially the same,

00:44:08.860 | which is to increase dopamine primarily,

00:44:11.660 | but also to increase levels of a neuromodulator

00:44:14.140 | called epinephrine or norepinephrine,

00:44:16.380 | also called noradrenaline and adrenaline.

00:44:18.260 | Those names are the same.

00:44:19.540 | And to some extent, to increase levels of serotonin

00:44:22.700 | in the brain and blood, but not so much serotonin,

00:44:25.760 | that's just kind of a small smidgen of effect, okay?

00:44:28.400 | So dopamine way up, norepinephrine and adrenaline way up,

00:44:32.820 | so that's motivation, drive, focus, and energy,

00:44:36.800 | and to some extent, a little bit of serotonin,

00:44:40.020 | which is really more about feeling calm and relaxed,

00:44:44.660 | and you could imagine why that would be

00:44:46.640 | a good balancing effect for dopamine and norepinephrine.

00:44:51.980 | So what I'm essentially saying is that the drugs

00:44:53.980 | that are used to treat ADHD are stimulants,

00:44:56.940 | and they look very much like, in fact,

00:44:59.420 | nearly identical to some of the so-called

00:45:01.780 | street drug stimulants that we all hear are so terrible.

00:45:05.820 | However, I do want to emphasize

00:45:08.140 | that at the appropriate dosages

00:45:10.140 | and working with a quality psychiatrist

00:45:13.640 | or neurologist or family physician,

00:45:16.180 | does have to be a board certified MD

00:45:17.820 | that prescribes these things,

00:45:19.420 | many people with ADHD achieve excellent relief

00:45:23.820 | with these drugs, not all of them, but many of them do,

00:45:26.260 | especially if these treatments are started early in life.

00:45:30.180 | So now knowing what these drugs are,

00:45:31.980 | I want to raise the question of why prescribe these drugs?

00:45:36.420 | I mean, everyone has to make a decision for themselves

00:45:38.520 | or for their child as to whether or not

00:45:39.760 | they're going to take these things or not.

00:45:42.620 | I also want to acknowledge that many people out there,

00:45:46.340 | many, many people out there are taking these drugs,

00:45:49.800 | even though they have not been clinically diagnosed

00:45:52.220 | with ADHD, and when I say these drugs,

00:45:53.980 | I'm specifically referring to Ritalin and Adderall

00:45:56.240 | and Modafinil, but more typically it's Adderall, okay?

00:46:00.100 | People using cocaine and amphetamine

00:46:01.960 | for recreational purposes,

00:46:03.240 | that's a completely different beast,

00:46:05.340 | and it is indeed a beast,

00:46:06.460 | and it's something that I strongly discourage.

00:46:08.800 | However, I am aware that up to 25% of college students

00:46:15.500 | and perhaps as many as 35% of all individuals

00:46:19.360 | between the ages of 17 and 30 are taking Adderall

00:46:24.360 | on a regular or semi-regular basis in order to work,

00:46:28.780 | in order to study, and in order to function and focus

00:46:32.900 | in their daily life, even though they have not been diagnosed

00:46:36.100 | with ADHD, there's a whole black market for this,

00:46:38.300 | they're getting it from people with prescriptions.

00:46:40.660 | I'm not here to pass judgment,

00:46:41.860 | I just want to emphasize how these drugs work.

00:46:44.700 | Some of the things that they do to enhance cognition

00:46:48.180 | and focus that actually serve the brain well

00:46:49.980 | in certain individuals,

00:46:51.220 | and how they can be very detrimental in other individuals.

00:46:55.780 | I sort of blew right past it,

00:46:57.140 | but the fact that in upwards of 25% of young people

00:47:01.700 | are taking things like Adderall,

00:47:03.780 | despite not having a clinical diagnosis of ADHD,

00:47:08.340 | well, that's a ridiculously high number.

00:47:10.800 | A few years ago, it was estimated

00:47:13.580 | that Adderall use and Ritalin use without diagnosis of ADHD

00:47:18.200 | was second in incident only to cannabis.

00:47:21.560 | But actually now the consumption of Adderall

00:47:25.360 | without prescription is higher than the consumption

00:47:29.940 | of cannabis in that age group.

00:47:31.780 | So what that means is that there's a lot of stimulant use

00:47:35.100 | in that age group.

00:47:36.220 | And there are a lot of adults also using

00:47:39.460 | and abusing stimulants in order to gain focus.

00:47:42.140 | Now we could have a whole discussion about whether or not

00:47:43.800 | life is becoming more demanding,

00:47:45.660 | whether or not the need for focus is excessive,

00:47:48.140 | and that's why people are doing that.

00:47:50.060 | Frankly, it's an interesting discussion,

00:47:51.580 | but it's not one that would deliver us to any answers.

00:47:54.100 | Rather, I'd like to focus on the ways that people now

00:47:57.340 | and people have always been self-medicating

00:47:59.580 | to increase focus, right?

00:48:02.020 | Caffeine, which I indulge some, I don't think to access,

00:48:07.020 | has long been used as a stimulant to increase dopamine,

00:48:10.380 | increase norepinephrine, increase focus and energy.

00:48:13.100 | And in addition to that, it works through the so-called

00:48:16.340 | cyclic AMP, phosphodiesterase pathway.

00:48:19.180 | Remember, anytime you hear an ASE, that's an enzyme,

00:48:22.240 | phosphodiesterase is involved in the conversion

00:48:25.300 | of things like cyclic AMP into energy for cells

00:48:28.380 | and so forth.

00:48:29.220 | Basically coffee gives you energy.

00:48:30.040 | It makes you feel good.

00:48:31.180 | And it increases focus because of the circuits

00:48:34.080 | that it engages in the brain.

00:48:35.620 | People have been taking caffeine

00:48:38.580 | and continue to take caffeine for ages.

00:48:42.540 | People also used to smoke cigarettes, nicotine,

00:48:45.980 | in order to gain focus.

00:48:47.560 | Nowadays, that's less common because of the concerns,

00:48:50.720 | quite valid concerns about lung cancer from smoking,

00:48:54.220 | but there's a lot of vaping out there.

00:48:57.120 | There are a lot of people now consuming nicotine,

00:48:59.900 | which is the active substance in cigarettes

00:49:02.460 | and in most nicotine vapes that stimulates the brain

00:49:06.900 | to be more focused and more alert.

00:49:09.300 | So the idea of taking stimulants of consuming things

00:49:12.420 | or smoking things in order to increase alertness

00:49:15.620 | is not a new idea.

00:49:17.160 | It's just that in ADHD,

00:49:18.960 | it's surprising that these things would work, right?

00:49:22.580 | I mean, if the problem is attention deficit

00:49:24.700 | hyperactivity disorder,

00:49:26.580 | what we're really talking about here are children

00:49:30.160 | that are prescribed a drug that ought to be a stimulant.

00:49:33.340 | It ought to make them hyper hyperactive.

00:49:35.540 | And rather than doing that,

00:49:36.920 | it actually somehow serves to calm them a bit

00:49:40.380 | or at least allow them to focus.

00:49:42.620 | Here's the reason.

00:49:43.780 | Children have a brain that's very plastic,

00:49:47.060 | meaning it can remodel itself and change in response

00:49:50.620 | to experience very, very quickly compared to adults.

00:49:54.460 | Taking stimulants as a child,

00:49:56.940 | if you are a child diagnosed with ADHD,

00:50:00.060 | allows that forebrain task-related network to come online,

00:50:04.520 | to be active at the appropriate times.

00:50:07.400 | And because those children are young,

00:50:09.680 | it allows those children to learn what focus is

00:50:12.680 | and to sort of follow or enter that tunnel of focus.

00:50:16.840 | Now, by taking a drug, it's creating focus artificially.

00:50:20.300 | It's not creating focus

00:50:21.940 | because they're super interested in something.

00:50:24.060 | It's chemically inducing a state of focus.

00:50:27.200 | And let's face it, a lot of childhood and school

00:50:30.180 | and becoming a functional adult

00:50:31.500 | is about learning how to focus

00:50:32.660 | even though you don't want to do something.

00:50:34.060 | In fact, when I was in college,

00:50:35.140 | I had this little trick that may or may not work

00:50:37.180 | for some of you, which is,

00:50:39.300 | if I couldn't focus on the material I was trying to learn,

00:50:42.320 | I would delude myself into thinking

00:50:44.460 | that it was the most interesting thing in the world.

00:50:46.420 | I would just kind of lie to myself and tell myself,

00:50:48.460 | okay, this, I won't mention the subjects.

00:50:50.860 | I absolutely love this.

00:50:53.960 | I would tell myself that I loved it.

00:50:56.240 | And I noticed that just that selective

00:50:58.940 | or deliberate engagement of that desire to know circuit,

00:51:03.060 | whatever that is in my brain, no doubt involves dopamine,

00:51:06.100 | allowed me to focus and remember the information.

00:51:08.340 | And somewhat surprisingly, or perhaps not surprisingly,

00:51:11.620 | I would often fall in love with the information.

00:51:13.440 | I find that that was my favorite class.

00:51:15.100 | It was what I wanted to learn the most.

00:51:17.060 | So that's one way you can do it artificially,

00:51:19.820 | but kids with ADHD, they can't do that, right?

00:51:21.960 | They're told to sit still

00:51:23.080 | and they end up getting up 11 times.

00:51:25.260 | You know, they are told that they can't speak out in class

00:51:28.420 | or that they have to remain in their seats for 10 minutes.

00:51:31.620 | And they just, despite their best effort,

00:51:33.760 | they simply cannot do it.

00:51:35.060 | They're highly distractible.

00:51:37.140 | So what are we to make of this whole picture

00:51:39.340 | that we need more dopamine, but these kids with ADHD,

00:51:42.660 | they're getting their dopamine by way of a drug,

00:51:45.180 | which is for all the world, amphetamines, right?

00:51:47.920 | It's speed.

00:51:48.760 | That's really what it is.

00:51:50.140 | What are the long-term consequences?

00:51:51.460 | What are the short-term consequences?

00:51:53.940 | And what should we make of people taking these drugs

00:51:57.080 | without a clinical need?

00:51:58.180 | What are the consequences there?

00:52:00.060 | Well, in order to get to some of those answers,

00:52:02.340 | I went to one of my colleagues.

00:52:04.260 | This is a colleague that I've actually known

00:52:05.680 | for a very long time.

00:52:07.020 | I was their teaching assistant

00:52:08.260 | when they were an undergraduate.

00:52:10.100 | They went on to get an MD, a medical degree,

00:52:12.940 | as well as a PhD and have become a pediatric neurologist

00:52:17.940 | that specializes in the treatment of epilepsy and ADHD

00:52:21.900 | in kids of all ages, from age three to 21.

00:52:25.680 | That's the age range, pretty broad age range,

00:52:27.580 | and has extensive knowledge in this.

00:52:30.180 | And what makes them particularly interesting

00:52:33.300 | for sake of this discussion is that they have a child,

00:52:36.960 | a young boy, who's now showing signs of ADHD,

00:52:40.780 | and they are on the threshold of trying to decide

00:52:43.940 | whether or not they will prescribe Adderall

00:52:47.220 | or something similar.

00:52:49.180 | So we had a discussion about this,

00:52:51.300 | and prior to learning that their child may have ADHD,

00:52:56.180 | I asked the following questions.

00:52:57.780 | First of all, I asked,

00:52:58.860 | what do you think about giving young kids amphetamine?

00:53:02.220 | And their answer was, you know, on the face of it,

00:53:06.420 | it seems crazy,

00:53:07.980 | but provided that the lowest possible dose is used

00:53:12.020 | and that that dosage is modulated as they grow older

00:53:15.780 | and develop those powers of attention,

00:53:17.920 | their observation was that they've seen more kids benefit

00:53:22.700 | than not benefit from that.

00:53:25.500 | Now, I'm certainly not saying what people should do.

00:53:27.700 | You obviously have to go to a doctor because as I always say,

00:53:30.420 | I'm not a doctor, I don't prescribe anything,

00:53:32.300 | I'm a professor, so I profess things.

00:53:33.980 | And here I'm professing that you talk to your doctor

00:53:35.900 | if you're considering giving Ritalin or Adderall

00:53:39.100 | or any type of stimulant to your child, of course.

00:53:41.460 | What could be more important than the health of your child?

00:53:44.000 | But it was a very interesting answer

00:53:45.420 | because typically we hear yes, Medicaid or don't Medicaid.

00:53:48.580 | Rarely do we hear that the medication should be adjusted

00:53:51.560 | across the lifespan and in any particular kind of way.

00:53:54.620 | Now, the fact that this person,

00:53:56.340 | this now friend of mine and colleague of mine

00:53:58.540 | has so much expertise in the way that the brain works

00:54:02.780 | and is considering putting their child on such medication,

00:54:06.660 | I said, you know,

00:54:08.840 | why wouldn't you wait until your kid reaches puberty?

00:54:11.460 | I mean, we know that in boys and in girls

00:54:14.660 | there are increases in testosterone and estrogen

00:54:16.620 | during puberty that dramatically change

00:54:19.820 | the way that the body appears,

00:54:21.400 | but also that dramatically changed

00:54:23.020 | the way that the brain functions

00:54:24.180 | in particular, we know this,

00:54:26.660 | that puberty triggers the activation

00:54:29.420 | of so-called frontotemporal task-related

00:54:32.960 | executive functioning.

00:54:33.980 | That's just fancy science speak for being able to focus,

00:54:37.220 | being able to direct your attention,

00:54:38.580 | being able to control your impulses.

00:54:40.240 | Look at a small child or look at a puppy

00:54:42.420 | and then look at an older child or look at a dog,

00:54:45.160 | very different levels, patterns of spontaneous behavior.

00:54:47.880 | Young children move around a lot.

00:54:49.060 | They're, I don't want to say shifty

00:54:50.620 | 'cause that makes it sound like

00:54:51.460 | they're up to something bad, which they might be,

00:54:53.460 | but they don't have to be up to something bad.

00:54:55.480 | They fidget a lot.

00:54:56.500 | So do puppies, everything's a stimulus.

00:54:58.500 | As animals and humans get older,

00:55:00.460 | they learn how to control their behavior and sit still,

00:55:04.220 | listen and focus, even if they don't want to.

00:55:07.540 | So giving a drug that allows a child

00:55:11.140 | to access that stillness early on,

00:55:14.740 | it's thought will allow them to maintain that ability

00:55:18.060 | as time goes on.

00:55:19.580 | But I decided to push a little bit further.

00:55:21.520 | I said, well, why would you do it now

00:55:25.060 | as opposed to during puberty or after puberty?

00:55:28.420 | And their answer was very specific

00:55:30.540 | and I think very important.

00:55:31.500 | What they said was, look,

00:55:33.500 | neuroplasticity is greatest in childhood

00:55:37.180 | and tapers off after about age 25,

00:55:40.320 | but neuroplasticity from age three

00:55:42.980 | until age 12 or 13 is exceedingly high.

00:55:47.980 | And they're right.

00:55:49.020 | When you sit back

00:55:49.860 | and you look at the literature on neuroplasticity,

00:55:52.040 | you'd say childhood plasticity and young adult plasticity

00:55:54.640 | is much greater than adult plasticity,

00:55:56.960 | but that early childhood plasticity is far and away

00:56:00.280 | the period in which you can reshape the brain

00:56:03.420 | at an accelerated rate.

00:56:05.380 | So this lines up really well with the clinical literature,

00:56:08.820 | not surprisingly, they're a clinician,

00:56:10.720 | that early treatment is key.

00:56:13.480 | If you have the opportunity to work with a quality physician

00:56:16.520 | and treat these things early,

00:56:18.400 | these drugs can allow these frontal circuits,

00:56:21.100 | these task-related circuits,

00:56:23.040 | to achieve their appropriate levels of functioning

00:56:26.040 | and for kids to learn how to focus

00:56:27.800 | in a variety of different contexts.

00:56:30.380 | Now, is that the only thing that they should be doing?

00:56:33.320 | Of course not.

00:56:34.320 | So the next question I asked was,

00:56:36.620 | what should we make of all this diet related stuff, right?

00:56:40.040 | I've heard before that the so-called elimination diet

00:56:44.260 | or ingesting no sugars or no dairy or no gluten,

00:56:48.820 | that all of these things have been purported

00:56:50.980 | to improve symptoms of ADHD.

00:56:53.420 | And people and parents with ADHD go to fanatic lengths

00:56:57.540 | to try and find the exact foods that are causing problems

00:57:01.300 | and the exact foods that the kids can eat

00:57:04.820 | in order to try and get their brain wired up right

00:57:07.260 | and correctly and to avoid lifelong ADHD.

00:57:11.940 | And their answer was really interesting.

00:57:14.060 | But before I tell you their answer,

00:57:16.020 | I want to tell you the studies and the data related

00:57:19.020 | to this question of whether or not food

00:57:21.700 | and the constellation of foods that one avoids

00:57:24.940 | and will eat has anything to do with our levels of attention

00:57:28.100 | and in particular, whether or not that can be used

00:57:30.140 | as a leverage point to treat ADHD.

00:57:33.420 | So you can imagine the challenges of exploring the role

00:57:36.260 | of diet and nutrition in any study,

00:57:39.120 | but especially in a study on ADHD.

00:57:41.220 | Why?

00:57:42.060 | Well, because as I mentioned before,

00:57:43.580 | children with ADHD and it turns out adults with ADHD tend

00:57:47.020 | to pursue sugary foods or any types of food

00:57:49.660 | that increase their levels of dopamine.

00:57:51.500 | They are naturally drawn to those foods,

00:57:53.060 | whether or not they realize it or not,

00:57:55.260 | presumably as a way to try and treat their lack of focus

00:57:58.300 | and impulsivity.

00:57:59.960 | So in this study that I'm about to share with you,

00:58:03.300 | there was no drug treatment.

00:58:04.740 | It was just a study manipulating diet

00:58:07.740 | and involved a hundred children,

00:58:09.240 | 50 in the so-called elimination diet group,

00:58:12.380 | the special diet where certain foods were eliminated

00:58:14.620 | and 50 in the so-called control group.

00:58:16.640 | However, being a well-designed randomized controlled trial,

00:58:21.380 | the study also included a crossover,

00:58:23.740 | meaning where the kids would serve as their own control

00:58:27.480 | or control group at a certain portion of the studies.

00:58:30.020 | They will be in one group where they eliminated

00:58:31.500 | certain foods and then after a period of time in the study,

00:58:33.860 | they would swap to the other group.

00:58:35.220 | This is a powerful way to design a study for reasons

00:58:37.660 | that you can imagine because you start to eliminate changes

00:58:41.260 | in effects due to individual differences.

00:58:43.500 | In any case, a hundred children total,

00:58:45.700 | 50 in each group at any one period in time.

00:58:48.180 | And the effects that they observed were extremely dramatic.

00:58:52.260 | In the world of statistics and analysis of scientific data,

00:58:54.980 | we talk about P values, probability values.

00:58:57.180 | What's the likelihood that something could happen

00:58:59.200 | according to chance?

00:59:00.060 | And typically the cutoff would be something like P

00:59:02.640 | less than 0.05.

00:59:04.340 | That's less than 0.05 chance essentially

00:59:08.700 | of the effect being due to chance.

00:59:11.780 | However, in this study, every single one of the effects

00:59:14.340 | is P less than 0.0001.

00:59:17.480 | Very, very infinitesimally small probability

00:59:20.660 | that the effects observed could be due to chance.

00:59:23.320 | So what were these effects?

00:59:24.240 | These effects were enhanced ability to focus,

00:59:26.960 | less impulsivity, even less tendency to move

00:59:30.620 | when trying to sit still.

00:59:32.740 | So everything from mental focus to the ability

00:59:34.900 | to control their bodies improved when they were

00:59:36.820 | in the elimination diet group.

00:59:38.680 | What was eliminated?

00:59:39.660 | Well, the elimination diet in this particular study

00:59:44.100 | was a so-called oligoantigenic diet.

00:59:47.520 | It was a diet in which each kid took a test to determine

00:59:51.100 | which foods they had antibodies for,

00:59:53.900 | meaning that they were mildly allergic to.

00:59:56.800 | Now in this study, it was very important

00:59:58.300 | that the kids not be extremely allergic to any food

01:00:00.620 | because as I mentioned before,

01:00:01.900 | they actually served as a control at one point in the study

01:00:05.320 | where they were eating all sorts of foods,

01:00:06.920 | including foods that they had mild allergies to.

01:00:08.860 | So basically what this study said

01:00:11.700 | was that eliminating foods to which children have allergies

01:00:16.300 | can dramatically improve their symptoms of ADHD.

01:00:19.720 | And this study, not surprisingly,

01:00:22.020 | because it was published in such a high quality journal,

01:00:24.280 | Lancet, et cetera, large number of subjects,

01:00:26.700 | set the world on fire.

01:00:28.800 | People were extremely excited about these results

01:00:32.060 | because here in the absence of any drug treatment,

01:00:34.760 | there was a significant improvement

01:00:36.240 | in ADHD symptoms observed.

01:00:38.040 | And then came the criticisms.

01:00:40.860 | So many papers were published after this,

01:00:44.580 | specifically dealing with reanalysis of these data.

01:00:48.020 | And I want to be fair in saying that the data in the paper

01:00:52.360 | look good, but there are criticisms

01:00:55.060 | of the overall structural design in the study.

01:00:57.660 | I don't want to go into all the details exactly

01:00:59.460 | 'cause it gets really nuanced about some of the statistics

01:01:02.420 | and the way that one examines these types of data,

01:01:05.700 | but there was skepticism.

01:01:07.580 | And in science, skepticism is healthy,

01:01:09.400 | especially when making decisions about whether or not

01:01:11.460 | to treat or feed children one food or another,

01:01:14.300 | or give them one drug or another.

01:01:16.000 | Now I want to return to the story of my friend

01:01:19.560 | who is a pediatric neurologist and treats ADHD

01:01:23.220 | and has a child who is on the precipice

01:01:25.600 | of perhaps starting to take drugs

01:01:27.900 | for the treatment of ADHD.

01:01:29.400 | I asked the simple question,

01:01:31.900 | do you see an effect of diet?

01:01:33.740 | Meaning when parents control the diet of their children,

01:01:37.660 | does it make a positive or negative or no difference

01:01:41.100 | in terms of the way that the kids respond to ADHD drugs

01:01:44.760 | like Ritalin and Adderall,

01:01:46.540 | or whether or not it can help them avoid

01:01:48.340 | treating with those drugs entirely?

01:01:50.100 | And her response was very straightforward.

01:01:52.140 | She said, "Elimination of simple sugars

01:01:54.900 | has a dramatic and positive effect."

01:01:56.940 | She's observed that over and over and over again

01:01:59.340 | in many dozens, if not hundreds of patients, okay?

01:02:03.300 | Now that's not a peer reviewed study,

01:02:04.820 | that's a statement that I'm conveying to you anecdotally,

01:02:07.100 | but it's a highly, highly informed one.

01:02:09.120 | I said, "What about these elimination diets?"

01:02:12.760 | She said, and I found other sources to support this,

01:02:15.500 | that these only go into genic diets are controversial.

01:02:18.500 | There are many people who really believe

01:02:21.100 | in identifying all the things that you're allergic to

01:02:23.700 | and making sure that you and especially your kids

01:02:26.340 | avoid those foods.

01:02:27.540 | However, there's another camp that's starting to emerge

01:02:30.580 | in the peer reviewed scientific literature

01:02:33.620 | showing that when kids are not exposed to certain foods,

01:02:37.540 | in particular nuts and things of that sort,

01:02:40.100 | they develop allergies to those foods

01:02:42.660 | and then when exposed to them later,

01:02:44.240 | they cause real problems.

01:02:45.360 | So there's a whole galaxy of discussion and controversy

01:02:48.940 | and outright fighting about allergies in kids

01:02:51.560 | and whether or not the oligoantigenic diet

01:02:53.320 | is the appropriate one.

01:02:54.160 | However, out of the four neurologists and psychiatrists

01:02:58.400 | that I spoke to about ADHD in preparation for this,

01:03:01.620 | every single one said,

01:03:03.320 | "Children with ADHD as much as possible

01:03:05.720 | should be encouraged to avoid high sugar

01:03:08.940 | and simple sugar foods of most kinds."

01:03:11.320 | And if they can find particular foods

01:03:14.680 | that exacerbate their symptoms,

01:03:16.360 | obviously eliminating those foods is beneficial.

01:03:20.360 | And the foods that exacerbate their symptoms change

01:03:24.160 | over time.

01:03:25.800 | So I don't like giving a complicated answer,

01:03:28.700 | but I also don't like giving an incomplete answer.

01:03:31.320 | What this tells me is that children,

01:03:34.640 | and especially young children who have ADHD

01:03:37.880 | should probably not eat much sugar,

01:03:41.460 | in particular simple sugars.

01:03:43.220 | In addition to that,

01:03:44.660 | exploring whether or not they have existing allergies

01:03:47.720 | to foods they already consume

01:03:50.000 | might be a good idea.

01:03:52.180 | At least that's what this paper,

01:03:53.840 | the Pelser et al. Lancet paper seems to speak to.

01:03:56.560 | And I should mention that that paper was published in 2011.

01:03:59.880 | Since then, there have been many dozens of studies

01:04:03.120 | exploring the same thing,

01:04:04.120 | as well as meta-analyses of all those data.

01:04:06.460 | And it does appear that diet can have

01:04:09.320 | a highly significant role in eliminating

01:04:13.200 | or at least reducing the symptoms of ADHD.

01:04:15.320 | So much so that some of the children

01:04:17.700 | are able to not take medication at all

01:04:19.720 | or eventually wean themselves off medication

01:04:22.960 | as young adults and as adults.

01:04:25.680 | One interesting question is whether or not adults

01:04:28.480 | should modify their diet

01:04:29.760 | in order to increase their levels of focus

01:04:32.680 | if they're already having normal levels of focus,

01:04:35.520 | but would like more,

01:04:36.400 | or would like to reduce existing adult ADHD.

01:04:40.280 | That's an interesting and even more controversial topic.

01:04:44.740 | It brings us right into the realm

01:04:46.520 | of what are called omega-3 fatty acids.

01:04:48.600 | I've talked many times on this podcast

01:04:50.120 | about the known benefits of omega-3 fatty acids,

01:04:53.220 | in particular, getting one gram, 1,000 milligrams or more,

01:04:58.220 | even as much as 2,000 milligrams each day

01:05:00.880 | of the so-called EPA component of omega-3 fatty acids,

01:05:05.880 | known to have antidepressant effects,

01:05:08.600 | mood elevating effects,

01:05:09.640 | known to have important effects

01:05:13.080 | protecting the cardiovascular system.

01:05:15.560 | I think it's now clear

01:05:17.080 | that the immune system also benefits

01:05:18.820 | that omega-3 fatty acids

01:05:20.720 | that include a gram or more of EPAs are very beneficial.

01:05:25.520 | Typically, that's done through fish oil.

01:05:27.080 | Liquid fish oil is going to be the most cost efficient,

01:05:29.080 | but there are capsule forms.

01:05:30.440 | For those of you that don't like fish oil,

01:05:33.040 | you can ingest this through other means.

01:05:34.280 | You can get it from certain algaes or krill, et cetera.

01:05:36.920 | You have to make it compatible with your particular diet,

01:05:40.680 | whether or not you're vegan or vegetarian

01:05:42.000 | or omnivore, et cetera.

01:05:43.220 | Omega-3s have been shown

01:05:46.000 | to have all these positive health benefits.

01:05:48.480 | Do they have positive effects on focus and attention?

01:05:52.260 | And the answer is,

01:05:53.680 | you can find studies that support that statement,

01:05:57.320 | and the effects are significant,

01:05:59.360 | but the effects are modest.

01:06:01.300 | You can also find studies that show no effect.

01:06:06.340 | However, much like with omega-3s and antidepressants,

01:06:11.520 | whereby ingestion of omega-3 fatty acids

01:06:16.360 | of a gram or more of EPA per day

01:06:18.320 | allows people with major depression

01:06:20.140 | to get away with taking lower doses

01:06:21.920 | of antidepressant medication,

01:06:23.760 | it does seem that ingestion of omega-3 fatty acids in adults

01:06:28.640 | that include EPAs of 1,000 milligrams or more

01:06:33.880 | can allow adults with ADHD

01:06:36.040 | or mild attention deficit issues

01:06:38.560 | to function well on lower doses of medication

01:06:43.560 | and in rare cases to eliminate medication entirely.

01:06:47.340 | So what this says is once again

01:06:49.360 | that the omega-3 fatty acids are beneficial.

01:06:51.600 | Will they cure or eliminate ADHD?

01:06:54.760 | I think it's safe to say no.

01:06:57.040 | They are playing a supportive

01:06:58.380 | or what we call a modulatory role.

01:07:00.680 | Just like good sleep plays a supportive and modulatory role

01:07:04.320 | for essentially everything,

01:07:05.500 | your immune system, your ability to think,

01:07:07.100 | your ability to regulate your emotion,

01:07:08.440 | it's modulating that process.

01:07:10.780 | This component of modulation

01:07:12.960 | is extremely important to highlight.

01:07:14.840 | And I think I want to spend a moment on it

01:07:16.880 | because this is especially important

01:07:19.080 | in the context of ADHD

01:07:20.480 | and all the information that's out there.

01:07:22.880 | There are biological processes that are mediated

01:07:26.160 | by particular compounds like dopamine.

01:07:28.920 | So for instance, the ability to feel motivated

01:07:31.200 | and to attend, to focus,

01:07:33.160 | is mediated by the circuits in the brain

01:07:35.860 | that release dopamine.

01:07:38.400 | However, attention is also modulated by how rested you are.

01:07:42.680 | If you want to eliminate your ability to think well at all,

01:07:45.760 | just stay up for two nights and don't sleep at all, right?

01:07:48.640 | If you do that, you will have modulated the circuits

01:07:51.760 | in your brain that respond to various things

01:07:55.280 | and you will be highly distractible.

01:07:56.960 | You will be highly emotional.

01:07:58.120 | You will feel like garbage.

01:07:59.600 | But that doesn't mean that sleep mediates focus

01:08:02.720 | and attention, it modulates it indirectly.

01:08:05.800 | Likewise, I think these omega-3 fatty acids,

01:08:08.540 | in particular the EPAs, which are so beneficial for mood

01:08:12.320 | and apparently also for attention,

01:08:14.680 | they don't directly mediate attention and mood.

01:08:18.440 | What they do is they modulate those circuits.

01:08:20.600 | They make dopamine more available.

01:08:23.120 | They make whatever dopamine is available

01:08:25.200 | more likely to bind to the various receptors

01:08:28.480 | that are present on neurons and so forth.

01:08:30.640 | And I think this is very important because likewise,

01:08:33.100 | diet and any discussion about nutrition

01:08:35.260 | has to include this framework of is the diet,

01:08:38.440 | the elimination diet or whether or not it's some other diet

01:08:41.420 | or esoteric diet, ketogenic diet,

01:08:43.080 | is it modulating or mediating a process?

01:08:46.120 | And most likely in the context of ADHD,

01:08:48.780 | it's modulating that process.

01:08:50.960 | So if the ADHD is mild or if it's caught early enough

01:08:54.340 | or if it's in conjunction with pharmacology

01:08:57.680 | with a prescription treatment,

01:08:59.280 | well, then it might help guide the child or adult

01:09:01.860 | to a better place of being able to focus.

01:09:03.940 | But it's not going to be the switch that flips everything.

01:09:07.120 | Now, that does not mean that consuming the wrong foods,

01:09:10.780 | sugary foods or foods that you happen to be allergic to

01:09:13.120 | is a good idea.

01:09:14.120 | It will still be detrimental.

01:09:16.040 | So I hope that conceptual framework helps

01:09:18.000 | 'cause if you go online, if you're somebody with ADHD or not

01:09:21.080 | you are going to be bombarded with the ADHD diet,

01:09:24.460 | the oligoantigenic diet, the elimination,

01:09:26.920 | this supplement, that EPA.

01:09:29.200 | And I think it's very important to understand

01:09:31.560 | whether or not you're talking about

01:09:32.680 | something mediating a process or modulating a process.

01:09:36.280 | Now, drugs like Ritalin, drugs like Adderall,

01:09:38.840 | they are tapping into the circuitries

01:09:41.020 | and the neurochemistries that mediate attention and focus.

01:09:45.320 | They are not the only alternatives

01:09:47.400 | or the only choices rather for treatment of these circuits

01:09:50.340 | and enhancement of the circuits for focus.

01:09:52.200 | I'm going to talk about other alternatives

01:09:53.940 | and some behavioral alternatives

01:09:55.980 | that are not very well known,

01:09:57.420 | but are very, very effective in a few minutes.

01:10:00.920 | But I really want to make this clear distinction

01:10:03.460 | between modulation and mediation

01:10:05.600 | because it's vital for anyone that's trying to modulate

01:10:09.120 | or mediate anything within their own brain.

01:10:11.600 | If any of you are interested in this oligoantigenic diet

01:10:14.360 | as it relates to ADHD,

01:10:16.080 | and you want to explore a more recent study

01:10:19.680 | besides that classic 2011 Lancet study

01:10:22.740 | that's rather controversial,

01:10:23.820 | there's a paper that was published

01:10:25.200 | in Frontiers in Psychiatry just last year, 2020.

01:10:29.060 | The title of the paper is Oligoantigenic Diet

01:10:31.580 | Improves Children's ADHD Rating Scale Scores Reliably

01:10:35.780 | in Added Video Rating.

01:10:37.740 | The added video rating is just that they're using

01:10:39.540 | an additional measure of focus and attention.

01:10:43.260 | Again, that's Frontiers in Psychiatry 2020.

01:10:46.180 | I'll put a link to it in the caption,

01:10:48.260 | and that's a more recent study for you to peruse.

01:10:51.080 | So we've talked about the neural circuits of focus

01:10:53.100 | and the chemistry of focus,

01:10:55.200 | but we haven't talked yet about what would make us better

01:10:59.400 | at focusing and what focusing better really is.

01:11:01.960 | So let's take a step back and think about how we focus

01:11:06.080 | and how to get better at focus.

01:11:07.820 | And I'm going to share with you a tool

01:11:10.040 | for which there are terrific research data

01:11:13.280 | that will allow you in a single session

01:11:15.680 | to enhance your ability to focus in theory forever.

01:11:20.080 | What I'm about to read you is from an excellent book

01:11:24.520 | that I recommend if any of you are interested in neuroscience

01:11:27.380 | and things like meditation and default mode networks

01:11:30.500 | and things of that sort.

01:11:32.120 | The book is called Altered Traits.

01:11:33.900 | Science reveals how meditation changes your mind,

01:11:37.920 | brain, and body.

01:11:39.220 | And no, I'm not going to try and convince you to meditate.

01:11:41.760 | I'm going to share with you a small passage in the book

01:11:44.520 | that relates some research data related to focus

01:11:47.380 | that are very important.

01:11:48.680 | If you want to meditate, that's your choice.

01:11:50.600 | That's a separate matter.

01:11:51.440 | This is a book by Daniel Goleman and Richard Davidson,

01:11:54.240 | and I should just mention that Goleman is a well-known

01:11:56.880 | author, he's written books on emotional intelligence

01:11:59.420 | and so forth.

01:12:00.820 | Richard Davidson is also a PhD.

01:12:04.200 | He's a professor of psychology and psychiatry,

01:12:06.500 | and he's at a University of Wisconsin, Madison.

01:12:09.520 | He's done terrific work on brain states

01:12:12.280 | and modulation of brain states and so forth.

01:12:14.520 | What we're about to talk about is when attention works

01:12:19.440 | and when attention falters.

01:12:21.920 | And what we are specifically going to talk about

01:12:24.080 | are what are called attentional blinks,

01:12:26.780 | not actual eye blinks.

01:12:28.040 | We're going to talk about that in a few minutes,

01:12:29.780 | but we're going to talk about attentional blinks.

01:12:32.180 | I'm paraphrasing here because Goleman and Davidson

01:12:37.560 | wrote about this so beautifully.

01:12:39.200 | I'd rather paraphrase from them than try and just make up

01:12:41.700 | a new way to say it that is less interesting or less good,

01:12:44.960 | but I want to credit them.

01:12:46.880 | Attentional blinks are really easy to understand

01:12:48.840 | if you think about a where's Waldo task.

01:12:50.760 | You know this task, where's Waldo,

01:12:52.260 | where there are a bunch of people and objects

01:12:54.920 | and things in a picture.

01:12:56.160 | And somewhere in there is Waldo with the striped hat

01:12:58.580 | and the glasses and kind of a skinny dude,

01:13:00.680 | and you have to find Waldo.

01:13:02.360 | And so it's a visual search and it's visual search

01:13:05.220 | for an object that has distinct features,

01:13:07.300 | but is embedded in this ocean of other things

01:13:10.660 | that could easily be confused as Waldo.

01:13:12.700 | So you tend to look, look, look, look, look, look, look, look.

01:13:14.860 | And then you find Waldo.

01:13:16.560 | Kids can do this, they enjoy doing this.

01:13:18.240 | Adults may or may not enjoy it, but they can do it too.

01:13:21.120 | They find Waldo.

01:13:22.080 | When you find Waldo or when you search for a target

01:13:26.120 | in some other visual search task,

01:13:28.160 | at that moment, your nervous system celebrates a little bit.

01:13:31.920 | And it celebrates through the release of neurochemicals

01:13:34.720 | that make you feel good.

01:13:35.560 | You found it and you pause.

01:13:38.260 | Now the pause is interesting because when you pause,

01:13:41.780 | what we know from many experiments is that in that moment

01:13:45.920 | of pause and mild celebration, however mild,

01:13:51.140 | you are not able to see another Waldo

01:13:54.280 | sitting right next to it.

01:13:56.140 | So what this means is in attending to something,

01:13:59.360 | in searching and in identifying a visual target,

01:14:03.960 | your attention blinked, it shut off for a second.

01:14:07.180 | And there's a more formal and more laboratory type way

01:14:11.220 | that we look at this.

01:14:12.260 | The more typical way to do this is to give someone

01:14:16.600 | a string of letters or a string of numbers.

01:14:19.480 | And beforehand, you tell them be on the lookout

01:14:23.140 | for the letters R and Z, okay?

01:14:27.320 | You're just going to watch this string of numbers go by

01:14:30.080 | and there will be a letter R in there

01:14:31.840 | and there will be a letter Z in there

01:14:33.760 | and try and spot them both.

01:14:35.860 | And what you find is when you present that string of numbers

01:14:40.320 | and then they see the R, they see the R,

01:14:43.520 | they register it consciously and they tend to miss the Z,

01:14:48.900 | just like in the Waldo type example.

01:14:51.400 | Now, of course, the numbers are going by pretty quickly,

01:14:53.560 | but they can spot the R.

01:14:55.100 | They could also spot the Z if you told them beforehand,

01:14:58.880 | just spot the Z and the numbers are moving through

01:15:02.060 | at the same rate in both conditions.

01:15:03.560 | So what that means is that in every case,

01:15:05.920 | you are capable of seeing the R or the Z.

01:15:10.220 | It's when you try and see both that seeing the first one

01:15:13.960 | prevents you from seeing the second one.

01:15:16.400 | It's what we call an attentional blink.

01:15:19.180 | We do this all the time and people with ADHD

01:15:23.720 | tend to have many more attentional blinks

01:15:26.620 | than people that don't.

01:15:27.520 | And this is true for children and for adults.

01:15:29.760 | This is an important point.

01:15:32.060 | So important that I want to emphasize it twice

01:15:34.040 | in case you intentionally blinked.

01:15:36.540 | If you see something that you're looking for

01:15:39.060 | or you're very interested in something,

01:15:40.860 | you are definitely missing other information.

01:15:45.100 | In part, because you're over focusing on something.

01:15:48.020 | And this leads to a very interesting hypothesis

01:15:50.300 | about what might go wrong in ADHD,

01:15:53.400 | where we've always thought that they cannot focus

01:15:56.520 | and yet we know they can focus on things

01:15:58.320 | they care very much about.

01:16:00.420 | Well, maybe, just maybe,

01:16:03.020 | they are experiencing more attentional blinks

01:16:06.140 | than people who do not have ADHD.

01:16:09.000 | And indeed there are data now to support the possibility

01:16:12.420 | that that's actually what's happening.

01:16:14.100 | And that should be exciting to anyone that has ADHD.

01:16:16.900 | It should also be exciting to anyone that cares

01:16:18.740 | about increasing their focus and their ability to attend.

01:16:22.100 | What this is saying is that these circuits

01:16:23.740 | that underlie focus and our ability to attend

01:16:26.360 | and our ability to eliminate distraction,

01:16:28.540 | they aren't just failing to focus.

01:16:32.060 | That's just a semantic way of describing the outcome.

01:16:35.420 | They are over focusing on certain things

01:16:37.580 | and thereby missing other things.

01:16:39.580 | And so our distractibility or the distractibility

01:16:42.600 | of somebody with ADHD could exist

01:16:45.560 | because they are over focusing on certain elements

01:16:49.400 | and they are therefore missing other elements

01:16:51.880 | that they should be attending to.

01:16:53.900 | So what they really need is this property

01:16:57.500 | that we call open monitoring.

01:16:59.020 | Now, open monitoring is something that's described

01:17:01.440 | in the book that I just referred to.

01:17:02.800 | And that typically is associated with people

01:17:05.880 | who have done a lot of meditation,

01:17:07.540 | so-called vipassana meditation,

01:17:09.200 | or have spent a lot of time learning how to do

01:17:12.540 | what's called open gaze visual analysis

01:17:15.280 | and open gaze thinking.

01:17:16.300 | But there's a simpler version of this

01:17:17.740 | that allows us to bypass all that.

01:17:19.700 | First of all, your visual system

01:17:23.820 | has two modes of processing.

01:17:26.740 | It can be highly focused, a soda straw view.

01:17:28.880 | So looking for the R in this string of numbers

01:17:31.340 | in the example that I just gave,

01:17:33.020 | or if you're very excited about something,

01:17:34.740 | you're in that soda straw view of the world

01:17:36.420 | and you're missing other things, okay?

01:17:37.960 | That's high levels of attention.

01:17:40.300 | However, there's also a property of your visual system

01:17:43.340 | that allows you to dilate your gaze,

01:17:45.040 | to be in so-called panoramic vision.

01:17:47.300 | Panoramic vision is something you can do right now,

01:17:49.360 | no matter where you are, and I can do it right now.

01:17:51.900 | You won't know that I'm doing it,

01:17:53.220 | but even though I'm still looking directly at you,

01:17:56.380 | I'm consciously dilating my gaze

01:17:58.340 | so that I can see the ceiling, the floor,

01:17:59.820 | and the walls all around me.

01:18:01.140 | That panoramic vision is actually mediated

01:18:03.520 | by a separate stream or set of neural circuits

01:18:06.860 | going from the eye into the brain.

01:18:08.460 | And it's a stream or set of circuits

01:18:10.920 | that isn't just wide angle view.

01:18:13.180 | It also is better at processing things in time.

01:18:16.240 | Its frame rate is higher.

01:18:18.160 | So you've seen slow motion video

01:18:20.060 | and you've seen standard video.

01:18:21.740 | Slow motion video gives you that slow motion look

01:18:26.620 | because it's a higher frame rate, your thin slicing time.

01:18:30.180 | You can use panoramic vision to access the state

01:18:35.380 | that we call open monitoring.

01:18:36.680 | When people do that, they are able to attend to

01:18:41.060 | and recognize multiple targets

01:18:44.260 | within this string of numbers.

01:18:46.100 | They can see the R and they can see the Z

01:18:48.200 | and they can see additional things.

01:18:50.140 | So this is something that can be trained up

01:18:52.660 | and people can practice whether or not

01:18:53.980 | they have ADHD or not.

01:18:56.140 | What it involves is learning

01:18:57.560 | how to dilate your gaze consciously.

01:18:58.980 | That's actually quite easy for most people.

01:19:01.420 | Whether or not you wear corrective lenses

01:19:03.380 | or contacts or not, you can consciously go into open gaze

01:19:06.260 | and then you can contract your field of view as well.

01:19:09.640 | There have also been studies done

01:19:11.340 | where people were taught to think in a particular way

01:19:15.940 | for a very short period of time

01:19:17.760 | and that forever changed their ability to limit

01:19:21.480 | or reduce the number of these attentional blinks.

01:19:24.300 | There are now published accounts in the literature

01:19:26.020 | of a simple practice done for about 15 minutes

01:19:29.820 | where subjects were asked to just sit quietly,

01:19:32.220 | eyes closed and do what is sort of akin to meditation

01:19:35.060 | but to not direct their mind

01:19:36.340 | into any particular state or place

01:19:38.340 | but simply to think about their breathing

01:19:40.380 | and to focus on their so-called interoception,

01:19:42.640 | focus on how their body feels,

01:19:44.240 | their mind drifted to bring it back.

01:19:45.940 | Okay, so it's basically meditation for about 15 minutes.

01:19:50.200 | That might not seem like a significant or unusual practice

01:19:53.620 | or that it would have any impact at all

01:19:55.900 | but remarkably just doing that once for 17 minutes

01:20:01.820 | significantly reduced the number of attentional blinks

01:20:05.140 | that people would carry out.

01:20:06.560 | In other words, their focus got better

01:20:08.540 | in a near permanent way without any additional training.

01:20:12.360 | There's something about that practice

01:20:13.980 | of reducing the amount of visual information coming in

01:20:17.140 | and learning to pay attention to one's internal state,

01:20:19.580 | what we call interoception,

01:20:21.420 | that allowed them an awareness

01:20:23.100 | such that when they needed to look for visual targets,

01:20:26.060 | when they need to focus on multiple things in sequence,

01:20:29.000 | they didn't experience the same number of attentional blinks.

01:20:32.500 | And I should mention not incidentally,

01:20:34.980 | as people age and their working memory gets worse

01:20:38.200 | and their ability to focus gets worse,

01:20:40.860 | the number of attentional blinks that they carry out goes up.

01:20:44.180 | And there are now studies exploring

01:20:45.740 | whether or not this simple meditation-like practice

01:20:48.900 | of 15 to 20 minutes or so of sitting

01:20:51.620 | and just quietly resting and paying attention

01:20:53.980 | to one's breathing and internal state

01:20:55.900 | can also offset some of that age-related,

01:20:58.700 | what is called cognitive decline.

01:21:01.380 | So what these data tell me is that regardless

01:21:04.300 | of whether or not you're a child or you're an adult,

01:21:07.100 | whether or not you have ADHD or not,

01:21:09.900 | whether or not you're experiencing

01:21:11.140 | age-related cognitive decline,

01:21:12.680 | or you would simply like to avoid

01:21:14.240 | age-related cognitive decline,

01:21:15.860 | a simple practice of taking 17 minutes sitting

01:21:21.420 | and paying attention to your internal state,

01:21:23.740 | just interocepting, registering your breathing,

01:21:26.980 | registering the contact of your skin

01:21:29.140 | with whatever surface you're on,

01:21:31.220 | can forever rewire your brain to be able to attend better

01:21:35.560 | and possibly even offset

01:21:37.380 | some of that age-related attentional drift.

01:21:40.120 | Now, I don't expect anyone to start meditating regularly.

01:21:44.900 | I don't expect anyone to do anything they don't want to do,

01:21:47.500 | but I think most of us could handle one meditation session

01:21:51.460 | of 17 minutes or so.

01:21:53.500 | And so if ever there was a tool

01:21:54.980 | that stood to rewire our attentional circuitry

01:21:57.340 | in a powerful way, this seems to be it.

01:22:00.700 | And in addition, the ability to engage in panoramic vision,

01:22:05.540 | to dilate our gaze, this so-called open monitoring

01:22:08.820 | that allows the brain to function in a way

01:22:10.820 | that it can detect more information faster,

01:22:13.200 | that's a powerful tool as well.

01:22:14.660 | And the beauty of that tool is that it works the first time

01:22:17.180 | and it works every time.

01:22:19.020 | Now, how exactly it works is a little bit unclear.

01:22:23.740 | Is it, for instance, orchestrating this synchrony

01:22:28.020 | or asynchrony between the default mode network

01:22:30.580 | and the task-related networks?

01:22:31.760 | We don't know.

01:22:32.700 | Those studies have not yet been carried out.

01:22:35.340 | Nonetheless, the effects are significant,

01:22:37.620 | they are long lasting,

01:22:39.180 | and they appear to exist after just one session

01:22:42.460 | of this quiet 17-minute interoception,

01:22:45.740 | which to me makes it seem like a very worthwhile thing

01:22:47.860 | to do for everybody.

01:22:49.780 | So we just talked about attentional blinks,

01:22:51.940 | which are essentially blinks of thinking.

01:22:54.320 | It's your mind shutting off for a moment

01:22:56.480 | and missing information.

01:22:58.660 | Now let's talk about actual blinks,

01:23:00.740 | the sort that you do with your eyelids.

01:23:03.060 | Now, this might come across as somewhat obvious,

01:23:05.500 | but you can do fast, what are called spontaneous blinks,

01:23:10.020 | and they are always coordinated between the two eyes.

01:23:12.800 | Or you can do long blinks,

01:23:14.060 | like when you go to sleep at night,

01:23:15.540 | you do one very long blink, and I'm not being facetious.

01:23:19.460 | When you go to sleep at night,

01:23:20.460 | you are shutting your eyelids

01:23:23.740 | and you are limiting the amount of information coming in,

01:23:27.480 | and your perception of time starts to drift

01:23:30.460 | as you go into sleep.

01:23:31.660 | Your perception of time changes from very fast

01:23:35.820 | at one moment to very slow,

01:23:37.980 | meaning the frame rate

01:23:40.140 | at which you are analyzing information,

01:23:43.100 | dreaming, et cetera, is variable when you are in sleep.

01:23:46.700 | Sometimes it's very fast,

01:23:48.160 | meaning you experience things in slow motion,

01:23:49.820 | sometimes it's very fast.

01:23:51.100 | In waking too,

01:23:52.960 | your experience of time can sometimes be very fast,

01:23:57.260 | sometimes be very slow.

01:23:58.540 | Typically, the more alert you are,

01:24:00.900 | the higher the frame rate,

01:24:02.020 | your thin slicing your experience.

01:24:05.100 | You've probably had this happen.

01:24:06.360 | If you're ever very stressed

01:24:07.460 | and you're waiting for something or somebody,

01:24:09.860 | it seems like it takes forever

01:24:12.260 | because your frame rate is higher,

01:24:14.020 | you're analyzing time more finely.

01:24:16.420 | Conversely, if you are very relaxed or even sleepy,

01:24:21.060 | you wake up and you have to think about all the things

01:24:22.660 | you have to do,

01:24:23.500 | it will seem like the world is going by very, very fast

01:24:25.680 | and that you are moving very slow.

01:24:28.000 | Time is going at the same rate,

01:24:30.320 | but your perception of time is what's changed.

01:24:33.580 | Believe it or not,

01:24:35.020 | your perception of time is also changed on a rapid basis,

01:24:39.240 | moment to moment basis by how often you blink.

01:24:44.220 | This is a well-established literature

01:24:46.780 | in the world of neuroscience

01:24:48.140 | that unlike the literature and claims about blinking

01:24:52.660 | and sociopathy, which have no basis,

01:24:55.660 | the science of blinking as it relates to time perception

01:24:59.020 | has some very good data to support it.

01:25:01.220 | I want to just emphasize one study in particular,

01:25:03.940 | which is quite appropriately titled

01:25:06.500 | Time Dilates After Spontaneous Blinking.

01:25:09.060 | This is a paper that was published in Current Biology.

01:25:11.480 | The first author is Terhune, T-E-R-H-U-N-E.

01:25:15.400 | It's a wonderful paper.

01:25:16.600 | They examined the relationship between fluctuations

01:25:21.100 | in timing and blinking.

01:25:23.960 | And to make a long story short,

01:25:26.180 | what they found is that right after blinks,

01:25:29.920 | we reset our perception of time, okay?

01:25:33.520 | So blinks in that sense are a little bit like

01:25:36.080 | the curtain coming down on a scene between scenes in a play

01:25:40.080 | or takes in a movie, you know, when they clap thing,

01:25:43.160 | they start it, take, you know, what do they say?

01:25:45.980 | Action.

01:25:46.820 | And then at the end, they do the thing

01:25:48.720 | and they click it down and they say, it's a take.

01:25:51.320 | That's one take.

01:25:52.520 | When you blink, it's a take, okay?

01:25:55.040 | Now what's interesting and will immediately make sense to you

01:26:00.200 | as to why this is important

01:26:02.720 | is that the rate of blinking is controlled by dopamine.

01:26:08.320 | So what this means is that dopamine is controlling attention,

01:26:11.500 | blinks relate to attention and focus,

01:26:14.240 | and therefore the dopamine and blinking system

01:26:16.880 | is one way that you constantly modulate

01:26:20.680 | and update your perception of time.

01:26:23.800 | And fortunately, it's also one that you can control.

01:26:27.040 | So the basic takeaway of this study

01:26:29.120 | was that blinking controls time perception,

01:26:31.160 | but also that levels of dopamine

01:26:33.800 | can alter your sense of time and, stay with me here,

01:26:38.280 | and that blinking and dopamine are inextricably linked.

01:26:42.880 | They are working together to control your attention.

01:26:46.020 | When dopamine levels go up,

01:26:48.440 | people tend to overestimate how long something lasted.

01:26:53.120 | Why?

01:26:53.940 | Because they are processing time more finely.

01:26:56.240 | It's slow motion mode.

01:26:58.160 | When dopamine levels are lower,

01:27:01.040 | they tend to underestimate time intervals.

01:27:04.400 | Let's remember back to the very beginning of the episode,

01:27:07.200 | what's going on in people with ADHD?

01:27:09.340 | They are not good at managing their time.

01:27:12.600 | They tend to run late or they are disorganized.

01:27:15.100 | They are not just disorganized in space,

01:27:17.720 | meaning in the physical space around them,

01:27:20.080 | they're disorganized in time.

01:27:23.560 | Their dopamine is low.

01:27:25.280 | We know that as well.

01:27:26.720 | And so they are underestimating time intervals.

01:27:29.600 | And so it makes perfect sense that they would be late.

01:27:32.120 | It makes perfect sense that they would lose track of time

01:27:34.460 | or the ability to focus.

01:27:36.620 | This is really exciting because what it means is that

01:27:39.680 | children with ADHD, adults with ADHD,

01:27:42.320 | or people with normal levels of focus

01:27:44.140 | that want to improve their ability to focus

01:27:46.900 | can do so through a training that involves learning

01:27:51.040 | how often to blink and when,

01:27:53.240 | and how to keep their visual focus on a given target.

01:27:56.820 | And it turns out this study has actually been done.

01:27:59.880 | There's a study, again, I'll link to this study,

01:28:02.220 | entitled Improvement of Attention in Elementary School

01:28:05.320 | Students Through Fixation-Focused Training Activity.

01:28:08.720 | I won't go through all the details,

01:28:10.180 | but what they found was a short period of

01:28:14.260 | focusing on a visual target allowed these schoolchildren

01:28:18.600 | to greatly enhance their ability to focus

01:28:21.140 | on other types of information.

01:28:23.600 | And a significant component of the effect

01:28:25.520 | was due to the way that they were controlling the shutters

01:28:28.360 | on their eyes, their eyelids, and controlling their blinks.

01:28:31.680 | So what they did in this study is they had these kids

01:28:34.200 | focus their visual attention on some object

01:28:36.760 | that was relatively close, like their hand,

01:28:39.160 | for a minute or so, which actually takes some effort

01:28:41.920 | if you try and do that.

01:28:42.840 | They were allowed to blink.

01:28:45.080 | However, it's known from other work

01:28:47.660 | that if people can consciously override the desire to blink,

01:28:51.480 | at least to the point where they feel like they have to

01:28:53.980 | or else their eyes would dry out,

01:28:55.440 | that actually can increase attention even further.

01:28:58.520 | And they had conditions where they would look

01:29:00.240 | at a point further across the room

01:29:02.240 | and even further across the room.

01:29:04.580 | It only took a few minutes each day to do this,

01:29:07.240 | 30 seconds in one condition or maybe a minute,

01:29:09.680 | and then at another station of looking

01:29:11.560 | a little bit further out and a little bit further out.

01:29:13.720 | However, there was an important feature of this study

01:29:16.380 | that is definitely worth mentioning,

01:29:18.560 | which is before they did this visual focus task or training,

01:29:23.560 | they did a series of physical movements with the kids

01:29:27.360 | so that the kids could sort of eliminate or move out

01:29:30.480 | some of their desire to move

01:29:32.600 | and would thereby enhance their ability to sit still.

01:29:36.360 | Now, it's long been known that kids need a recess.

01:29:38.740 | They need time to run around and play and roll around,

01:29:41.400 | do whatever it is that they do

01:29:42.440 | in order to be able to sit still at all.

01:29:44.820 | Adults probably need this too, frankly,

01:29:46.440 | but kids need it more because the circuits in the brain

01:29:49.700 | that control reflexive movements

01:29:52.600 | and as we say, kind of rhythmic undulating behavior

01:29:56.160 | and things like that, that's an active suppression.

01:29:58.800 | And kids have less of that circuitry built up

01:30:00.760 | until they hit about age 15 or 16.

01:30:03.920 | So they had the kids move around a bit

01:30:06.140 | and then do this focus training.

01:30:08.500 | That brings me to another treatment

01:30:10.560 | that's actively used nowadays in schools for kids with ADHD,

01:30:14.380 | but also it's starting to be used by many kids

01:30:18.380 | and by parents in order to keep their kids focusing

01:30:22.480 | and not going crazy in the car or not acting out in general.

01:30:27.320 | And that's the prevalence of these so-called fidgeter toys

01:30:31.100 | or things that kids can do actively and repetitively

01:30:33.600 | in order to move out some of their underlying

01:30:36.520 | reverberatory activity in their nervous system.

01:30:39.280 | So what you will find is that some kids with ADHD

01:30:43.000 | are now given a rubber band on their desk,

01:30:45.660 | literally a rubber band that's attached to their desk

01:30:47.440 | and they're able to pull on it,

01:30:49.160 | even snap it against the desk.

01:30:50.600 | If I had done that when I was a kid,

01:30:51.640 | I think my teachers would have thrown me out of class,

01:30:53.380 | but I think it's great that they're allowing them

01:30:54.880 | to do this now as a way of moving

01:30:57.480 | some of their physical energy out

01:31:00.640 | or engage their physical energy rather,

01:31:03.120 | as opposed to trying to sit,

01:31:04.760 | statue still all the time and attend.

01:31:06.900 | And it turns out that does enhance

01:31:08.840 | these children's ability to focus mentally

01:31:11.320 | when they have some physical activity to attend to.

01:31:13.560 | And it turns out it also can work for adults.

01:31:16.940 | I'll share with you a related anecdote

01:31:19.120 | because it illustrates the underlying mechanism.

01:31:21.720 | I've had the great privilege of being able to do

01:31:24.400 | a number of surgeries, brain surgeries during my career.

01:31:28.480 | So one thing you find when you do brain surgeries

01:31:30.640 | is that the brain's pretty small,

01:31:32.440 | regardless of the species that you're working on

01:31:34.260 | and you're in there

01:31:35.100 | and you're trying to do something very specific.

01:31:36.880 | And the more you try and hold your hands really steady,

01:31:40.420 | the more they want to shake, all right?

01:31:42.480 | So it's not natural for any of our limbs

01:31:44.600 | to sit perfectly still.

01:31:46.760 | Depending on how much coffee you've had,

01:31:48.140 | how well rested you are,

01:31:49.680 | and your sort of baseline level of autonomic arousal,

01:31:52.040 | some of you may find that you can hold out your hand

01:31:54.240 | absolutely rock solid.

01:31:55.680 | Others will shake a little bit more.

01:31:58.360 | Doesn't mean you're nervous if you're shaking,

01:31:59.840 | doesn't mean you're calm if you're still.

01:32:02.480 | What it relates to is the amount

01:32:05.120 | of what we call premotor activity,

01:32:06.600 | the number of commands to move

01:32:08.320 | that are being sent through the system.

01:32:09.680 | And that's what I mean by reverberatory activity.

01:32:11.960 | And it does seem that kids with ADHD and adults with ADHD

01:32:15.980 | have a lot of reverberatory activity

01:32:18.440 | in their nervous system.

01:32:19.540 | And so that's that constant desire to move.

01:32:21.120 | It's hard for them to sit still

01:32:22.800 | and therefore it's hard for them to attend,

01:32:24.880 | to harness their attention.

01:32:26.240 | When you do a surgery and you find that your hands

01:32:30.360 | are shaking, what you learn from your mentors,

01:32:33.840 | which I did, and what works extremely well,

01:32:36.100 | whether or not you're doing a surgery or not,

01:32:37.760 | is that you simply tap your foot

01:32:39.520 | or you bounce your knee a little bit,

01:32:40.920 | which you might think would make your hand shake even more,

01:32:44.200 | but provided that it's subtle,

01:32:45.920 | what it does is it actually shuttles some of the activity

01:32:49.200 | from those premotor circuits to elsewhere in the body.

01:32:51.920 | And then you're able to sit much more still with your hand.

01:32:55.100 | You're able to perform the surgery with much more precision.

01:32:57.680 | You are able to write with much better handwriting.

01:33:00.440 | And for those of you who engage in public speaking,

01:33:03.560 | if you're ever too nervous,

01:33:04.800 | that's why pacing while you public speak helps

01:33:06.980 | if you're nervous.

01:33:07.820 | That's why bouncing your knee behind the podium

01:33:10.100 | works as well.

01:33:10.940 | That's why nodding your head and gesticulating can help.

01:33:13.840 | It's not a matter of quote unquote moving energy

01:33:16.560 | out of the body that doesn't actually happen.

01:33:18.440 | What it is is you're engaging those premotor circuits

01:33:20.940 | that are sending through commands.

01:33:22.300 | It's like trying to stuff a bunch of stuff through a funnel

01:33:24.960 | and it creates this tension.

01:33:26.640 | So you're giving it an outlet for the neural circuitry

01:33:30.980 | to be able to move something

01:33:32.320 | so that you can keep other components of your body

01:33:34.600 | and your mental attention engaged

01:33:37.480 | and locked onto something, what we call focus.

01:33:40.960 | One thing related to this whole business of blinking

01:33:43.240 | and focus and training yourself to focus

01:33:45.480 | and not blinking, et cetera,

01:33:47.440 | is that most all of the drugs, ritalin, Adderall,

01:33:52.440 | and recreational drugs that increase dopamine,

01:33:55.100 | even coffee and tea and other forms of caffeine,

01:33:58.300 | they tend to make us blink less.

01:34:01.740 | And when we get tired, we tend to blink more.

01:34:04.540 | Now, this is sort of a duh, right?

01:34:07.220 | But being wide-eyed with excitement or fear

01:34:10.540 | or with your eyes barely being able to keep them open,

01:34:15.320 | now it should make perfect sense

01:34:16.740 | that these shutters on the front of your eyes,

01:34:18.460 | they aren't just there for winking

01:34:20.300 | and they aren't just there for cosmetic purposes.

01:34:22.940 | They are there to regulate the amount of information

01:34:26.280 | going into your nervous system.

01:34:27.680 | And they're there to regulate how long

01:34:31.100 | you are bringing information into your nervous system

01:34:33.960 | and in what bins,

01:34:35.820 | how widely or finely you are binning time

01:34:39.020 | is set by how often you blink

01:34:40.940 | and how widely or specifically you are grabbing attention

01:34:45.720 | from the visual world is set by whether or not

01:34:47.340 | you're viewing things very specifically,

01:34:48.880 | like a crosshair or through a soda straw view like this,

01:34:51.780 | or whether or not you were in this panoramic

01:34:54.000 | sort of whole environment mode,

01:34:57.160 | this kind of fisheye lens or wide angle lens mode.

01:35:00.500 | And in fairness to the pharmacology and the circuitry,

01:35:03.220 | while dopamine and heightened levels of alertness

01:35:07.740 | and excitement tend to make us blink less and attend more,

01:35:12.740 | there's actually a study that's looked

01:35:14.380 | at the other neurochemical systems and drugs

01:35:17.760 | and how those relate to blinking.

01:35:19.400 | And so this will all be obvious by the title of the paper

01:35:22.160 | I'm about to share with you.

01:35:23.060 | This is a paper entitled

01:35:25.300 | Decreased Spontaneous Eye Blink Rates

01:35:27.940 | in Chronic Cannabis Users,

01:35:29.920 | Evidence for Striatal Cannabinoid Dopamine Interactions.

01:35:34.120 | Okay, I'm not going to go into all the details here,

01:35:36.100 | but one thing that is somewhat surprising

01:35:38.980 | is that many people with ADHD use or abuse cannabis.

01:35:44.700 | You might think, well, why would they do that?

01:35:47.080 | Because I thought that a increase in dopamine

01:35:50.520 | is actually what's going to lead

01:35:51.520 | to heightened levels of attention,

01:35:52.680 | and that's what these people and children crave.

01:35:55.160 | Well, it turns out that cannabis also increases

01:35:58.680 | dopamine transmission in the brain,

01:36:00.720 | but because of the other chemicals it increases,

01:36:03.400 | namely serotonin and some components

01:36:05.280 | of the cannabinoid and opioid system,

01:36:07.480 | it creates that kind of alert but mellow feel.

01:36:13.080 | And again, here, I'm not a proponent of this.

01:36:15.480 | I personally am not a THC or cannabis user.

01:36:17.980 | It's just not my thing.

01:36:19.800 | And obviously it's illegal some places,

01:36:21.760 | and so you have to determine that for yourself.

01:36:24.360 | It does have medical purposes,

01:36:25.800 | and in some places it is legal,

01:36:28.340 | but THC increases dopamine and increases neurochemicals

01:36:32.200 | that can also create a state of calm.

01:36:34.100 | So it's that sort of middle ground.

01:36:35.920 | And this paper has a beautiful demonstration

01:36:38.460 | whereby not just while people are using cannabis,

01:36:42.480 | but depending on how long they've been using cannabis

01:36:45.280 | across their lifespan, the rates of eye blinking change.

01:36:49.120 | So if you look at the number of years

01:36:51.880 | that people have been using cannabis on a regular basis,

01:36:54.840 | either daily or up to, excuse me, weekly or up to daily,

01:36:58.620 | what you find is that for people

01:37:00.640 | that have not been using cannabis at all

01:37:02.720 | or have only been using it for about two years,

01:37:05.480 | their rates of eye blinks are much higher

01:37:08.220 | than people who've been using it chronically for 10 years.

01:37:10.600 | In other words, people who've been using cannabis

01:37:12.420 | for 10 years don't blink very often at all.

01:37:15.400 | Now, cannabis has well-known effects in depleting memory,

01:37:19.480 | but it does seem to engage the focus and blinking system

01:37:23.560 | in a way that increases focus.

01:37:25.580 | So basically what I'm saying is marijuana

01:37:27.760 | seems to increase people's focus,

01:37:29.200 | but then they can't remember what they were focusing on.

01:37:32.040 | Something I'd like to discuss just briefly

01:37:33.920 | is the so-called interoceptive awareness

01:37:37.480 | that's present in people with ADHD,

01:37:39.480 | both children and adults.

01:37:40.800 | Interoceptive awareness is one sense

01:37:43.660 | of one's own internal state, heartbeat, breathing,

01:37:47.520 | contact of skin with a given surface, et cetera.

01:37:50.540 | For a long time, there was this hypothesis,

01:37:52.780 | this idea that people with ADHD

01:37:54.940 | were just not in touch with how they felt,

01:37:57.560 | that somehow they weren't registering

01:37:59.380 | all the stuff that was going on inside them,

01:38:01.400 | changes in heart rate and so forth,

01:38:02.940 | and so they were behaving in a way

01:38:04.860 | that was dysregulated or appear dysregulated,

01:38:08.740 | and that if they could just learn to attend

01:38:11.360 | to their internal state better,

01:38:13.200 | that somehow they would function better in the world.

01:38:16.280 | Now, before we described a process,

01:38:19.300 | literally a 17-minute interoceptive exercise

01:38:23.080 | that does seem to lead to improvements

01:38:25.840 | in one's ability to focus for a longer period of time.

01:38:29.920 | However, it's very unlikely that that was due

01:38:33.560 | to increasing interoceptive awareness per se.

01:38:37.320 | It probably wasn't because people gain a much heightened

01:38:41.380 | or improved ability to understand what's going on internally.

01:38:46.120 | In fact, you can imagine how that might actually prevent

01:38:48.440 | one's ability to pay attention to things

01:38:49.920 | in the outside world.

01:38:51.440 | So while there is benefit to just sitting there

01:38:53.620 | and being in stillness, as they say,

01:38:55.340 | or focusing on one's breathing and internal state

01:38:57.860 | for sake of then accessing information

01:39:00.340 | in the external world,

01:39:02.320 | a really nice study called Interoceptive Awareness

01:39:06.480 | in Attention Deficit Hyperactivity Disorder

01:39:08.560 | explored whether or not interoceptive awareness

01:39:11.120 | was different in people with ADHD or did not have ADHD.

01:39:16.120 | And the findings were essentially that there's no difference,

01:39:20.160 | that people with ADHD, children and adults,

01:39:22.400 | they are aware of what's going on inside them

01:39:25.320 | just as much as anyone else is.

01:39:27.520 | And the typical measure of interoceptive awareness

01:39:29.840 | is one's ability to count their own heartbeats.

01:39:33.120 | This is actually challenging for some individuals

01:39:36.000 | and very easy for other individuals,

01:39:37.840 | regardless of their attentional capacity.

01:39:39.620 | Some people just can really feel their heartbeat

01:39:41.820 | without taking their pulse, other people cannot.

01:39:44.980 | And these studies are pretty straightforward to do.

01:39:47.360 | You ask people to sit there and to count their heartbeats

01:39:50.780 | and then you are monitoring their heartbeats

01:39:52.660 | and you get to gauge how accurate they are.

01:39:55.100 | So it's important to understand that people with ADHD

01:39:58.940 | are in touch with how they feel.

01:40:01.520 | It's really a question of whether or not

01:40:03.640 | they can take the demands that are placed upon them

01:40:06.720 | and enter a cognitive state, a mental state

01:40:09.380 | that allows them to access the information

01:40:11.180 | they need to access.

01:40:12.020 | In other words, whether or not they can focus.

01:40:13.260 | But it is absolutely wrong to think that the child

01:40:16.280 | that's getting up 11 times during a short six-minute

01:40:20.060 | interaction at the table or whether or not a child

01:40:23.920 | who somehow has to venture off every moment

01:40:26.240 | or a coworker of yours who's an adult

01:40:28.260 | who's constantly fidgeting or moving things around

01:40:30.200 | that somehow they are unaware that they are oblivious.

01:40:32.360 | They're not oblivious to how they feel.

01:40:34.200 | Chances are they are very challenged in the situations

01:40:36.480 | that they're in and they're doing everything they can

01:40:38.480 | to try and regulate their attention.

01:40:40.380 | So I think it's an important study to highlight

01:40:42.800 | because it really underscores the fact that something else

01:40:45.480 | is going on and that something else has everything to do

01:40:48.280 | with this ability to coordinate these task-directed networks

01:40:51.440 | and to coordinate that in the proper way

01:40:53.880 | with that default mode network.

01:40:55.800 | And that is a process, as you now know,

01:40:58.080 | that's regulated exquisitely by certain neurochemicals

01:41:02.480 | and in particular, the neurochemicals dopamine,

01:41:04.700 | norepinephrine, and serotonin.

01:41:07.080 | And a fourth one I'd like to throw into the mix,

01:41:09.000 | which is acetylcholine,

01:41:10.360 | which is very vital for cognitive focus.

01:41:12.960 | So now I want to switch back to talking about

01:41:15.360 | some of the drugs that are typically used

01:41:17.520 | to access those systems, prescription drugs.

01:41:19.760 | And I want to talk about some of the new

01:41:21.480 | and emerging non-prescription approaches

01:41:23.880 | to increasing the levels of dopamine,

01:41:25.920 | acetylcholine, and serotonin in the brain

01:41:28.100 | using various supplement type compounds

01:41:30.200 | because several of them are showing

01:41:32.700 | really remarkable efficacy

01:41:34.720 | in excellent peer-reviewed studies.

01:41:36.680 | So before moving to some of the newer atypical compounds

01:41:39.720 | and things sold over the counter,

01:41:41.840 | I'd like to just briefly return to the classic drugs

01:41:46.260 | that are used to treat ADHD.

01:41:48.320 | These are the ones I mentioned earlier,

01:41:51.560 | methylphenidate, also called Ritalin, modafinil,

01:41:56.360 | armodafinil is another one, and Adderall.

01:42:00.420 | Again, all of these work by increasing levels of dopamine

01:42:03.600 | and norepinephrine.

01:42:05.480 | Typically they are taken orally in pill form

01:42:08.800 | or sometimes in capsule form.

01:42:11.600 | The dosages that are appropriate

01:42:13.560 | vary according to severity of the condition

01:42:17.280 | for a given person and the age of the person.

01:42:20.840 | This is a complicated landscape for each individual.

01:42:24.200 | They have to figure out the pharmacology

01:42:25.720 | that's best for them.

01:42:26.960 | Some individuals are even layering long

01:42:30.320 | or time to release Ritalin with Adderall in smaller doses.

01:42:35.100 | It can get quite complex

01:42:36.320 | or it can be quite straightforward.

01:42:37.780 | If you are really interested in these drugs

01:42:40.180 | and how they work, and you'd like to get a glance

01:42:44.080 | at a table of all the results from all the studies

01:42:47.700 | of which there are now hundreds,

01:42:49.800 | there's an excellent review about these drugs

01:42:52.740 | and their use and their comparison

01:42:55.520 | to similarly structured drugs,

01:42:57.220 | in particular MDMA and cocaine and amphetamine,

01:43:01.480 | meaning street amphetamine,

01:43:03.000 | to really illustrate the similarities of action

01:43:06.440 | and some of the problems associated with long-term use.

01:43:10.240 | I don't expect you to read this article in full.

01:43:11.840 | I'm here so that you don't have to go read these articles,

01:43:14.320 | but in case you want a ton of information,

01:43:17.060 | the paper is Esposito et al.

01:43:18.840 | Frontiers in Biosciences.

01:43:20.720 | It's an excellent, excellent review

01:43:23.160 | of the entire literature.

01:43:24.640 | It is quite long.

01:43:26.700 | I can put a link to that study in our caption.

01:43:29.820 | And it essentially describes all the studies

01:43:33.080 | that have been done, peer reviewed and published.

01:43:35.940 | And it refers to these drugs in an interesting way.

01:43:39.120 | It doesn't just refer these drugs as for treatment of ADHD.

01:43:41.920 | It actually refers to them using language

01:43:44.220 | that ordinarily I'm not very fond of,

01:43:46.640 | but I'll agree to here, which is so-called smart drugs

01:43:50.020 | or nootropics.

01:43:51.340 | It also covers caffeine, which again,

01:43:55.800 | as I mentioned earlier, increases dopamine, norepinephrine,

01:43:59.340 | and to some extent serotonin.

01:44:01.860 | But what I like about this review so much

01:44:04.520 | is that in putting these drugs of abuse,

01:44:07.000 | methamphetamine and cocaine,

01:44:08.200 | right alongside these drugs like Ritalin and Adderall

01:44:11.360 | and also caffeine, we start to realize

01:44:13.340 | that the distinction between drugs of abuse

01:44:15.880 | and the distinction between drugs of treatment

01:44:18.000 | is actually a very fine and sometimes even a blurry line.

01:44:21.720 | And in thinking about whether or not

01:44:23.960 | one wants to use these prescription,

01:44:26.600 | I want to emphasize prescription, not drugs of abuse,

01:44:28.420 | but prescription drugs

01:44:29.480 | for treatment of one's own attentional capacity,

01:44:32.180 | I think it is important to understand

01:44:35.260 | the extent to which they all carry

01:44:37.100 | more or less the same side effects.

01:44:38.580 | The one exception being caffeine.

01:44:40.000 | Caffeine side effects can be anxiety

01:44:42.840 | if you ingest too much of it, insomnia,

01:44:44.680 | if you drink it too late in the day,

01:44:46.280 | but typically it will not cause

01:44:48.280 | the major side effects of the other drugs,

01:44:50.880 | such as high propensity for addiction and abuse.

01:44:54.420 | Amphetamines of any kind, as well as cocaine,

01:44:58.520 | can cause sexual side effects

01:45:00.640 | because they're vasoconstrictors,

01:45:02.160 | so men have trouble achieving erection.

01:45:06.480 | There can often be the intense desire or libido for sex,

01:45:11.480 | but an inability to actually perform.

01:45:14.320 | So that's an issue with any kind of stimulant.

01:45:16.940 | So these drugs are not without their consequences.

01:45:19.240 | In addition, and here I'd lump caffeine back into the mix,

01:45:24.000 | in addition, they almost all carry cardiac effects, right?

01:45:27.720 | They increase heart rate,

01:45:28.840 | but they also have effects on constriction of blood vessels

01:45:32.800 | and arteries and veins and so forth

01:45:34.520 | in ways that can create cardiovascular problems.

01:45:37.520 | Now, caffeine is a bit of a complicated one.

01:45:40.500 | I talked about this on a podcast long ago,

01:45:42.600 | but I'll just remind you that it turns out

01:45:44.900 | that if you are caffeine adapted,

01:45:46.680 | in other words, if you are used to drinking caffeine,

01:45:49.260 | then the ingestion of caffeine

01:45:51.240 | most often will cause vasodilation.

01:45:53.240 | It will actually allow more blood flow through.

01:45:55.520 | However, if you are not caffeine adapted,

01:45:57.680 | it will cause vasoconstriction

01:45:59.560 | due to an increased stress response.

01:46:02.120 | So if you're familiar with caffeine,

01:46:04.180 | caffeine can actually have a little bit more

01:46:06.320 | of a relaxation response,

01:46:08.040 | although if you drink enough of it,

01:46:09.060 | it will make you amped up.

01:46:10.960 | These other drugs almost always lead to vasoconstriction,

01:46:14.920 | increased heart rate, dilation of the pupils,

01:46:17.320 | less blinking, heightened levels of attention,

01:46:19.860 | which looks very much like stress.

01:46:22.000 | And at its extremes,

01:46:23.260 | looks very much like the effects of street drugs,

01:46:25.180 | like cocaine and amphetamine.

01:46:27.240 | Because of the large amounts of dopamine

01:46:29.120 | that are released in the brain,

01:46:30.580 | people tend to crave that state over and over,

01:46:33.320 | and yet with each subsequent use

01:46:36.240 | are able to get less and less of that euphoric feeling

01:46:39.360 | or that really, really focused feeling.

01:46:41.300 | So one thing that's being explored quite extensively now

01:46:43.520 | in the treatment of ADHD are drug schedules,

01:46:47.720 | whether or not people should take Adderall every day

01:46:51.680 | or every other day,

01:46:52.760 | whether or not they should take it

01:46:53.800 | only every once in a while,

01:46:55.120 | whether or not young children can take it just a few times

01:46:57.720 | and engage in behavioral training of the sort

01:47:00.400 | that I talked about before where they're doing,

01:47:02.940 | maybe it's a 17 minute meditation type exercise,

01:47:05.960 | but more likely it would be the movement

01:47:08.080 | followed by the visual focusing,

01:47:10.400 | 'cause that's only done for 20 or 30 or 60 seconds.

01:47:12.960 | Why would you do that?

01:47:13.820 | Well, in a chemically enhanced state,

01:47:16.460 | your brain is more plastic.

01:47:17.800 | The circuits are able to modify and learn better.

01:47:21.700 | That's the optimal time to engage in focus

01:47:25.800 | in a very deliberate way.

01:47:27.320 | So just taking a drug and expecting focus

01:47:29.740 | to just work at any point

01:47:31.080 | and being able to turn focus on and off at will,

01:47:35.040 | that's an unrealistic expectation, right?

01:47:37.960 | More likely the best use of things like Adderall,

01:47:42.960 | modafinil, armodafinil, and Ritalin

01:47:46.740 | is going to be to combine those treatments

01:47:48.680 | with behavioral exercises that actively engage

01:47:52.660 | the very circuits that you're trying to train up and enhance

01:47:55.320 | and then perhaps, I want to highlight perhaps,

01:47:57.980 | tapering off those drugs

01:47:59.360 | so that then one can use those circuits

01:48:01.540 | without any need for chemical intervention.

01:48:04.440 | So despite any controversy that might be out there,

01:48:07.120 | I think it's fair to say

01:48:08.120 | that the consumption of omega-3 fatty acids

01:48:11.280 | can positively modulate the systems for attention and focus.

01:48:16.600 | So then the question becomes how much EPA,

01:48:20.480 | how much DHA does that differ

01:48:22.520 | for what's helpful for depression, et cetera?

01:48:25.760 | And actually it does differ.

01:48:27.880 | In reviewing the studies for this,

01:48:29.280 | it appears that a threshold level of 300 milligrams of DHA

01:48:34.280 | turns out to be an important inflection point.

01:48:37.160 | So typically fish oils or other sources of omega-3s

01:48:41.680 | will have DHA and EPA.

01:48:43.920 | And typically it's the EPA

01:48:45.820 | that's harder to get at sufficient levels.

01:48:48.120 | Meaning you have to take quite a lot of fish oil

01:48:50.120 | in order to get above that 1000 milligram

01:48:52.340 | or 2000 milligram threshold to improve mood

01:48:55.700 | and other functions.

01:48:56.640 | But for sake of attention,

01:48:59.240 | there are 10 studies that have explored this in detail.

01:49:02.360 | And while the EPA component is important,

01:49:05.400 | the most convincing studies point to the fact

01:49:07.560 | that getting above 300 milligrams per day of DHA

01:49:12.080 | is really where you start to see the attentional effects.

01:49:14.240 | Now, fortunately, if you're getting sufficient EPA

01:49:16.440 | for sake of mood and other biological functions,

01:49:19.360 | almost without question,

01:49:22.560 | you're getting 300 milligrams or more of DHA.

01:49:25.200 | So that usually checks that box just fine.

01:49:27.800 | What's interesting is that there's another compound,

01:49:30.040 | phosphatidylsterine that has been explored for its capacity

01:49:35.040 | to improve the symptoms of ADHD.

01:49:37.640 | Again, I don't think this is any direct way,

01:49:39.700 | but rather in a modulatory way.

01:49:41.840 | But it appears that phosphatidylsterine taken for two months

01:49:46.160 | for 200 milligrams per day

01:49:49.640 | was able to reduce the symptoms of ADHD in children.

01:49:52.920 | It has not been looked at in adults yet,

01:49:55.400 | at least as far as I know,

01:49:57.240 | but that this effect was greatly enhanced

01:50:00.560 | by the consumption of omega-3 fatty acids.

01:50:03.520 | So now we're starting to see synergistic effects

01:50:05.680 | of omega-3 fatty acids and phosphatidylsterine.

01:50:08.900 | Again, that was 200 milligrams per day.

01:50:11.180 | This is something that sold over the counter

01:50:12.800 | in capsule form, at least in the US.

01:50:15.200 | There were two studies, both were double blind studies

01:50:18.440 | carried out for anywhere from one to six months

01:50:21.080 | on both boys and girls.

01:50:22.700 | And it really was boys and girls, not men and women.

01:50:24.760 | This was kids age one to six or seven to 12.

01:50:28.820 | And it was a fairly large number of subjects.

01:50:32.120 | So 147 subjects in one case and 36 in the other.

01:50:35.520 | The takeaway is that getting sufficient levels of EPAs,

01:50:39.240 | in particular this 300 milligram threshold of DHA,

01:50:42.760 | plus if you are interested in it and it's right for you,

01:50:46.720 | 200 milligrams of phosphatidylsterine

01:50:48.920 | can be an important augment

01:50:50.400 | for improving the symptoms of ADHD.

01:50:53.480 | You'll also find literature out there

01:50:55.360 | and many claims about so-called ginkgo bilboa,

01:50:59.240 | which has been shown to have minor effects

01:51:01.780 | in improving the symptoms of ADHD.

01:51:04.500 | Not nearly as effective as Ritalin and Adderall.

01:51:07.860 | Ginkgo bilboa is not appropriate for many people.

01:51:12.440 | I am one such person.

01:51:14.120 | I don't have ADHD, but when I've taken ginkgo,

01:51:18.140 | even at very low doses,

01:51:19.280 | I get absolutely splitting headaches.

01:51:21.640 | Some people do not experience those headaches,

01:51:23.400 | but it's known to have very potent vasoconstrictive

01:51:26.400 | and vasodilating properties that vary

01:51:29.200 | depending on when you took the compound.

01:51:31.960 | So for those of you that are exploring ginkgo bilboa,

01:51:35.760 | and you will see a lot of claims about ginkgo bilboa

01:51:38.040 | for attention in ADHD,

01:51:39.560 | definitely take the vasodilation, vasoconstriction,

01:51:42.980 | headache issue into consideration.

01:51:45.980 | So I'd like to talk about the drug modafinil

01:51:48.400 | and the closely related drug armodafinil,

01:51:50.920 | and that's AR modafinil because modafinil and armodafinil

01:51:55.480 | are gaining popularity out there,

01:51:57.320 | both for treatment of ADHD and narcolepsy,

01:52:00.260 | but also for communities of people

01:52:03.760 | that are trying to stay awake long periods of time.

01:52:05.920 | So it's actively used in the military by first responders.

01:52:09.980 | It's gaining popularity on college campuses,

01:52:13.100 | and people are using it more and more as an alternative

01:52:15.440 | to Adderall and Ritalin and excessive amounts of coffee.

01:52:20.600 | It does increase focus, and to a dramatic extent.

01:52:23.640 | Modafinil typically was very expensive.

01:52:28.200 | I don't know if it's still this expensive,

01:52:30.080 | but when one has a prescription for it,

01:52:32.680 | it could still cost as much as eight or $900

01:52:35.560 | or even a thousand dollars a month.

01:52:37.920 | R-modafinil is a far less expensive version

01:52:41.940 | that's chemically slightly different than modafinil.

01:52:44.900 | Regardless of price,

01:52:45.840 | people are taking modafinil and R-modafinil.

01:52:48.920 | Want to emphasize that unlike Ritalin and Adderall,

01:52:52.520 | modafinil and R-modafinil

01:52:54.720 | are weak dopamine reuptake inhibitors,

01:52:57.720 | and that's how they lead to increases in dopamine.

01:53:00.100 | So whereas Ritalin and Adderall, amphetamine and cocaine

01:53:03.040 | lead to big increases in dopamine,

01:53:05.320 | also through reuptake mechanisms and so forth,

01:53:07.880 | modafinil is a weaker dopamine reuptake stimulator.

01:53:12.800 | And so what that means is that it leaves more dopamine

01:53:15.800 | around to be active at the synapse,

01:53:17.720 | the gaps between neurons.

01:53:19.880 | However, it also activates other systems.

01:53:22.040 | It acts on the orexin system,

01:53:24.240 | which is actually a peptide that we talked about

01:53:26.380 | in the episode on hunger,

01:53:28.400 | because it regulates hunger and appetite,

01:53:31.100 | and it regulates sleepiness and feelings of sleepiness.

01:53:34.280 | In fact, the orexin, also called hypocretin system,

01:53:37.700 | the orexin hypocretin system

01:53:39.320 | is what's disrupted in narcolepsy.

01:53:42.040 | That was the important discovery of my colleagues,

01:53:44.400 | Emmanuel Mignon and Seiji Nishino

01:53:46.600 | at Stanford some years ago,

01:53:48.320 | they identified the biological basis of narcolepsy,

01:53:50.960 | and it's a disruption in the orexin hypocretin system,

01:53:54.800 | and modafinil is one of the primary treatments

01:53:56.960 | for narcolepsy.

01:53:58.120 | It also has these other effects on the dopamine system

01:54:01.600 | and on the norepinephrine system.

01:54:03.900 | Even though it doesn't lead to quite as intense levels

01:54:08.480 | of dopamine and arousal and focus,

01:54:11.360 | it does have the property

01:54:12.600 | of raising levels of attention and focus,

01:54:14.840 | and that's why people are using it.

01:54:16.160 | So it's a somewhat milder form of Adderall.

01:54:19.400 | R-modafinil, for some people, works as well as modafinil,

01:54:23.120 | and as I mentioned before, it's much lower cost.

01:54:24.760 | For other people, it doesn't.

01:54:26.240 | I have an experience, meaning I do have an experience

01:54:30.280 | that I'll share with you with R-modafinil.

01:54:32.500 | A few years ago, I was suffering from jet lag

01:54:34.560 | really terribly, and I was traveling overseas.

01:54:38.860 | I went to a meeting to give a talk.

01:54:40.780 | I took half of the prescribed dose of R-modafinil.

01:54:45.740 | It was prescribed to me.

01:54:47.680 | I took that half dose, and I gave my lecture,

01:54:51.220 | and then I stayed around to answer questions,

01:54:53.120 | and then four hours later, a friend of mine came up to me

01:54:57.160 | and said, "You know, you've been talking

01:54:59.080 | for four and a half hours,

01:55:01.040 | and there are only a few people still here."

01:55:03.580 | Luckily, there were still a few people.

01:55:04.920 | It'd be a lot weirder if the room was completely empty

01:55:07.680 | since it wasn't being recorded.

01:55:09.420 | So I have firsthand knowledge

01:55:10.940 | of the sorts of cognitive effects that it can create.

01:55:13.980 | I personally would not want to be in that state

01:55:16.460 | for sake of studying or learning

01:55:18.120 | or for doing this podcast, for instance,

01:55:21.280 | and I can honestly say that today all I've ingested

01:55:24.400 | is some coffee and some yerba mate tea and some water.

01:55:28.140 | I'm not on any of the compounds that I've described

01:55:30.440 | during the course of today's episode.

01:55:32.780 | You might ask why I took half the recommended dose

01:55:36.060 | of R-modafinil, and the reason is that I'm somebody

01:55:39.720 | who's fairly hypersensitive to medication of any kind.

01:55:44.500 | What you find if you look in the literature

01:55:46.800 | is that about 5% of people

01:55:48.580 | are hyper hypersensitive to medication.

01:55:50.800 | They require far lower doses of any medication

01:55:53.880 | than other people in order to experience the same effects.

01:55:56.560 | I'm somebody that I think is sort of modest hyper,

01:56:00.120 | if that sort of oxymoronic statement,

01:56:02.120 | but a modest hypersensitivity to medication,

01:56:05.340 | so I've almost always been able to get by

01:56:07.160 | on taking less of whatever was prescribed for me

01:56:09.800 | and feel just fine,

01:56:11.880 | or in this case to feel like it was still too much.

01:56:13.960 | It turned out that the right dose of R-modafinil for me

01:56:17.160 | was zero milligrams.

01:56:19.080 | Now you may notice that I haven't talked much

01:56:21.000 | about acetylcholine.

01:56:22.760 | Acetylcholine is a neurotransmitter

01:56:24.920 | that at the neuron to muscle connections,

01:56:26.960 | the so-called neuromuscular junctions,

01:56:28.840 | is involved in generating muscular contractions

01:56:30.840 | of all kinds for all movements.

01:56:34.080 | Acetylcholine is also released from two sites in the brain,

01:56:37.160 | so a little bit of nomenclature here.

01:56:38.520 | Again, feel free to ignore the nomenclature,

01:56:41.040 | but there is a collection of neurons in your brain stem

01:56:43.680 | that send projections forward,

01:56:45.080 | kind of like a sprinkler system that's very diffuse

01:56:48.400 | to release acetylcholine,

01:56:50.040 | and those neurons reside in an area or a structure

01:56:53.640 | that's called the pedunculopontine nucleus, the PPN.

01:56:57.240 | And then there's a separate collection of neurons

01:56:59.340 | in the basal forebrain

01:57:01.040 | called unimaginatively nucleus basalis,

01:57:04.040 | the nucleus at the base.

01:57:05.700 | And they also hose the brain with acetylcholine,

01:57:09.260 | but in a much more specific way.

01:57:11.800 | So one is sort of like a sprinkler system,

01:57:13.720 | and the other one is more like a fire hose

01:57:15.400 | to a particular location.

01:57:16.480 | And those two sources of acetylcholine collaborate

01:57:21.000 | to activate particular locations in the brain

01:57:23.760 | and really bring about a tremendous degree of focus

01:57:26.500 | to whatever is happening at those particular synapses.

01:57:29.700 | So it could be a focus on visual information

01:57:31.980 | or auditory information.

01:57:33.180 | If you're listening closely to what I'm saying right now,

01:57:35.980 | you just heard closely step out from the rest of my sentence,

01:57:39.380 | no doubt there was acetylcholine released at the sites

01:57:42.560 | in your brain where the neurons that represent

01:57:45.020 | your recognition of the word closely occurred, okay?

01:57:49.240 | So now you have an example and you have an understanding

01:57:51.340 | and hopefully a picture in your mind

01:57:52.500 | of how all this is working.

01:57:54.560 | Not surprisingly then,

01:57:56.020 | drugs that increase cholinergic or acetylcholine transmission

01:58:00.260 | will increase focus and cognition.

01:58:03.340 | One such compound is so-called alpha-GPC,

01:58:06.380 | which is a form of choline

01:58:08.320 | and increases acetylcholine transmission.

01:58:11.020 | Dosages as high as 1200 milligrams per day,

01:58:14.620 | which is a very high dosage spread out,

01:58:16.500 | typically it's 300 or 400 milligrams spread out

01:58:19.560 | throughout the day,

01:58:21.220 | have been shown to offset some of the effects

01:58:24.560 | of age-related cognitive decline,

01:58:26.240 | improve cognitive functioning,

01:58:27.460 | people that don't have age-related cognitive decline,

01:58:29.560 | that's a very high dose.

01:58:30.940 | Typically when people are using alpha-GPC to study

01:58:34.700 | or to enhance learning of any kind,

01:58:36.900 | they will take somewhere between 300 and 600 milligrams,

01:58:39.960 | that's more typical.

01:58:41.660 | Again, you have to check with your doctor,

01:58:43.620 | you have to decide if the safety margins

01:58:45.380 | are appropriate for you.

01:58:47.060 | Obviously you'll want to check that out,

01:58:49.520 | but alpha-GPC is effective in creating more focus

01:58:53.180 | by way of this cholinergic system,

01:58:54.880 | it stimulates acetylcholine release

01:58:56.740 | from both of those locations,

01:58:58.900 | the PPN in the back of the brain

01:59:00.760 | and nucleus basalis in the front of the brain.

01:59:03.420 | There are two other over-the-counter compounds

01:59:07.440 | that are in active use out there for treatment of ADHD

01:59:11.520 | and in use for simply trying to improve focus.

01:59:15.820 | And the first one is L-tyrosine,

01:59:17.640 | it's an amino acid that acts as a precursor

01:59:20.240 | to the neuromodulator dopamine.

01:59:22.340 | And now knowing everything you know

01:59:23.460 | about dopamine attention and the circuits involved,

01:59:25.780 | it should come as no surprise

01:59:26.860 | as to why people are exploring the use of L-tyrosine

01:59:29.940 | for that purpose.

01:59:31.300 | L-tyrosine does lead to increases in dopamine,

01:59:34.640 | they are fairly long-lived

01:59:37.260 | and L-tyrosine can improve one's ability to focus,

01:59:41.340 | however, the dosaging can be very tricky to dial in,

01:59:46.060 | sometimes it makes people feel too euphoric

01:59:48.700 | or too jittery or too alert

01:59:50.500 | that they are then unable to focus well.

01:59:53.220 | So the dosage ranges are huge,

01:59:56.280 | you see evidence for 100 milligrams

01:59:58.600 | all the way up to 1200 milligrams,

02:00:00.860 | it's something that really should be approached

02:00:02.180 | with caution, especially for people

02:00:04.140 | that have any kind of underlying psychiatric

02:00:06.380 | or mood disorder,

02:00:07.540 | because dysregulation of the dopamine system

02:00:10.100 | is central to many of the mood disorders

02:00:13.980 | such as depression, but also especially mania,

02:00:17.520 | mania bipolar disorder, schizophrenia, things of that sort,

02:00:21.000 | so it's something that really should be approached

02:00:22.640 | with caution, nonetheless, in exploring what's out there

02:00:25.920 | and even some studies online that were done,

02:00:30.480 | either animal studies or human studies,

02:00:32.520 | it's clear that L-tyrosine is being explored

02:00:35.560 | for that purpose, as is PEA and phenylethylamine,

02:00:39.380 | which is essentially PEA, but some related compounds,

02:00:43.880 | so there's a whole class of dopaminergic

02:00:46.680 | or dopamine stimulating supplements

02:00:48.760 | that people are using to try

02:00:49.700 | and get their dopamine levels up,

02:00:50.980 | and again, it's kind of a fine line

02:00:53.700 | between too little, enough, and too much.

02:00:57.380 | If you want to get the literature on those two compounds,

02:01:00.840 | there I will refer you to this great website, examine.com,

02:01:05.840 | just as it sounds, and you can put in L-tyrosine or PEA,

02:01:09.740 | and you can get the details on that,

02:01:11.020 | but I highly recommend also going to their section on ADHD

02:01:14.640 | to see how those particular compounds relate specifically

02:01:17.760 | to ADHD and cognitive focus.

02:01:20.920 | And last but not least,

02:01:22.520 | in terms of these different compounds,

02:01:24.240 | I do want to mention the racetams.

02:01:26.860 | These are somewhat esoteric,

02:01:30.420 | and probably most of you haven't heard about them,

02:01:32.600 | but some of you probably know a lot about them,

02:01:35.320 | and they are becoming more popular.

02:01:36.760 | They go by names like Nupept and things of that sort.

02:01:40.600 | The racetams are illegal in certain countries.

02:01:43.760 | They are gray market in other countries,

02:01:45.660 | and they are sold over the counter

02:01:47.800 | in this country, in the US.

02:01:50.480 | So they have different margins for safety.

02:01:54.280 | You definitely need to consult your doctor,

02:01:56.560 | especially if you have ADHD,

02:01:58.620 | but Nupept has been shown when taken at 10 milligrams

02:02:03.040 | twice daily can be more effective

02:02:05.960 | than some of the other racetams.

02:02:07.800 | What is Nupept?

02:02:08.640 | Nupept taps into the cholinergic system,

02:02:10.960 | the acetylcholine system,

02:02:12.000 | in ways very similar to alpha-GPC,

02:02:14.720 | but seems to have a slightly higher affinity

02:02:17.340 | for some of the receptors involved

02:02:19.320 | and can lead to those heightened states

02:02:21.140 | of cognitive capacity.

02:02:23.080 | And there are these studies, one in particular,

02:02:26.440 | comparative studies of Nupept and paracetam

02:02:28.520 | in the treatment of patients with mild cognitive disorders

02:02:31.800 | and brain diseases of vascular and traumatic origin.

02:02:34.300 | That's a mouthful.

02:02:35.140 | What this study basically points to

02:02:37.500 | is the fact that people who are experiencing

02:02:39.440 | some degree of inability to focus

02:02:42.200 | due to prior concussion or some vascular event,

02:02:45.540 | a stroke or ischemia of any kind,

02:02:47.800 | because neurons need blood,

02:02:49.080 | when the blood supply is cut off to neurons

02:02:50.920 | or when there's a bleed in the brain,

02:02:52.760 | subsequent to that,

02:02:53.760 | often there are challenges in maintaining focus.

02:02:56.720 | This is very common for people that have done sports

02:02:59.080 | where there's a lot of running into each other

02:03:00.620 | with your head, like rugby, football, hockey, and so forth,

02:03:04.320 | but also people who have experienced head blows

02:03:06.100 | or often overlooked is the fact

02:03:08.120 | that most traumatic head injury

02:03:10.040 | is not actually from sports, even football,

02:03:11.960 | it's from things like construction work,

02:03:14.080 | from high impact work of that kind.

02:03:16.600 | So there does seem to be some efficacy

02:03:18.520 | of Nupept and paracetam and things like it.

02:03:21.720 | It's an emerging area.

02:03:24.140 | And as I mentioned in the US,

02:03:25.480 | these things are sold over the counter.

02:03:27.320 | Again, you have to figure out if it's right for you,

02:03:29.600 | but they are beginning to show some promise.

02:03:32.860 | And I'm intrigued by them because of the way

02:03:35.640 | that they tap into the cholinergic system,

02:03:37.660 | which is both directly involved in focus

02:03:40.600 | and the ability to focus,

02:03:42.400 | but is also important for things

02:03:45.380 | related to age-related cognitive decline.

02:03:47.640 | So a decline in cholinergic transmission or acetylcholine,

02:03:51.280 | as we call it in the brain,

02:03:53.120 | is one of the things associated with cognitive decline.

02:03:55.540 | And it does seem that increasing cholinergic transmission

02:03:58.360 | can offset some of that cognitive decline

02:04:00.360 | and perhaps even more so in conditions

02:04:03.240 | such as vascular damage or concussion to the brain.

02:04:06.280 | If you're interested in atypical treatments for ADHD,

02:04:09.520 | compounds to improve focus and related themes,

02:04:13.280 | and you like reading about this stuff,

02:04:14.920 | there's an excellent review article that I can refer you to.

02:04:17.960 | It's by Ann et al, AHN.

02:04:20.880 | It was published in 2016.

02:04:22.560 | So it's a little bit behind the times,

02:04:24.240 | although it's surprisingly comprehensive given that,

02:04:27.680 | which lines up all the various drugs that I've discussed,

02:04:32.500 | racetams and Adderall and Ritalin and various forms

02:04:36.520 | of dopaminergic agents and cholinergic agents,

02:04:39.380 | spells out whether or not they are sold

02:04:41.280 | over the counter by prescription,

02:04:43.320 | and really lines them up in all their effects,

02:04:45.180 | their drawbacks, et cetera.

02:04:48.100 | I'll refer you to that study.

02:04:49.360 | It's available in its full length form online for free.

02:04:52.280 | It's on et al, the journal is Neuroplasticity 2016.

02:04:58.280 | Should be very easy to find if you put those keywords in.

02:05:01.360 | And while it is a review, it is a very comprehensive review.

02:05:04.360 | And if you're really into this stuff

02:05:06.080 | and you also want to learn a thing or two

02:05:07.980 | about how these things interact with neurofeedback, et cetera,

02:05:11.440 | there's some information in there as well.

02:05:13.440 | I know I've already covered a lot of information,

02:05:15.540 | but there is one more category of technology

02:05:18.480 | for the treatment of ADHD and for enhancement of focus

02:05:22.520 | in anyone that I would like to emphasize,

02:05:25.880 | and that's transcranial magnetic stimulation.

02:05:28.880 | Transcranial magnetic stimulation, also called TMS,

02:05:31.940 | is achieving increasing popularity nowadays

02:05:34.560 | for the treatment of all sorts of neurologic conditions

02:05:38.360 | and psychiatric conditions.

02:05:40.160 | It is a non-invasive tool.

02:05:41.800 | It involves taking a coil, it's a device with a coil

02:05:45.480 | that's placed over particular locations in the brain,

02:05:48.920 | and then sends magnetic stimulation into the brain.

02:05:53.320 | It can actually pass through the skull

02:05:54.520 | without having to drill through the skull.

02:05:56.520 | And nowadays can be used to both lower

02:05:59.800 | the amount of activity or increase the amount of activity

02:06:02.520 | in specific brain areas.

02:06:04.720 | Its spatial precision is not remarkable.

02:06:09.720 | That doesn't mean it's not of use,

02:06:11.160 | but it is not a super fine-grain tool, okay?

02:06:16.160 | It's not a cannon, but it's also not a needle.

02:06:19.440 | It is somewhere in between.

02:06:21.160 | It can direct the activity of particular brain regions

02:06:23.800 | at particular depths.

02:06:25.560 | And as I mentioned, it can increase

02:06:27.160 | or decrease that activity.

02:06:28.400 | So for instance, I've had a TMS coil placed on my head,

02:06:31.120 | not for therapeutic purposes.

02:06:33.320 | Even it was, I wouldn't tell you, but rather just for,

02:06:36.600 | well, I'm a neuroscientist and I worked in a lab with one

02:06:38.960 | for entertainment, exploratory purposes.

02:06:41.240 | Please don't do this at home.

02:06:42.640 | It was placed over my motor cortex,

02:06:46.720 | which generates voluntary action.

02:06:49.200 | And it was a coil that at that time

02:06:52.200 | could only inhibit neurons.

02:06:54.100 | And so what I was doing is I was moving objects around

02:06:56.900 | on a table, just like I am now.

02:06:58.440 | It was actually a pencil, not a pen.

02:07:00.280 | And I was tapping the pencil

02:07:01.940 | and then the TMS coil was turned on.

02:07:04.440 | And for the life of me, I could not move that pencil, okay?

02:07:08.520 | Because it was inhibiting my upper motor neurons

02:07:11.480 | in the portion of my cortex

02:07:12.920 | that controls voluntary activity.

02:07:15.560 | As soon as the coil was turned off,

02:07:16.920 | I could return to tapping the pencil again.

02:07:19.900 | Nowadays, it's possible to stimulate motor cortex

02:07:23.120 | or any area of the brain with some degree of precision

02:07:26.140 | that could create the impulse to move

02:07:29.500 | without actually making the decision to move.

02:07:31.640 | So you can literally engage certain neural circuits

02:07:34.760 | and therefore behaviors and certain thought

02:07:36.820 | and emotional patterns

02:07:37.940 | by way of transcranial magnetic stimulation.

02:07:40.700 | This has far reaching and vast implications

02:07:43.800 | as you can probably imagine.

02:07:46.080 | In discussing ADHD with a colleague that uses TMS,

02:07:50.720 | what they are doing is they are taking the TMS coil

02:07:55.360 | to children and adults that have ADHD

02:07:59.240 | and they're using it to stimulate the portions

02:08:01.920 | of the prefrontal cortex that we talked about earlier

02:08:04.720 | that engage task-directed focused states.

02:08:08.560 | So rather than using a drug that generally increases dopamine

02:08:11.440 | and some of the other chemicals involved,

02:08:13.080 | they're using directed TMS stimulation of these circuits.

02:08:17.280 | And fortunately, I was quite relieved to hear this,

02:08:20.440 | they are combining that with a focused learning task.

02:08:24.040 | So they're literally teaching the brain to learn

02:08:25.900 | in a non-invasive way, no drug at all.

02:08:28.780 | And right now there are experiments,

02:08:30.880 | clinical trials going on comparing TMS of this sort

02:08:34.080 | to the drug treatments of the sort that we described earlier

02:08:37.520 | that engage these circuits through pharmacologic mechanisms.

02:08:40.120 | So very exciting times for TMS,

02:08:43.040 | very exciting times for pharmacology related to ADHD

02:08:48.040 | and for enhancing focus in general.

02:08:49.720 | And when I say very exciting times, I mean,

02:08:52.180 | no drug is perfect, but the constellation of drugs

02:08:56.680 | that's out there is getting much larger,

02:08:58.880 | but because they tap into different aspects

02:09:01.280 | of their circuitry, I do think that we are well on our way

02:09:04.020 | to identifying the ideal combinations of drug treatments,

02:09:06.800 | technological treatments and behavioral paradigms

02:09:09.800 | for increasing focus in both children and adults with ADHD.

02:09:14.080 | And as a final, final point,

02:09:16.620 | I also want to mention something about technologies

02:09:18.940 | that are making it harder for all of us to focus,

02:09:22.100 | regardless of whether or not we have preexisting ADHD or not.

02:09:26.060 | You can probably guess where this is going.

02:09:28.760 | Everybody nowadays seems to have a smartphone.

02:09:31.160 | I'm sure there are a few individuals out there

02:09:33.200 | that don't have a smartphone.

02:09:35.500 | Nonetheless, most people have them.

02:09:37.120 | Most kids want one as soon as they can get them

02:09:40.040 | and they are small.

02:09:43.520 | They grab our attention entirely,

02:09:45.880 | but within that small box of attention,

02:09:48.520 | there are millions of attentional windows scrolling by.

02:09:53.120 | So just because it's one device that we look at

02:09:55.140 | does not mean that we are focused.

02:09:56.760 | We are focused on our phone,

02:09:58.600 | but because of the way in which context switches up so fast

02:10:02.240 | within the phone, it's thought that the brain

02:10:05.280 | is struggling now to leave that rapid turnover of context.

02:10:09.500 | Many, many shows, many, many Instagram pages,

02:10:12.160 | many, many Twitter feeds, many, many websites,

02:10:14.200 | basically the whole world, at least in virtual format,

02:10:17.880 | is available within that small box.

02:10:20.120 | Unlike any other technology humans

02:10:21.840 | have ever dealt with before,

02:10:23.080 | even though there are trillions,

02:10:25.340 | infinite number of bits of information

02:10:27.120 | in the actual physical world,

02:10:29.240 | your attentional window, that aperture of constriction

02:10:32.700 | and dilating that visual window

02:10:34.860 | is the way in which you cope

02:10:36.080 | with all that overwhelming information typically.

02:10:39.120 | Well, within the phone,

02:10:40.600 | your visual aperture is set to a given width.

02:10:43.980 | It's about this big.

02:10:45.000 | Typically the phone seemed to be getting bigger,

02:10:46.720 | but nonetheless, it's about that big.

02:10:48.920 | And within there, your attentional window

02:10:52.300 | is grabbing a near infinite number of bits of information,

02:10:56.160 | colors, movies.

02:10:57.260 | If a picture is worth a thousand words,

02:10:59.080 | a movie is worth a billion pictures.

02:11:01.400 | The brain loves visual motion.

02:11:03.520 | And so the question is,

02:11:06.060 | does that sort of interaction on a regular basis

02:11:09.360 | lead to deficits in the types of attention that we need

02:11:12.560 | in order to perform well

02:11:13.580 | in work and school relationships, et cetera?

02:11:15.840 | And the short answer is, yes, it does appear so.

02:11:19.160 | We are inducing a sort of ADHD.

02:11:22.120 | And while the studies on this are ongoing

02:11:24.280 | because prominent use of smartphones

02:11:26.120 | really took off right around 2010 and we're only in 2021,

02:11:30.200 | longstanding studies take time,

02:11:33.520 | which is essentially to say the same thing as longstanding.

02:11:36.880 | There are some studies and one in particular

02:11:39.060 | that I'd like to highlight.

02:11:39.900 | One was actually carried out pretty early in 2014.

02:11:42.860 | This is a study that explored smartphone use,

02:11:46.040 | at the time they called it mobile phone use,

02:11:47.940 | but smartphone use and inattention,

02:11:50.620 | difficulties in attending in 7,102 adolescents.

02:11:55.620 | So this is a huge study,

02:11:57.980 | a population-based cross-sectional study.

02:12:01.260 | And you will be probably surprised and somewhat dismayed

02:12:06.260 | to hear that in order to avoid this decrease

02:12:10.040 | in attentional capacity, adolescents needed

02:12:13.800 | to use their smartphone for less than 60 minutes per day

02:12:18.800 | in order to stay focused and centered on their other tasks.

02:12:22.960 | Otherwise they started to really run into significant issues.

02:12:26.380 | So 60 minutes is not much.

02:12:28.280 | I have a feeling that most young people

02:12:31.360 | are using their phone more than 60 minutes per day.

02:12:33.640 | I know I am.

02:12:35.120 | I think for adults, the number is probably higher,

02:12:38.120 | meaning if you're an adult,

02:12:40.640 | I'm going to just extrapolate from what I read in this study.

02:12:43.760 | It seems that probably two hours a day on the phone

02:12:47.080 | would be the upper limit beyond which

02:12:49.720 | you would probably experience

02:12:51.400 | pretty severe attentional deficits.

02:12:54.020 | I'm a big fan of Cal Newport who wrote the book, "Deep Work."

02:12:57.880 | He's also written the excellent book, "A World Without Email."

02:13:00.360 | I've never met him, but I'm a huge admirer of his work.

02:13:02.420 | And I will paraphrase something that he said

02:13:05.120 | far more eloquently than I ever could,

02:13:07.400 | which is that the brain does not do well

02:13:11.100 | with constant context switching, meaning it can do it,

02:13:15.560 | but it diminishes our capacity to do meaningful work

02:13:18.580 | of any other kind.

02:13:20.260 | And so Cal, as I understand,

02:13:22.840 | he's a computer science professor at Georgetown, by the way,

02:13:26.760 | is very structured and very disciplined

02:13:29.860 | in his avoidance of cell phone use.

02:13:32.260 | I think we're all striving to do that.

02:13:34.820 | I'm not here to tell you what to do,

02:13:36.060 | but I think whether or not you have ADHD or not,

02:13:39.480 | if you're an adolescent,

02:13:40.580 | limiting your smartphone use to 60 minutes per day or less,

02:13:45.320 | and if you are an adult to two hours per day or less

02:13:49.900 | is going to be among the very best ways to maintain,

02:13:54.100 | just to maintain your ability to focus

02:13:56.600 | at whatever level you can now.

02:13:58.780 | And as I always say,

02:14:01.320 | most of the things that we get recognized for in life,

02:14:03.580 | success in life in every endeavor,

02:14:05.860 | whether or not it's school, relationships, sport,

02:14:09.180 | creative works of any kind are always proportional

02:14:12.760 | to the amount of focus that we can bring that activity.

02:14:16.020 | It is important to rest, of course, to get proper sleep,

02:14:18.240 | but I stand behind that statement.

02:14:20.340 | And I leave you with that study about attention

02:14:23.340 | and cell phones and how cell phones are indeed eroding

02:14:26.660 | our attentional capacities.

02:14:28.580 | So I realized I covered a lot of information about ADHD

02:14:31.640 | and the biology of focus and how to get better at focusing.

02:14:35.660 | We talked about the behavioral

02:14:37.540 | and psychological phenotypes of ADHD.

02:14:40.220 | We talked about the underlying neural circuitry.

02:14:43.600 | We also talked about the neurochemistry,

02:14:45.860 | and we talked about the various prescription drug treatments

02:14:48.900 | that are aimed at that neurochemistry

02:14:51.100 | and aimed at increasing focus

02:14:52.860 | in children and adults with ADHD.

02:14:55.500 | We also talked about over-the-counter compounds,

02:14:58.240 | the role of particular types of diets and elimination diets.

02:15:01.660 | And we talked about interactions

02:15:03.400 | between these various features in dictating outcomes

02:15:07.020 | for ADHD and enhancing focus in general.

02:15:10.060 | We also talked a little bit

02:15:11.100 | about emerging neurotechnologies

02:15:13.380 | and how certain technologies like the smartphone

02:15:15.840 | are no doubt hindering our ability to focus

02:15:18.540 | and put us at greater risk of developing ADHD at all ages.

02:15:23.500 | I do acknowledge the irony and somewhat the contradiction

02:15:26.980 | of doing a two-hour plus episode on ADHD

02:15:30.620 | if indeed people who are watching this

02:15:32.840 | have challenges with attention.

02:15:34.420 | I want to emphasize that this podcast,

02:15:36.420 | like all of our podcast episodes,

02:15:38.460 | are timestamped for a specific reason.

02:15:41.180 | They are designed to be digested

02:15:42.380 | in whatever batch one chooses, right?

02:15:45.540 | You don't have to watch

02:15:46.380 | or listen to the entire thing all at once.

02:15:48.340 | However, if you've gotten to this point in the podcast,

02:15:51.300 | I want to thank you.

02:15:52.260 | I do hope that you've learned a lot about this condition.

02:15:55.360 | I hope you've also learned a lot

02:15:56.980 | about your own capacity to focus

02:15:58.940 | and things that you can do to enhance your focus.

02:16:00.800 | We even talked about a tool that takes just one

02:16:02.840 | 17-minute session to enhance your ability to focus

02:16:06.380 | thereafter, presumably forever.

02:16:09.240 | If you're enjoying this podcast and you're learning from it,

02:16:11.620 | please subscribe to our YouTube channel.

02:16:13.220 | That really helps us.

02:16:14.180 | In addition, in the comment section on YouTube,

02:16:16.940 | you can leave us suggestions for future podcast guests

02:16:19.980 | and suggestions for future podcast topics

02:16:22.580 | that we may have not covered

02:16:23.780 | or that you'd like to see covered in the future.

02:16:26.180 | In addition, please subscribe to the podcast

02:16:27.980 | on Apple and Spotify.

02:16:29.500 | And on Apple, you have the opportunity to leave us a comment

02:16:32.140 | and up to a five-star review.

02:16:34.480 | In addition, please check out the sponsors mentioned

02:16:36.680 | at the beginning of the podcast.

02:16:37.920 | That's a terrific way to support us.

02:16:40.020 | And for those of you that would like to support research

02:16:42.460 | on stress, neurobiology, and human performance,

02:16:44.980 | you can go to hubermanlab.stanford.edu,

02:16:47.840 | and there you can make a tax-deductible donation

02:16:50.440 | for research on neurobiology in my laboratory.

02:16:53.860 | In addition, we have a Patreon.

02:16:55.260 | It's patreon.com/andrewhuberman.

02:16:58.480 | There, you can support the podcast

02:17:00.480 | at any level that you like.

02:17:01.880 | During today's episode,

02:17:02.780 | we talked a lot about supplement-based compounds.

02:17:05.940 | If you're interested in supplements

02:17:07.220 | and you want to see the supplements that I personally take,

02:17:09.500 | you can go to Thorne, that's T-H-O-R-N-E,

02:17:12.820 | slash the letter U, slash Huberman,

02:17:15.660 | and you can see everything that I take,

02:17:17.860 | and you can get 20% off any of those supplements.

02:17:20.580 | Or if you navigate into the Thorne site through that portal,

02:17:23.840 | you can get 20% off any of the supplements that Thorne makes.

02:17:27.340 | Supplements aren't for everybody.

02:17:28.740 | You by no means have to take supplements,

02:17:30.700 | but if you are going to take supplements,

02:17:32.060 | it's important that you take supplements

02:17:33.280 | from a source that's reputable,

02:17:35.200 | in which the ingredients are very high quality,

02:17:38.180 | and in which the amount of the ingredients

02:17:40.460 | that listed on the bottle

02:17:41.760 | actually matches what's in the bottle.

02:17:43.380 | That's why we partnered with Thorne,

02:17:44.960 | because they have the highest levels of stringency

02:17:46.900 | in terms of quality and specificity of the ingredients.

02:17:50.000 | And finally, I want to thank you for your time

02:17:52.000 | and your attention,

02:17:53.260 | and as always, thank you for your interest in science.

02:17:56.180 | (upbeat music)

02:17:58.760 | [MUSIC PLAYING]

ADHD & How Anyone Can Improve Their Focus | Huberman Lab Podcast #37

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