- I wanted to ask about behavioral tools for ADHD. I've seen some of the literature claiming that certain video games might actually be useful for training focus. I've managed to find a few papers that talk about focus and meditation tasks that kids in particular, but adults may be able to get better at.

I mean, are any of these brain training games to get people better at focusing? Are any of them known to be worthwhile according to like real data or clinical observation? - So I'll start by stepping back a little bit and broadening it, I'll get to the video game things.

But one of the effective approaches that helps with symptomatic reduction with ADHD is cognitive behavioral therapy. So that's a form of talking therapy. And my quick overview of it is that it focuses on actions, thoughts, and feelings and that humans can have direct control of their actions and thoughts, not too much over their feelings, but all three are affecting each other.

And the traditional CBT was developed by Aaron Beck to treat depression, probably 50 years ago. maybe longer 60s, I think, late 60s. Anyway, on the surface, it's a horrible match for ADHD because we know it requires lots of repetitive, boring homework, doing the same thing. It involves introspection of being aware of what you're doing already, looking at those patterns, looking at what the triggers, you know, to see if you can see triggers for them.

And then doing lots and lots of repetitive homework, which, and when it's successful for depression or PTSD or other venues, we know it actually changes brain wiring and brain chemistry. So lots of people still think talking therapies are sort of up here doing something and chemicals and medications are really changing the brain.

If your thoughts are changing, if your behavior is changing, your brain has changed. That's the only place that thoughts and behaviors come from. But there have been at least two groups, Mary Salanto's in New York and a Harvard group by, I'm blanking on his first, Safran and some other, Ramsey at Pennsylvania, developed approaches using CBT techniques specifically designed for people with ADHD to help overcome some of those hurdles and barriers.

And both of them encourage actually the use of medications in combination with it. Because many people with ADHD are too unfocused, too unable to sit down and do it. But these are approaches and both approaches are amazingly similar, although devised completely independently. At the core of both of those approaches is having a system of scheduling each day.

That doesn't mean micromanaging each minute, but it's having the essentials in place, having blocks of time that you know what you're going to do. And having a task list in combination with that. And ways of learning to prioritize and move things up or down. And again, with ADHD being interest-driven rather than importance-driven, you may have a task.

I mean, you probably have 17 task lists. One's New York coffee. One's at the grocery store. One, it's having one consolidated list, because if it's everywhere, then it's nowhere. And two is the simplest triaging or organizing approach is having the things that are both urgent and important. So that happens to happen today, those get in the A category.

The things that are important but aren't as urgent are the B category. And all the other things are the C. And one of the temptations that people with ADHD have is, oh, I need to be productive. You know, it's fun to go buy shoelaces, and that's on my list.

So I'll go to buy shoelaces, because then I can cross something off my list. But I didn't move the car. I didn't do my taxes. I haven't done my homework. And all the important things remain undone. So it's a system for getting done what's really needed to be done.

And eventually, if your shoes don't work, the shoelaces will move up to that. A category. But for most people, they're not really there. And it's not a good use of your time to do them first. So that-- and there's much more to it. So the CBT approach can work with decreasing procrastination.

It can help with structuring your own workspace, given that you probably have much more trouble doing that and not doing it spontaneously. It's how to eliminate distractions and modules on even extending your concentration time. So the answer with the video games, there is one product that's actually been FDA approved for use in ADHD.

And the really important thing to remember there is the FDA's system for addressing medications is much more rigorous, much more thorough. You have to demonstrate it really works and does something. When the FDA approves devices, basically, they're saying it's not going to kill anyone. It might help. I mean, it might help tremendously.

But having the FDA imprimatur for that doesn't guarantee that or mean that at all. Do you recall if the study of that device or the study of that video game has a conflict of interest? Was it run by the company? Yeah, so almost all of them have been run by the company.

I mean, it's good people at UCSF who are at least partly involved in it. Oh, is this Adam Gazzelli's group? I think so. Yeah, I should just say that I've followed his work for some years. He's a neuroscientist. I know people who have been in his lab. He's known for doing very, very high quality and stringent work.

Their product and some of the others can clearly show you get better at their product and you get better at tests that look exactly like their product. But in terms of real world, how much is this really helping ADHD symptoms on a day-to-day basis? Not a lot of data at all.

So again, that doesn't mean it doesn't work. And I'm going to go sideways and talking about neurofeedback because there's lots and lots of neurofeedback companies across the country that are making lots and lots of money. And there was an article in the American Journal of Psychiatry in the last year.

I'm not remembering which group did it. And it was another failure to find a significant impact from neurofeedback. And again, I'm not saying it doesn't have an effect, but I've had lots of people saying, writing me, should I keep spending hundreds of dollars each week because my insurance isn't covering this and the doctor is saying, oh, maybe 20 more episodes will retrain your brain.

And so this gets back to a topic you brought up earlier. How much are we retraining our brains with immersion in social media? And the evidence is we are rewiring our brains. So maybe anything pushing in an opposite direction or maybe this is reinforcing some of the bad things we don't want.

it's we're in a messy world without clear answers yet. I've made it a point to put social media on an old phone. So those apps are only on that phone. I don't even know the number to that phone. If I need to post something, I airdrop it onto that phone.

And this has helped tremendously in segregating that activity and limiting it. It also means that people send me something which would otherwise direct me to social media. It's much more difficult for me to go look it up. It's helped tremendously. I just pass it on because it's one of the things that's really allowed me to restrict my social media time.

And yet still be, you know, in keeping with the fact that I think social media has its uses. I post there, et cetera. Yes. Getting back to the scheduling. I mean, what I recommend to people and one of my week, I don't know the specific apps, but there are apps that will help shut you out of Facebook or discord or TikTok or whatever it is.

If you can't exert your own willpower, which again is harder to do if you have ADHD. And if the app approach doesn't work, the next level up is there are all sorts of companies making lock boxes and physical devices where you can lock yourself out to your device for certain hours of the day.

And I think that's a good idea for lots of people. I do too. And I think it also helps, at least in my experience, to do things that are very different than social media as well, but still consuming content. So I make it a point to read from an actual physical book a bit each day or night.

Also because I was raised doing that and writing by hand is just sort of in keeping with the way that my brain was wired, so maybe that's more specific to me and my generation. But I find that when I'm doing those other activities, when I go onto social media, it feels more like a departure from the rest of life as opposed to the other way around.

That's a good sign for preserving.