- Welcome to the Huberman lab podcast,

where we discuss science and science-based tools

for everyday life.

[upbeat music]

I'm Andrew Huberman,

and I'm a professor of neurobiology and ophthalmology

at Stanford school of medicine.

Today, we are going to talk all about attention deficit,

hyperactivity disorder, or ADHD.

We are also going to talk about normal levels of focus.

What are normal levels of focus and how all of us,

whether or not we have ADHD or not can improve our ability

to focus our ability to rule out distraction.

It turns out those are two separate things,

as well as remember information better.

We are also going to talk about

how we can learn to relax while focusing,

which turns out to be a critical component of learning new

information and for coming up with new creative ideas.

So whether or not you have ADHD or know someone who does,

or if you're somebody who feels that they do not have ADHD,

but would simply like to improve their ability to focus

or to be more creative.

This episode is definitely for you as well.

We are going to talk about drug based tools

that are out there.

We are going to talk about behavioral tools.

We will talk about the role of diet and supplementation,

and we will talk about new emerging

brain machine interface devices,

things like transcranial magnetic stimulation.

If you don't know what that is, don't worry,

I will explain it to you.

These are non-invasive methods for rewiring your brain

in order to make focusing more natural for you

and to teach you how to increase your depth of focus.

Now, just a quick reminder

that any time we discuss a psychiatric disorder,

it's important that we remember

that all of us have the temptation to self-diagnose

or to diagnose others.

So, as I list off some of the symptomology of ADHD,

some of that symptomology might resonate with you.

You might think, oh, maybe I have ADHD

or you might decide that someone you know,

definitely has ADHD.

However, it is very important that you don't self-diagnose

or diagnose somebody else

the clear and real diagnosis of ADHD

really should be carried out by a psychiatrist, a physician,

or a very well-trained clinical psychologist.

There are clear criteria for what constitutes

full-blown ADHD.

However, many of us have constellations of symptoms

that make us somewhat like somebody with ADHD

and if you're struggling with focus nowadays,

as a lot of people are because of stress,

because of smartphone use,

which turns out can induce adult ADHD.

We'll talk about that.

We'll then pay attention to the symptomology.

You may actually require professional treatment

you might not,

equally important is to remember

that some of the terms that we cover,

like impulse control and attention and concentration

are somewhat subjective and they can change over time.

Sometimes we have a better level of attention than others.

Maybe it depends on how we slept

or other events going on in our life

where something that we're entirely unaware of.

The important thing to remember

is that we can all improve our attentional capacity.

We can all rewire the circuits that make heightened levels

of focus, more accessible to us.

We can do that through multiple types of interventions,

and we are going to cover all those interventions today.

Before we march into the material,

I'd like to remind that this podcast is separate

from my teaching and research roles at Stanford.

It is however, part of my desire and effort

to bring zero cost to consumer information about science

and science related tools to the general public.

And keeping with that theme,

I'd like to thank the sponsors of today's podcast.

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I've spent a lifetime working on the visual system

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So let's talk about ADHD,

Attention Deficit Hyperactivity Disorder.

Let's also talk about focus and attention

and everybody's ability to focus and attend

not just people with ADHD.

We are also going to talk about tools

that would allow anyone,

whether or not they have ADHD or not

to enhance their level of concentration and focus.

Now, ADHD used to be called ADD Attention Deficit Disorder.

We have record of ADD in the medical literature

dating back to as early as 1904.

Now there's nothing special about 1904.

That's just the first time that it showed up

in the standard medical literature.

We have to believe that ADD,

which we now call ADHD existed before 1904

and probably long before 1904, why?

Well, because it has a strong genetic component.

If you have a close relative that has ADHD,

there's a much higher probability that you will have ADHD

and that probability goes up depending on how closely

related to that person you happen to be.

So for instance,

if you're an identical twin and your twin has ADHD,

there's a very high concordance as we say,

a very high probability that you will have ADHD

up to 75% chance.

If you have a fraternal twin with ADHD,

that number goes down a bit in the 50 to 60% range

and so on.

If you have a parent with ADHD,

that number ranges anywhere from 10 to 25% likelihood,

that you will have ADHD if you have two parents

and so on and so on, okay?

So there's a genetic component

that genetic component it turns out,

relates directly to how specific neural circuits

in the brain wire up,

the chemicals they use and the way they use those chemicals,

a topic that we are going to discuss in depth today.

Now, if you have a close relative with ADHD,

that does not mean that you are faded to have ADHD

and if you happen to have ADHD,

there are ways to overcome those symptoms

of lack of attention, impulsivity and so on.

Another important point about ADHD

is that it has nothing to do with intelligence,

whether or not we're talking about intelligence

measured by a standard IQ test

a rather controversial issue as many of you probably know,

there are lots of forms of intelligence

that a standard IQ test just wouldn't pick up

emotional intelligence, musical intelligence,

spatial intelligence, all sorts of intelligences.

None of them are related to ADHD.

Being very high functioning doesn't make you

more likely to have ADHD and being ADHD

doesn't necessarily mean that you have a low IQ.

So there are people with ADHD who have low IQs

people with ADHD with high IQ,

people with ADHD with high emotional IQ or with low IQ

in the emotional scale, it's all over the place.

The important point is that your ability to attend and focus

does not relate to how smart you are or your IQ of any type,

not just a standard IQ.

The renaming of the ADD to ADHD took place

in the mid to late 1980s

when the psychiatric community

and the psychological community

started taking better notice of the fact that

so-called hyperactive kids also had attentional issues.

This might seem obvious,

but there's been extensive and ongoing revision

of the criteria for designating a psychiatric disorder

and this is still an ongoing process even today.

So in the mid eighties,

we started hearing about ADHD

and then gradually that term ADD has been dropped away.

However, just the renaming of ADD to ADHD

has led to much better diagnosis and detection of ADHD.

So right now the current estimates are that

about one in 10 children and probably more have ADHD.

The current estimates are anywhere from 10%, one in 10

to as high as 12%.

Now, fortunately about half of those

will resolve with proper treatment,

but the other half typically don't.

The other thing that we are seeing a lot nowadays

is increased levels of ADHD in adults

and there's some question as to whether or not

those adults had ADHD that went undetected

during their childhood or whether or not

ADHD is now cropping up in adulthood

due to the way that we are interacting with the world

in particular smart phone use,

the combination of email, text, real-world interactions,

multiple apps and streams of media and social media

all coming in at once trying to manage life.

All of the things that are going on

are creating a kind of cloud of poles on our attention

and so there is this question to whether or not

we are creating ADHD in adults that never had ADHD

prior to being an adult.

So let's talk about attention

and first let's just define what we mean by attention

out there in the scientific literature

and in discussions about ADHD,

we will hear things like attention and focus

and concentration and impulse control

for sake of today's discussion,

attention, focus, and concentration

are essentially the same thing, okay?

We could split hairs and the scientific literature

does split hairs about these.

But if we want to understand the biology

and we want to have

a straightforward conversation about ADHD,

if I say attention or focus,

I'm basically referring to the same thing,

unless I specify otherwise, okay?

So people with ADHD have trouble holding their attention.

What is attention?

Well, attention is perception.

It's how we are perceiving the sensory world.

So just a little bit of neurobiology 101,

we are sensing things all the time.

There's information coming into our nervous system

all the time.

For instance, right now you're hearing sound waves.

You are seeing things,

you are sensing things against your skin,

but you're only paying attention to some of those

and the ones that you're paying attention to

are your perceptions.

So if you hear my voice, you are perceiving my voice.

You are not paying attention to your other senses

at the moment, okay?

You might even be outside in a breeze

and until I said that,

you might not be perceiving that breeze,

but your body was sensing it all along.

So attention and focus are more or less the same thing,

but impulse control is something separate because impulse

control requires pushing out or putting the blinders on

to sensory events in our environment.

It means lack of perception,

impulse control is about limiting our perception.

People with ADHD have poor attention

and they have high levels of impulsivity

they're easily distractable.

But the way that shows up is very surprising.

You might think that people with ADHD

just simply can't attend anything.

They really can't focus,

even if they really want to, but that's simply not the case.

People with ADHD yes, they are distractable.

Yes, they are impulsive.

Yes, they are easily annoyed

by things happening in the room.

They sometimes have a high level of emotionality as well.

Not always, but often

however people with ADHD can have a hyper focus

and incredible ability to focus

on things that they really enjoy

or and are intrigued by.

Now, this is a very important point

because typically we think of somebody with ADHD

as being really wild and hyperactive,

or having no ability whatsoever to sit still and attend

and while that phenotype as we call it

that contour of behavior and cognition can exist,

many people, if not all people with ADHD,

if you give them something they really love,

like if the child loves video games

or if a child loves to draw,

or if an adult loves a particular type of movie

or a person very much, they will obtain laser-focus

without any effort.

So that tells us that people with ADHD

have the capacity to attend,

but they can't engage that attention

for things that they don't really, really want to do

and as we all know much of life,

whether or not you're a child or an adult

involves doing a lot of things that we don't want to do,

much of our schooling involves doing things

that we would prefer not to do

and sort of forcing ourselves to do it, to attend,

even though we are not super interested

in what we are attending to.

There are a couple other things

that people with ADHD display quite often.

One is challenges with time perception.

Now time perception is a fascinating aspect

of how our brain works

and later we're going to talk about time perception

and how you can actually get better at time perception.

It's very likely that right now you are doing things

that get in the way of optimal time perception

and I will tell you how to adjust your ability

to measure time with your brain.

People with ADHD often run late.

They often procrastinate,

but what's interesting and surprising

is that if they are given a deadline,

they actually can perceive time very well

and they often can focus very well

if the consequences of not completing a task

or not attending are severe enough.

It's a little bit like the way that people with ADHD

can really focus if they like something.

Well, if they're scared enough about the consequences

of not attending, oftentimes not always,

but oftentimes they can attend.

If they're not really concerned about a deadline

or a consequence,

well, then they tend to lose track of time

and they tend to underestimate how long things will take.

Now many people do that, not just people with ADHD,

but people with ADHD have challenges,

understanding how to line up the activities of their day

in order to meet particular deadlines

even if it's just a simple thing,

like finishing one set of tasks before lunch,

oftentimes they will remember that lunch starts at noon,

but somehow they aren't able to fill the intervening time

in a way that's productive

and they can obsess about

the upcoming deadline for instance,

we will talk about how to remedy this.

In addition,

their spatial organization skills are often subpar,

not always, but often you will find that somebody with ADHD

uses what's called the pile system

in order to organize things,

they will take many belongings

and this could be in the kitchen or in their bedroom

or in their office or in any space

and they will start piling things up

according to a categorization system

that makes sense to them and only them.

It doesn't really have any logical framework.

Now, many people use the pile system

and if you use the pile system,

that doesn't mean that you have ADHD

in fact, if you're unpacking a house

or you've moved recently,

or you've received a lot of presence recently,

the pile system makes perfect sense to organize your space.

But people with ADHD tend to organize things

according to the pile system all the time

and that pile system doesn't work for them.

Okay, so that's the key distinction

that they use a filing system, and it's not really files,

they're piling things up in a way that makes sense to them,

but then it doesn't work for them in terms of what tasks

they actually need to perform.

They can't find things

or if anyone moves one thing then it's very disruptive

to their overall plan because their overall plan

doesn't really work in the first place.

So that's a common phenotype as we call it.

A phenotype by the way,

is just an expression of a particular set of underlying

genetic or psychological components, okay?

So we say the phenotype.

So a phenotype can brown hair and green eyes,

like for me,

a phenotype could also be

that somebody uses the piling system, okay?

The other thing that people with ADHD have real trouble with

is so-called working memory.

Now you might think that people with ADHD

would have really poor memories,

but in fact, that's not the case.

People with ADHD often can have a terrific memory

for past events,

they can remember upcoming events quite well.

Their memory is clearly working.

However, one aspect of memory in particular

that we call working memory is often disrupted.

Working memory is the ability to keep

specific information online,

to recycle it in your brain over and over again,

so that you can use it in the immediate or short term.

A good example of this would be you meet somebody,

they tell you their name,

they give you their phone number verbally,

and you have to walk back to your phone

and enter it into your phone.

People without ADHD might have to put some effort into it,

it might feel like a bit of a struggle,

but typically they will be able to recite that phone number

in their mind over and over, and then put into their phone.

People with ADHD,

tend to lose the ability or lack the ability

to remember things that they just need to keep online for

anywhere from 10 seconds to a minute or two, okay?

So a string of numbers like 6, 4, 3, 7, 8, 1 for most people

would be pretty easy.

6, 4, 3, 7, 8, 1, 6, 4, 3, 7, 8, 1,

you could probably remember that a minute from now

without writing it down.

But if you add one more number to that 6, 4, 3, 7, 8, 1, 3,

it gets tougher, okay?

So there's a reason why phone numbers typically have

seven digits in them, of course, there's an area code,

but remembering information that strings out longer

than seven numbers or a sentence or two

that's challenging for most people,

people with ADHD have severe challenges,

even with much smaller batches of information

over even much smaller batches of time.

Deficits in working memory are also

something that we see in people who have

frontotemporal dementia,

so damage to the frontal lobes

or age-related cognitive decline

and so it will come as no surprise that later

when we discuss treatments, supplements,

and other tools for ADHD,

that many of those treatments,

supplements and tools for ADHD are similar to the ones

that work for age-related cognitive decline.

Okay, so we've more or less established

the kind of menu of items that people with ADHD tend to have

some have all of them.

Some have just a subset of them.

Their severity can range from very intense to mild,

but in general,

it's challenges with attention and focus,

challenges with impulse control, they get annoyed easily.

They have kind of an impulsivity,

they can't stay on task.

Time perception can be off,

they use the piling system

or a system that doesn't work well for them

in order to organize their things in physical space

and they have a hard time with anything that's mundane

that they're not really interested in.

But again, I just want to highlight that people with ADHD

are able to obtain heightened levels of focus,

even hyper-focus for things that are exciting to them

and that they really want to engage in.

So now you have the contour of what ADHD is,

and if you're somebody who doesn't have ADHD,

you should also be asking yourself which aspects of ADHD

are similar to things I've experienced before.

Because what we know about the healthy brain

is that there's also a range of abilities to focus.

Some people focus very well on any task.

You give them a task, they can just laser in on that task.

Other people that have to kind of fight an internal battle,

they have to convince themselves

that it's important or interesting.

They have to kind of incentivize themselves internally.

Other people doesn't matter,

they could be bored to tears with the information,

but they can do it just because they are,

"Very disciplined people."

We tend to admire those people

but as you'll see a little bit later,

it's not clear that that's the best way

to run your attentional system.

There might be something to this business

of having heightened levels of attention

for the things that you are

most interested or excited by.

So let's drill into this issue of why people with ADHD

actually can focus very intensely on things that they enjoy

and are curious about.

Now, enjoyment and curiosity are psychological terms,

they're not even really psychological terms.

They're just the way that we describe our human experience

of liking things, wanting to know more about them.

But from a neuro-biological perspective,

they have a very clear identity and signature

and that's dopamine.

Dopamine is released from neurons,

it's what we call a neuromodulator

and as a neuromodulator it changes the activity

of the circuits in the brain,

such that certain circuits are more active than others

and in particular,

dopamine creates a heightened state of focus.

It tends to contract our visual world

and it tends to make us pay attention to things

that are outside and beyond the confines of our skin.

That's what we call exteroception.

Dopamine also tends to put us in a state of motivation

and wanting things outside the confines of our skin.

So whether or not we're pursuing something

physical in our world,

or whether or not we're pursuing information

in our outside world,

dopamine is largely responsible for our ability

and our drive to do that.

But dopamine as a neuromodulator is also involved

in changing the way that we perceive the world.

So, as I mentioned earlier

you have all these senses coming in

and you can only perceive some of them

because you're only paying attention to some of them.

Dopamine when it's released in our brain

tends to turn on areas of our brain

that narrow our visual focus

and our auditory focus,

so it creates a cone of auditory attention,

that's very narrow,

creates a tunnel of visual attention that's very narrow.

Whereas when we have less dopamine,

we tend to view the entire world,

we tend to see the whole scene that we are in,

we tend to hear everything all at once.

So as I describe this,

hopefully you're already starting to see and understand

how having dopamine release can allow a person,

whether or not they have ADHD or not

to direct their attention to particular things

in their environment, all right?

So now what we're doing is we're moving away from attention

as this kind of vague ambiguous term,

and we're giving it a neurochemical identity dopamine,

and we are giving it a neural circuit identity

and just to put a little bit of flavor and detail

on which neurocircuits those are,

I want to discuss two general types of neurocircuits

that dopamine tends to enhance.

So let's talk neurocircuits

and for those of you that love hearing neuroscience,

nomenclature, you're going to eat this part up

and for those of you that don't like a lot of names

of brain areas I invite you to tune out

or just try and grab the top contour of this.

I will describe it in pretty general terms,

but I will give some detail because I know there are

some of you out there who really want to dig deeper into

what the exact structures and connectivities are, okay?

So there are two main types of circuits that

we need to think about with respect to ADHD,

attention and dopamine.

The first one is called the default mode network.

The default mode network is the network of brain areas

in your brain and my brain and in everybody's brain

that is active when we're not doing anything

when we're just sitting there idle at rest.

Now it's very hard to not think about anything,

but when you're not engaged in any type of specific task,

so you're not driving, you're not playing a video game,

you're not trying to study, you're not trying to listen,

you're just sitting there letting your brain

kind of go wherever it wants to go.

Your default mode network underlies that state of mind.

The other set of circuits that we're going to think about

and talk about with respect to ADHD are the task networks,

the networks of the brain that make you goal oriented,

or that are at least trying to make you goal oriented

and those are a completely different set of brain areas.

However, the default mode network

and these tasks networks are communicating with one another

and they're doing that in very interesting ways.

So first I want to describe how these two

sets of brain areas,

the default mode network

and the task networks normally interact, okay?

So little bit of naming here

again feel free to ignore it

if you don't want this level of detail,

but the default mode network includes

an area called the dorsolateral prefrontal cortex,

frontal cortex, no surprises in the front

and you have a dorsal, the top

and side lateral part dorsolateral, prefrontal cortex.

You got one on each side of your brain, right?

And then you have a brain area called

the posterior cingulate cortex

and then you have an area called the lateral parietal lobe.

Again, you don't need to remember these names for,

these are three brain areas that normally

are synchronized in their activity.

So when one of these areas is active in a typical person,

the other areas would be active as well.

So it's a little bit like a symphony or a band

like a three-piece band is like drums, guitar,

and bass they're playing together, okay?

That's how it is in a typical person

and in a person with ADHD,

or even a person who has subclinical ADHD

or in any human being who hasn't slept well,

what you find is the default mode network

is not synchronized.

These brain areas are just not playing well together.

Now the task networks include a different set of structures.

It still involves the prefrontal cortex,

but it's a different part of the prefrontal cortex, okay?

Tends to be the medial prefrontal cortex

and there are some other brain areas

that the medial prefrontal cortex is communicating to

all the time, mainly to suppress impulses.

It's shutting down the desire to stand up

or to scratch the side of your cheek or your nose,

if you're trying not to do that,

anytime you're restricting your behavior,

These task directed networks are very active, okay?

Now normally in a person without ADHD,

the task networks and the default mode networks

are going in kind of Seesaw fashion,

they are actually what we call anti-correlated.

So it's not just that they are not correlated,

they're actually opposing one another

they are anti-correlated.

In a person with ADHD,

the default mode networks and the tasks networks

are actually more coordinated.

That might come a surprising,

I think that we all have this tendency

to kind of jump to conclusion and assume that somebody

who doesn't have an easy time paying attention or has ADHD,

that their brain must be completely incoherent

that it's not working well

and because everything's out of whack,

but there's something interesting about people with ADHD

whereby the task networks and the default mode networks

are actually working together in a way that's correlated

and that is what's abnormal.

So this would be like the guitar bass and the drums

playing together in a way where

the bass isn't keeping the backbeat and the drums,

aren't keeping the backbeat that they're playing together,

they're all playing the melodies and harmonies

in a way that just doesn't sound right.

That's what's going on in the brain of somebody with ADHD

and we can now confidently say

based on brain imaging studies,

that when somebody gets better,

when they're treated for ADHD or when they age out of ADHD,

as sometimes it's the case that the default mode networks

and the task networks tend to become

anti-correlated again, okay?

So that's the underlying neurobiology,

but you'll notice that I didn't mention dopamine at all.

What dopamine is doing in this context

is dopamine is acting like a conductor.

Dopamine is saying this circuit should be active

then that circuit should be active.

It should be default mode network

and then when the default mode network is not active,

then it should be the task network.

So it's really acting as a conductor saying, you go,

now you go, now you go, now you go.

And in ADHD,

there's something about the dopamine system

that is not allowing it to conduct these networks

and make sure that they stay what,

the engineers or physicists or mathematicians would say

out of phase to be anti-correlated, okay?

Out of phase and anti correlate, essentially the same thing,

at least for purposes of this discussion.

So that raises two questions,

could it be that dopamine is not at sufficiently high levels

or could it be that dopamine is just doing it all wrong?

In other words,

is there no conductor or is the conductor playing with like

little tiny toothpicks

and so the instruments can't see

what they're supposed to do.

They can't get the instruction

'cause it's just not loud enough, so to speak,

or could it be that the information is getting out,

but the information that's getting out is wrong,

the conductor's there,

but the conductor is in very good at conducting.

Now we can gain insight into how the system works

and fails and how to treat it

by looking at some of the current

and previous treatments for ADHD,

as well as some of the recreational drugs

that people with ADHD tend to pursue and like

now I'm certainly not a proponent of people with ADHD

taking drugs recreationally,

that's not what this is about,

but if you look at their drug seeking behavior

and you couple that drug seeking behavior

to their desire to remedy their attention deficit,

you start gaining some really interesting insight

into how dopamine is regulating these circuits

in normal circumstances and in people with ADHD.

So what exactly is going on with the dopamine system,

in people with ADHD

and what's going on with the dopamine system

in people that have terrific levels of attention

for any task?

Well, in the year 2015, an important paper came out.

The first author is Spencer,

and it came out in a journal called Biological Psychiatry,

and it formalized the so-called

low dopamine hypothesis of ADHD.

The idea that dopamine was somehow involved

or not at the appropriate levels in people with ADHD

had been around for a pretty long time,

but a formal proposition of the low dopamine hypothesis

led to some really important experiments and understanding

of what goes wrong in ADHD.

It turns out that if dopamine levels are too low

in particular circuits in the brain,

that it leads to unnecessary firing of neurons in the brain

that are unrelated to the task that one is trying to do

and that is unrelated to the information

that one is trying to focus on.

So if you think back before you've got this

default mode network and a task-related network,

and they need to be in this kind of concert of

anti-correlation and an ADHD they're firing together.

Well, the problem seems to be that when dopamine is low,

certain neurons are firing when they shouldn't be,

this is like a band, right?

We'll go back to our band, that's a guitar bass in it,

and the person playing the drums

and it's as if one of those or several of those instruments

are playing notes when they shouldn't be playing, right?

The pauses and music are just as important

as the actual playing of notes.

When dopamine is too low neurons fire,

more than they should in these networks

that govern attention.

This is the so-called low dopamine hypothesis

and if you start looking anecdotally

at what people with ADHD have done for decades,

not just recently since the low dopamine hypothesis

has been proposed,

but what they were doing in the 1950s and then the 1940s

and the 1960s.

What you find is that they tend to use recreational drugs,

or they tend to indulge in non drug stimulants.

So things like drinking, six cups of coffee

or quadruple espressos,

or when it was more prominent

smoking a half a pack of cigarettes

and drinking four cups of coffee a day

or if the person had access to it

using cocaine as a recreational drug

or amphetamine as a recreational drug.

All of those substances that I just described

in particular cocaine and amphetamine,

but also coffee and cigarettes

increase levels of multiple neurotransmitters,

but all have the quality of increasing levels

of dopamine in the brain and in particular,

in the regions of the brain that regulate attention

and these task related and default mode networks okay?

Now young children,

fortunately don't have access to those kinds of stimulants

most of the time

and those stimulants all have high potential

for abuse in adults.

So we will talk about the potential for abuse

in a few minutes.

But if you look at children,

even very young children with ADHD,

they show things like preference for sugary foods,

which also act as dopamine inducing stimulants.

Now, of course, once they get access to soda pop

and coffee and tea,

they start to indulge in those more than other people.

For a long time,

it was thought that children with ADHD

consumed too many sugary foods or drank too much soda

or adults with ADHD

would take recreational drugs like methamphetamine

or cocaine or would drink coffee to excess

or smoke cigarettes to excess

because they had poor levels of attention

and because they couldn't make good decisions,

they were too impulsive and so forth

and while that certainly could be the case,

knowing what we now know about dopamine,

and the fact that having enough dopamine is required

in order to coordinate these neural circuits

that allow for focus and quality decision-making

an equally valid idea is that these children

and these adults are actually trying to self-medicate

by pursuing these compounds, right?

Things like cocaine lead to huge increases in dopamine.

Well, what happens was when somebody with ADHD

takes that drug,

it turns out they actually obtain

heightened levels of focus,

their ability to focus on things

other than things they absolutely care

intensely about goes up,

likewise, children who consume anything

that increases their levels of dopamine,

if those children have ADHD, they tend to be calmer,

they tend to be able to focus more.

Now, this is very different than children

who do not have ADHD.

When they consume too much sugar,

they tend to become super hyperactive.

When they consume any kind of stimulant,

they tend to go wild and run around like crazy.

Actually, I have an anecdote about this

just to illustrate it.

I have a friend,

he has two children that are now in their teens

and twenties, but when they were little,

one time, I brought them some chocolate just as a gift,

when I showed up at their house and within 30 minutes,

the kids were running around like crazy

I mean they were pretty high energy kids,

but they were going bonkers

and that's actually when the mother, my friend at the time,

unfortunately, still now looked at the chocolate,

realized that it was chocolate with espresso beans in it.

It was like dark chocolate with espresso beans

so I was really at fault there,

you don't want to give kids dark chocolate

with espresso beans,

but what you're really seeing that hyperactivity

that is dopamine, okay?

It's the sugar combined with the caffeine in this case,

combined with a few other compounds that exist in chocolate,

that really increase our levels of alertness

and our tendency to want to move around a lot, okay?

So dopamine and low levels of dopamine

apparently are what's wrong in people with ADHD,

that dopamine hypothesis

is what led to the idea that treating people,

children and adults included with dopaminergic compounds

would somehow increase their ability to focus

and if you look at the major drugs that were developed

and now marketed by pharmaceutical companies

for the treatment of ADHD,

those drugs have names like Ritalin.

Nowadays, it's typically things like Adderall, Modafinil

and some of the other derivatives,

they all serve to increase levels of dopamine

in particular dopamine in the networks

that control task directed behavior,

and that coordinate the default mode network

and these task-related networks.

So many of you have probably heard of Ritalin.

Ritalin is a prescription stimulant that is

prescribed for ADHD as well as for narcolepsy.

Narcolepsy is a condition

in which people tend to fall asleep

during the day time, quite a lot,

excessive daytime sleepiness,

not due to lack of sleep at night,

but also tend to fall asleep when they get excited,

if they're really emotionally excited or about to eat

or any other kind of activity that

would normally get somebody really aroused and alert

people with narcolepsy tend to fall asleep,

or they tend to become what's called cataplectic.

They tend to just sort of go limp in the muscles.

So it's this invasion of sleep into the daytime.

It's dysregulated by emotion.

You can imagine why a stimulant,

something that would wake you up, make you very alert,

focused and motivated

would be a good treatment for narcolepsy.

Adderall also is used to treat ADHD and to treat narcolepsy

things like Modafinil

also used to treat ADHD and narcolepsy.

So you're sensing a theme here.

So what are the differences and similarities

between these drugs

and what can that tell us about ADHD?

Well, Ritalin was one of the first-generation drugs

that was prescribed for ADHD in order to deal head on

with this dopamine hypothesis.

This idea that in ADHD, dopamine levels are too low.

Nowadays, Adderall is the more typically prescribed drug

for ADHD that has to do

with some of the so-called pharmacokinetics,

the rate at which those drugs enter the system

and how long they last in the system.

So for instance,

Ritalin was a drug that was packaged

into various time-release formulas.

Whereas initially Adderall was only released in a form that

had a very short life,

So meaning that it wasn't in the bloodstream very long

and didn't affect the brain for very long

and so the dosages could be controlled in a more typical way

without going into a lot of tangential detail.

As you all know, at different times of day,

you tend to be more or less alert.

So a long sustained release drug

while that might sound like a really terrific thing.

If that drug is having an effect

of making you more alert

and it's released across very many hours of your day,

there might be periods of your day

when you feel too alert,

periods of your day,

when you feel just right and periods of your day,

when you wished that you were more alert.

These are some of the pharmacokinetics, kinetics,

meaning movement of the different compounds

within the bloodstream and brain that could,

you could imagine in a very real way,

would impact whether or not someone would feel really good

on one of these drugs or whether or not

they would feel too anxious or too sleepy and so on.

Let's take a step back for a second and just ask,

what are these drugs?

We know they increase dopamine,

but what are they really?

Well, Ritalin also called methylphenidate

is very similar to amphetamine speed,

or what's typically call speed

in the street drug nomenclature.

Adderall, which goes by various other names, okay?

So Adderall, Adderall XR, my dialysis, things like that.

Adderall is basically a combination of

amphetamine and dextroamphetamine.

Now some of you probably realize this,

that Adderall is amphetamine,

but I'm guessing that there a good number of you out there,

perhaps even parents and kids that don't realize that

these drugs like cocaine and amphetamine methamphetamine,

which are incredibly dangerous and incredibly habit forming

and have high potential for abuse.

Well, the pharmaceutical versions of those

are exactly what are used to treat ADHD

and they're not exactly like cocaine or methamphetamine,

but they are structurally and chemically very similar

and their net effect in the brain and body

is essentially the same,

which is to increase dopamine primarily,

but also to increase levels of a neuromodulator

called epinephrin or norepinephrine

also called noradrenaline and adrenaline

those names are the same and to some extent

to increase levels of serotonin in the brain and blood,

but not so much serotonin,

that's just kind of a small smidgen of effect, okay?

So dopamine way up norepinephrine and adrenaline way up.

So that's motivation drive, focus and energy

and to some extent, a little bit of serotonin,

which is really more about feeling calm and relaxed

and you can imagine why that would be

a good balancing effect for dopamine and norepinephrine.

So what I'm essentially saying is that the drugs

that are used to treat ADHD are stimulants,

and they look very much alike.

In fact, nearly identical to

some of the so-called street drugs,

stimulants that we all here are so terrible.

However, I do want to emphasize

that at the appropriate dosages

and working with a quality psychiatrist

or neurologist or family physician

does have to be a board certified MD

that prescribes these things,

many people with ADHD achieve excellent relief

with these drugs, not all of them, but many of them do,
especially if these treatments are started early in life.

So now knowing what these drugs are,

I want to raise the question of why prescribe these drugs?

I mean, everyone has to make a decision for themselves

or for their child as to whether or not

they're going to take these things or not.

I also want to acknowledge that many people out there,

many, many people out there are taking these drugs,

even though they have not been clinically diagnosed

with ADHD when I say these drugs,

I'm specifically referring to Ritalin and Adderall

and Modafinil, but more typically it's Adderall, okay?

People using cocaine and amphetamine

for recreational purposes,

that's a completely different beast

and it is indeed a beast

and it's something that I strongly discourage.

However, I'm aware that up to 25% of college students,

and perhaps as many as 35% of all individuals

between the ages of 17 and 30 are taking Adderall

on a regular or semi-regular basis

in order to work, in order to study

and in order to function and focus in their daily life.

Even though they have not been diagnosed with ADHD,

there's a whole black market for this.

They're getting it from people with prescriptions.

I'm not here to pass judgment.

I just want to emphasize how these drugs work.

Some of the things that they do to enhance cognition

and focus that actually serve the brain well

in certain individuals and how they can be very detrimental

in other individuals.

I sort of blew right past it.

But the fact that in upwards of 25% of young people

are taking things like Adderall,

despite not having a clinical diagnosis of ADHD.

Well, that's a ridiculously high number.

A few years ago,

it was estimated that Adderall use and Ritalin use

without diagnosis of ADHD was second in incident

only to cannabis,

but actually now the consumption of Adderall

without prescription is higher than

the consumption of cannabis in that age group.

So what that means is that there's a lot of stimulant use

in that age group

and there are a lot of adults also

using and abusing stimulants in order to gain focus.

Then we can have a whole discussion about whether or not

life is becoming more demanding,

whether or not the need for focus is excessive

and that's why people are doing that.

But frankly, it's an interesting discussion,

but it's not one that would deliver us to any answers.

Rather, I'd like to focus on the ways that people now

and people have always been self-medicating

to increase, focus, right?

Caffeine, which I can indulge

some, I don't think to access has long been used

as a stimulant to increase dopamine,

increase norepinephrine,

increased focus and energy and in addition to that,

it works through the so-called cyclic amp,

phosphodiesterase pathway, remember anytime you see,

you hear an ASE, that's an enzyme.

Phosphodiesterase is involved in the

conversion of things like cyclic amp into

energy for cells and so forth.

Basically coffee gives you energy it makes you feel good

and it increases focus because of the circuits

that it engages in the brain.

People have been taking caffeine

and continue to take it caffeine for ages.

People also used to smoke cigarettes,

nicotine in order to gain focus.

Nowadays, that's less common because of the concerns,

quite valid concerns about lung cancer from smoking,

but there's a lot of vaping out there.

There are a lot of people now consuming nicotine,

which is the active substance in cigarettes

and in most nicotine vapes that stimulates the brain

to be more focused and more alert.

So the idea of taking stimulants of consuming things

or smoking things in order to increase alertness

is not a new idea.

It's just that in ADHD,

it's surprising that these things would work, right?

I mean, if the problem is

Attention Deficit Hyperactivity Disorder,

what we're really talking about here,

or children that are prescribed a drug

that ought to be a stimulant,

it ought to make them hyper hyperactive

and rather than doing that,

it actually somehow serves to calm them a bit,

or at least allow them to focus.

Here's the reason, children have a brain

that's a very plastic meaning it can remodel itself

and change in response to experience very, very quickly

compared to adults.

Taking stimulants as a child,

if you are a child diagnosed with ADHD

allows that forebrain task related network to come online,

to be active at the appropriate times

and because those children are young,

it allows those children to learn what focus is

and to sort of follow or enter that tunnel of focus.

Now, by taking a drug, it's creating focus artificially,

it's not creating focus because they're super interested

in something it's chemically inducing, a state of focus,

and let's face it a lot of childhood and school

and becoming a functional adult

is about learning how to focus

even though you don't want to do something.

In fact, when I was in college,

I had this little trick that may or may not work

for some of you,

which is if I couldn't focus on the material

I was trying to learn,

I would delude myself into thinking

that it was the most interesting thing in the world.

I would just kind of lie to myself and tell myself,

okay, this, I won't mention the subjects,

I absolutely love this.

I would just, I would tell myself that I loved it

and I noticed that just that selective

or deliberate engagement of that desire to know circuit,

whatever that is in my brain, no doubt involves dopamine,

allowed me to focus and remember the information

and somewhat surprisingly or perhaps not surprisingly,

I would often fall in love with the information.

I find that that was my favorite class.

So it was what I wanted to learn the most.

So that's one way you can do it artificially,

but kids with ADHD, they can't do that, right?

They're told to sit still

and they end up getting up 11 times.

They are told that they can't speak out in class

or that they have to remain in their seats for 10 minutes

and they just, despite their best effort,

they simply cannot do it,

they're highly distractable.

So what are we to make of this whole picture

that we need more dopamine, but these kids with ADHD,

they're getting their dopamine by way of a drug,

which is for all the world amphetamines, right?

It's speed, that's really what it is.

What are the long-term consequences,

where the short-term consequences and what should we make of

people taking these drugs without a clinical need?

What are the consequences there?

Well, in order to get to some of those answers,

I went to one of my colleagues,

this is a colleague that I've actually known

for a very long time, I was their teaching assistant

when they were an undergraduate,

they went on to get an MD, a medical degree,

as well as a PhD and become a pediatric neurologist

that specializes in the treatment of epilepsy

and ADHD in kids of all ages, from age three to 21,

that's the age range,

pretty broad age range and has extensive knowledge in this

and what makes them particularly interesting for sake of

this discussion is that they have a child, a young boy,

who's now showing signs of ADHD

and they are on the threshold of trying to decide

whether or not they will prescribe Adderall

or something similar.

So we had a discussion about this

and prior to learning that their child may have ADHD.

I asked the following questions.

First of all, I asked,

what do you think about giving young kids amphetamine?

And their answer was, on the face of it, it seems crazy,

but provided that the lowest possible dose is used

and that that dosage is modulating as they grow older

and develop those powers of attention,

their observation was that they've seen more kids benefit

than not benefit from that.

Now I'm certainly not saying what people should do.

You obviously have to go to a doctor

because as I always say, I'm not a doctor,

I don't prescribe anything,

I'm a professor so I profess things

and here I'm professing that you talk to your doctor,

if you're considering giving Ritalin or Adderall

or any type of stimulant to your child, of course,

what could be more important than the health of your child.

But it was a very interesting answer because

typically we hear yes, medicator don't medicate.

Rarely do we hear that the medication should be adjusted

across the lifespan and in any particular kind of way.

Now the fact that this person,

this now friend of mine and colleague of mine

has so much expertise in the way that the brain works

and is considering putting their child on such medication.

I said, why wouldn't you wait

until your kid reaches puberty?

I mean, we know that in boys and in girls,

there are increases in testosterone

and estrogen during puberty,

that dramatically change the way that the body appears.

But also that dramatically change

the way that the brain functions in particular we know this,

that puberty triggers the activation of so-called

frontotemporal task related executive functioning.

That's just fancy science speak for being able to focus,

being able to direct your attention,

being able to control your impulses, look at a small child,

or look at a puppy and then look at an older child,

or look at a dog, very different levels,

patterns of spontaneous behavior.

Young children move around a lot they're,

I don't want to say shifty,

cause that makes it sound like they're up to something bad,

which they might be,

but they don't have to be up to something bad,

they fidget a lot.

So to puppies,

everything's a stimulus as animals and humans get older,

they learn how to control their behavior and sit, still,

listen and focus even if they don't want to.

So giving a drug that allows a child to access that

stillness early on it's thought will allow them

to maintain that ability as time goes on.

But I decided to push a little bit further,

I said, well, why would you do it now

as opposed to during puberty or after puberty?

And their answer was very specific

and I think very important, what they said was look,

neuroplasticity is greatest in childhood

and tapers off after about age 25,

but neuroplasticity from age three until age 12 or 13

is exceedingly high and they're right,

when you sit back

and you look at the literature on neuroplasticity,

you'd say childhood plasticity and young adult plasticity

is much greater than adult plasticity,

but that early childhood plasticity is far and away

the period in which you can reshape the brain

at an accelerated rate.

So this lines up really well with the clinical literature.

Not surprisingly,

there are clinician that early treatment is key.

If you have the opportunity to work with a quality physician

and treat these things early,

these drugs can allow these frontal circuits,

these task-related circuits to achieve their appropriate

levels of functioning and for kids to learn how to focus

in a variety of different contexts.

Now, is that the only thing that they should be doing?

Of course not.

So the next question I asked was

what should we make of all this diet related stuff, right?

I've heard before that the so-called elimination diet

or ingesting no sugars or no dairy or no gluten,

that all of these things have been purported

to improve symptoms of ADHD and people and parents with ADHD

go to fanatic lanes to try and find the exact foods

that are causing problems and the exact foods

that the kids can eat in order to try

and get their brain wired up right,

and correctly, and to avoid lifelong ADHD

and their answer was really interesting.

But before I tell you their answer,

I want to tell you the studies and the data

related to this question of whether or not food

and the constellation of foods that one avoids

and will eat has anything to do with our levels of attention

and in particular,

whether or not that can be used as a leverage point

to treat ADHD.

So you can imagine the challenges of exploring the role

of diet and nutrition in any study,

but especially in a study on ADHD, why?

Well, because as I mentioned before, children with ADHD,

and it turns out adults with ADHD

tend to pursue sugary foods or any types of food

that increase their levels of dopamine.

They are naturally drawn to those foods,

whether or not they realize it or not,

presumably as a way to try and treat

their lack of focus and impulsivity.

So in this study that I'm about to share with you,

there was no drug treatment, it was just a study,

manipulating diet and involved 100 children,

50 in the so-called elimination diet group,

the special diet where certain foods were eliminated

and 50 in the so-called control group.

However, being a well-designed randomized controlled trial,

this study also included a crossover,

meaning where the kids would serve as their own control

or control group at a certain portion of the study.

So there'll be in one group

where they eliminated certain foods

and then after a period of time in the study,

they would swap to the other group.

This is a powerful way to design a study

for reasons that you can imagine,

because you start to eliminate changes and effects

due to individual differences.

In any case, 100 children total 50 in each group

at any one period in time

and the effects that they observed were extremely dramatic.

In the world of statistics and analysis of scientific data,

we talk about P-values, probability values.

What's the likelihood that something

could happen according to chance

and typically the cutoff would be

something like P less than 0.05,

that's less than 0.05 chance essentially,

of the effect being due to chance.

However, in this study,

every single one of the effects is P less than 0.0001,

very, very infant decimally small

probability that the effect observed could be due to chance.

So what were these effects?

These effects were enhanced ability to focus,

less impulsivity,

even less tendency to move when trying to sit still.

So everything from mental focus

to the ability to control their bodies improved

when they were in the elimination diet group,

what was eliminated?

Well, the elimination diet in this particular study

was a so-called oligoantigenic diet.

It was a diet in which each kid took a test to determine

which foods they had antibodies for,

meaning that they were mildly allergic to.

Now in this study, it was very important

that the kids not be extremely allergic to any food

because as I mentioned before,

they actually served as a control at one point in the study

where they were eating all sorts of foods,

including foods that had mild allergies to.

So basically what the study said was that eliminating foods

to which children have allergies

can dramatically improve their symptoms of ADHD.

And this study,

not surprisingly because it was published

in such a high quality journal Lancet, et cetera,

large number of subjects set the world on fire.

People were extremely excited about these results

because here in the absence of any drug treatment,

there was a significant improvement

in ADHD symptoms observed and then came the criticisms.

So many papers were published after this specifically

dealing with re-analysis of these data

and I want to be fair in saying that

the data in the paper look good,

but there are criticisms

of the overall structural design of the study.

I don't want to go into all the details exactly

'cause it gets really nuanced about some of the statistics

and the way that one examines these types of data,

but there was skepticism

and in science, skepticism is healthy,

especially when making decisions about

whether or not to treat or feed children

one food or another, or give them one drug or another.

Now I want to return to the story of my friend,

who is a pediatric neurologist and treats ADHD

and has a child who is on the precipice of

perhaps starting to take drugs for the treatment of ADHD.

I asked the simple question, do you see an effect of diet?

Meaning when parents control the diet of their children,

does it make a positive or negative or no difference in

terms of the way that the kids respond to ADHD,

drugs like Ritalin and Adderall or whether or not

it can help them avoid treating with those drugs entirely?

And her response was very straightforward, she said,

elimination of simple sugars

has a dramatic and positive effect.

She's observed that over and over and over again

in many dozens, if not hundreds of patients, okay?

Now that's not a peer reviewed study,

that's a statement that I'm conveying to you anecdotally,

but it's a highly, highly informed one.

I said, what about these elimination diets?

She said, and I found other sources to support this,

that these oligoantigenic diets are controversial.

There are many people who really believe

in identifying all the things that you're allergic to

and making sure that you

and especially your kids avoid those foods.

However, there's another camp that's starting to emerge

in the peer reviewed scientific literature,

showing that when kids are not exposed to certain foods

in particular nuts and things of that sort,

they develop allergies to those foods

and then when exposed to them later,

they cause real problems.

So there's a whole galaxy of discussion and controversy

and outright fighting about allergies

and kids and whether or not the oligoantigenic diet

is the appropriate one.

However, out of the four neurologists and psychiatrists

that I spoke to about ADHD in preparation for this,

every single one said children with ADHD,

as much as possible,

should be encouraged to avoid high sugar

and simple sugar foods of most kinds

and if they can find particular foods

that exacerbate their symptoms,

obviously eliminating those foods is beneficial

and the foods that exacerbate their symptoms

change over time.

So I don't like giving a complicated answer,

but I also don't like giving an incomplete answer.

What this tells me is that children,

especially young children who have ADHD

should probably not eat much sugar

in particular simple sugars.

In addition to that,

exploring whether or not they have existing allergies

to foods, they already consume might be a good idea.

At least that's what this paper,

the Pelsser et. al Lancet paper seems to speak to

and I should mention that that paper was published in 2011.

Since then there have been many dozens of studies exploring

the same thing, as well as meta analysis of all those data

and it does appear that diet can have

a highly significant role in eliminating

or at least reducing the symptoms of ADHD

so much so that some of the children

are able to not take medication at all,

or eventually wean themselves off medication

as young adults and as adults.

One interesting question is whether or not adults

should modify their diet in order to

increase their levels of focus,

if they're already having normal levels of focus,

but we'd like more or would like to reduce

existing adult ADHD, that's an interesting,

and even more controversial topic,

it brings us right into the realm of what are called

omega-3 fatty acids.

I've talked many times on this podcast about

the known benefits of omega-3 fatty acids in particular,

getting a one gram 1000 milligrams or more

even as much as 2000 milligrams each day of

the so-called EPA component of omega-3 fatty acids

known to have antidepressant effects,

mood elevating effects,

known to have important effects

protecting the cardiovascular system.

I think it's now clear that the immune system also benefits

that omega-3 fatty acids that include a gram or more of EPA

that are very beneficial typically

that's done through fish oil,

liquid fish oil is going to be the most cost efficient,

but they're capsule forms

for those of you that don't like fish oil,

you can ingest this through other means

you can get it from certain algaes or krill, et cetera.

You have to make it compatible with your particular diet,

whether or not you're vegan

or vegetarian or omnivore, et cetera.

Omega-3s have shown,

been shown to have all these positive health benefits.

Do they have positive effects on focus and attention?

And the answer is you can find studies

that support that statement and the effects are significant,

but the effects are modest.

You can also find studies that show no effect,

however much like with omega-3s and antidepressants,

whereby ingestion of omega-3 fatty acids of a gram or

more of EPA per day allows people with major depression

to get away with taking lower doses

of antidepressant medication.

It does seem that ingestion of omega-3 fatty acids in adults

that include EPA is of 1000 milligrams or more

can allow adults with ADHD

or mild attention deficit issues

to function well on lower doses of medication

and in rare cases to eliminate medication entirely.

So what this says is once again,

that the omega-3 fatty acids are beneficial,

will they cure or eliminate ADHD?

I think it's safe to say, no,

they are playing a supportive

or what we call a modulatory role.

Just like good sleep,

plays a supportive and modulatory role

for essentially everything, your immune system,

your ability to think your ability to regulate your emotion,

it's modulating that process.

This component of modulation

is extremely important to highlight

and I think I want to spend a moment on it because

this is especially important in the context of ADHD

and all the information that's out there.

There are biological processes that are mediated

by particular compounds like dopamine.

So for instance, the ability to feel motivated,

to attend to focus is mediated by the circuits in the brain

that release dopamine.

However, attention is also modulating by how rested you are.

If you want to eliminate your ability to think well at all,

just stay up for two nights and don't sleep at all right?

If you do that,

you will have modulating the circuits in your brain

that respond to various things

and you will be highly distractible.

You'll be highly emotional.

You will feel like garbage,

but that doesn't mean that sleep mediates,

focus and attention.

It modulates it indirectly.

Likewise, I think these omega-3 fatty acids

in particular the EPA is which are so beneficial for mood

and apparently also for attention,

they directly mediate attention and mood,

what they do is they modulate those circuits,

they make dopamine more available.

They make whatever dopamine is available,

more likely to bind to the various receptors

that are present on neurons and so forth

and I think this is very important because likewise diet

in any discussion about nutrition

has to include this framework of is the diet,

the elimination diet,

or whether or not it's some other diet or esoteric diet,

ketogenic diet, is it modulating or mediating a process?

And most likely in the context of ADHD,

it's modulating that process.

So if the ADHD is mild or if it's caught early enough,

or if it's in conjunction with pharmacology

with a prescription treatment,

well, then it might help guide the child or adult

to a better place of being able to focus.

But it's not going to be the switch that flips everything.

Now that does not mean that consuming the wrong foods,

sugary foods or foods that you happen to be allergic to

is a good idea it will still be detrimental.

So I hope that conceptual framework helps

because if you go online,

if you're somebody with ADHD

or not your going to be bombarded with the ADHD diet,

the oligoantigenic diet, the elimination this,

this supplement that EPA

and I think it's very important to understand whether or not

you're talking about something mediating a process

or modulating a process.

Now drugs like Ritalin, drugs like Adderall,

they are tapping into the circuitries

and the neurochemistries that mediate attention and focus.

They are not the only alternatives or the only choices

rather for treatment of these circuits

and enhancement of the circuits for focus.

I'm going to talk about other alternatives

and some behavioral alternatives

that are not very well known,

but are very, very effective in a few minutes.

But I really want to make this clear distinction

between modulation and mediation,

because it's vital for anyone that's trying to modulate

or mediate anything within their own brain.

If any of you are interested in this oligoantigenic diet,

as it relates to ADHD,

and you want to explore a more recent study

besides that classic 2011 Lancet study,

that's rather controversial.

There's a paper that was published in frontiers

in psychiatry just last year, 2020.

The title of the paper is,

"Oligoantigenic diet improves children's ADHD

rating scale scores reliably in added video rating."

The added video rating is just that they're using

an additional measure of focus and attention.

Again, that's Frontiers in psychiatry, 2020,

I'll put a link to it in the caption,

and that's a more recent study for you to peruse.

So we've talked about the neural circuits of focus

and the chemistry of focus,

but we haven't talked yet about what would make us better

at focusing and what focusing better really is.

So let's take a step back and think about

how we focus and how to get better at focus

and I'm going to share with you a tool for which there are

terrific research data

that will allow you in a single session

to enhance your ability to focus in theory forever.

What am I about to read you is from an excellent book

that I recommend,

if any of you are interested in neuroscience

and things like meditation and default mode networks

and things of that sort,

the book is called, "Altered Traits."

Science reveals how meditation changes your mind,

brain and body and no, I'm not going to try

and convince you to meditate.

I'm going to share with you a small passage in the book

that relates some research data related to focus

that are very important.

If you want to meditate, that's your choice.

That's a separate matter.

This is a book by Daniel Goleman and Richard Davidson

and I should just mention that

Goleman is a well-known author

has written books on emotional intelligence and so forth.

Richard Davidson is also a PhD.

He's a professor of psychology and psychiatry,

and he's at a University of Wisconsin Madison,

he's done terrific work on brain states

and modulation of brain states and so forth.

What we're about to talk about is

when attention works and when attention falters

and what we are specifically going to talk about

are what are called attentional blinks,

not actual eye blinks.

We're going to talk about that in a few minutes,

but we're going to talk about attentional blinks.

I'm paraphrasing here because

Goleman and Davidson wrote about this so beautifully.

I'd rather paraphrase from them than try and just

make up a new way to say it

that is less interesting or less good,

but I want to credit them.

Attentional blinks are really easy to understand,

if you think about a where's Waldo task,

you know this task where's Waldo where,

there are a bunch of people and objects

and things in a picture

and somewhere in there is Waldo

with the striped hat and the glasses and go skinny dude,

and you have to find Waldo

and so it's a visual search

and it's visual search for an object

that has distinct features,

but is embedded in this ocean of other things that

could easily be confused as Waldo.

So you tend to look, look,

look, look, look, look, look, look, look,

and then you find Waldo.

Kids can do this they enjoy doing this.

Adults may or may not enjoy it,

but they can do it too.

They find Waldo, when you find Waldo

or when you search for a target

in some other visual search task at that moment,

your nervous system celebrates a little bit

and it celebrates through the release of neurochemicals

that make you feel good, you found it and you pause.

Now, the pause is interesting because when you pause,

what we know from many experiments is that

in that moment of pause and mild celebration,

however, mild you are not able to see another Waldo

sitting right next to it.

So what this means is in attending to something

in searching and in identifying a visual target

your attention blinked it shut off for a second

and there's a more formal and more laboratory type

way that we look at this.

The more typical way to do this is to give someone

a string of letters or a string of numbers

and beforehand you tell them be on the lookout for the

letters R and Z, okay?

You're just going to watch this string of numbers go by

and there will be a letter R in there,

and there will be a letter Z in there

and try and spot them both

and what you find is when you present

that string of numbers, and then they see the R,

they see the R they register it consciously

and they tend to miss the Z,

just like in the Waldo type example.

Now, of course the numbers are going by pretty quickly,

but they can spot the R.

They could also spot the Z,

if you told them beforehand, just spot the Z

and the numbers are moving through at the same rate

in both conditions.

So what that means is that in every case,

you are capable of seeing the R or the Z

it's when you try and see both that seeing the first one

prevents you from seeing the second one,

it's what we call an attentional blink.

We do this all the time

and people with ADHD tend to have many more

attentional blinks than people that don't

and this is true for children and for adults.

This is an important point.

So important that I want to emphasize it twice

in case you attentionally blinked.

If you see something that you're looking for,

or you're very interested in something,

you are definitely missing other information

in part because you're over focusing on something

and this leads to a very interesting hypothesis

about what might go wrong in ADHD,

where we've always thought that they cannot focus

and yet we know they can focus on things

they care very much about,

well, maybe just maybe

they are experiencing more attentional blinks

than people who do not have ADHD

and indeed, there are data now to support the possibility

that that's actually what's happening

and that should be exciting to anyone that has ADHD.

It should also be exciting to anyone that cares about

increasing their focus and their ability to attend.

What this is saying is that these circuits,

that underlie focus in our ability to attend

and our ability to eliminate distraction,

they aren't just failing to focus.

That's just a semantic way of describing the outcome.

They are over focusing on certain things

and thereby missing other things.

And so our distractability or the distractability

of somebody with ADHD could exist because

they are over focusing on certain elements

and there are there for missing

other elements that they should be attending to.

So what they really need is this property

that we call open monitoring.

Now open monitoring is something

that's described in the book that I just referred to

and that typically is associated with people

who have done a lot of meditation,

so called Vipassana meditation,

or have spent a lot of time learning how to

do what's called open gaze visual analysis

and open gaze thinking.

But there's a simpler version of this

that allows us to bypass all that.

First of all,

your visual system has two modes of processing.

It can be highly focused, a soda straw view.

So looking for the R in this string of numbers

in the example that I just gave,

or if you're very excited about something

you're in that soda straw view of the world,

and you're missing other things, okay,

that's high levels of attention.

However, there's also a property of your visual system

that allows you to dilate your gaze,

to be in so-called panoramic vision.

Panoramic vision is something you can do right now,

no matter where you are, and I can do it right now,

you won't know that I'm doing it,

but even though I'm still looking directly at you,

I'm consciously dilating my gaze so that I can see the

ceiling, the floor and the walls all around me.

That panoramic vision is actually mediated by

a separate stream or set of neural circuits

going from the eye into the brain

and it's a stream or set of circuits

that isn't just wide angle view.

It also is better at processing things in time.

Its frame rate is higher.

So you've seen slow motion video,

and you've seen standard video,

slow motion video gives you that slow motion look,

because it's a higher frame rate.

You're thin slicing time, okay?

You can use panoramic vision to access the state

that we call open monitoring.

When people do that,

they are able to attend to and recognize

multiple targets within this string of numbers.

They can see the R and they can see the Z

and they can see additional things.

So this is something that can be trained up

and people can practice whether or not

they have ADHD or not.

What involves is learning

how to dilate your gaze consciously,

that's actually quite easy for most people,

whether or not you wear corrective lenses

or contacts or not

you can consciously go into open gaze

and then you can contract your field of view as well.

There have also been studies done

where people were taught to think in a particular way

for a very short period of time,

and that forever changed their ability to limit

or reduce the number of these attentional blinks.

There are now published accounts in the literature

of a simple practice done for about 15 minutes,

where subjects were asked to just sit quietly eyes closed

and do what is sort of akin to meditation,

but to not direct their mind

into any particular state or place,

but simply to think about their breathing

and to focus on their so-called interoception,

focus on how their body feels,

their mind drifted to bring it back, okay?

So it's basically meditation for about 15 minutes.

That might not seem like a significant or unusual practice

or that it would have any impact at all.

But remarkably, just doing that once for 17 minutes,

significantly reduced the number of attentional blinks

that people would carry out.

In other words, their focus got better

in a near permanent way without any additional training.

There's something about that practice of reducing the amount

of visual information coming in

and learning to pay attention to one's internal state,

what we call interoception that allow them an awareness,

such that when they needed to look for visual targets,

when they need to focus on multiple things in sequence,

they didn't experience

the same number of attentional blinks

and I should mention not incidentally as people age

and their working memory gets worse

and their ability to focus gets worse,

the number of attentional blinks

that they carry out goes up,

and there are now studies exploring whether or not

the simple meditation like practice of 15 to 20 minutes

or so of sitting and just quietly resting

and paying attention to one's breathing

and internal state can also offset some of that

age-related what is called cognitive decline.

So what these data tell me is that

regardless of whether or not you're a child

or you're an adult,

whether or not you have ADHD or not,

whether or not you're experiencing

age-related cognitive decline,

or you would simply like to avoid

age-related cognitive decline,

a simple practice of taking 17 minutes

sitting and paying attention to your internal state,

just interocepting, registering your breathing,

registering the contact of your skin

with whatever surface you're on,

can forever rewire your brain to be able to attend better

and possibly even offset

some of that age related attentional drift.

Now, I don't expect anyone to start meditating regularly.

I don't expect anyone to do anything they don't want to do,

but I think most of us could handle

one meditation's session of 17 minutes or so

and so if ever there was a tool that stood to rewire

our attentional circuitry in a powerful way.

This seems to be it

and in addition, the ability to engage in panoramic vision,

to dilate our gaze,

the so-called open monitoring that allows the brain

to function in a way

that it can detect more information faster,

that's a powerful tool as well

and the beauty of that tool is that it works the first time

and it works every time.

Now, how exactly it works is a little bit unclear.

Is it for instance,

orchestrating this synchrony or asynchrony

between the default mode network

and the task related networks we don't know.

Those studies have not yet been carried out.

Nonetheless, the effects are significant,

they are long lasting and they appear to exist

after just one session of this quiet

17 minute interoception,
which to me makes it seem like

a very worthwhile thing to do for everybody.

So we just talked about attentional blinks,

which are essentially blinks of thinking

it's your mind shutting off for a moment

and missing information.

Now let's talk about actual blinks,

the sort that you do with your eyelids.

Now, this might come across as somewhat obvious,

but you can do fast, what are called spontaneous blinks

and they're always coordinated between the two eyes

or you can do long blinks

like when you go to sleep at night,

you do one very long blink, and I'm not being facetious.

When you go to sleep at night,

you are shutting your eyelids

and you are limiting the amount of information coming in

and your perception of time starts to drift

as you go into sleep.

Your perception of time changes from very fast,

at one moment to very slow meaning the frame rate

at which you are analyzing information dreaming, et cetera,

is variable when you were in sleep,

sometimes it's very fast.

Meaning you experienced things in slow motion.

Sometimes it's very fast.

In waking to your experience of time

can sometimes be very fast sometimes be very slow.

Typically the more alert you are, the higher the frame rate,
your thin slicing your experience.

You've probably had this happen.

If you're ever very stressed

and you're waiting for something or somebody,

it seems like it takes forever because

your frame rate is higher

you're analyzing time more finely.

Conversely, if you are very relaxed or even sleepy,

you wake up and you have to think of

all the things you have to do.

It will seem like the world is going by very, very fast

and that you are moving very slow.

Time is going at the same rate,

but your perception of time is what's changed.

Believe it or not.

Your perception of time is also changed on a rapid basis.

Moment to moment basis by how often you blink.

This is a well-established literature

in the world of neuroscience that unlike the literature

and claims about blinking and sociopathy,

which have no basis,

the science of blinking as it relates to time perception

has some very good data to support it.

I want to just emphasize one study in particular,

which is quite appropriately titled,

"Time dilates after spontaneous blinking."

This is a paper that was published in current biology.

The first author is Terhune, T-E-R-H-U-N-E.

It's a wonderful paper.

They examine the relationship between fluctuations in timing

and blinking and to make a long story short

what they found is that right after blinks,

we reset our perception of time, okay?

So blinks in that sense are a little bit like

the curtain coming down on a scene

between scenes in a play

or takes in a movie, and they clap the clap thing,

they started take in our, what do they say, action

and then at the end they do the thing and they click it down

and they say, it's a take that's one take

when you blink it's a take, okay?

Now what's interesting

and will immediately make sense to you as to why

this is important is that the rate of blinking

is controlled by dopamine.

So what this means is that dopamine

is controlling attention.

Blinks relate to attention and focus,

and therefore the dopamine and blinking system is one way

that you constantly modulate and update

your perception of time

and fortunately, it's also one that you can control.

So the basic takeaway of this study was that blinking

controls time perception,

but also that levels of dopamine

can alter your sense of time and stay with me here,

and that blinking and dopamine are inextricably linked.

They are working together to control your attention.

When dopamine levels go up,

people tend to overestimate how long something lasted, why?

Because they are processing time more finely

it's slow motion mode.

When dopamine levels are lower,

they tend to underestimate time intervals.

Let's remember back to the very beginning of the episode,

what's going on in people with ADHD,

they are not good at managing their time,

they tend to run late, or they are disorganized.

They are not just disorganized in space,

meaning in that physical space, around them,

they're disorganized in time.

Their dopamine is low, we know that as well

and so they are underestimating time intervals

and so it makes perfect sense that they would be late.

It makes perfect sense that they would lose track of time

or the ability to focus.

This is really exciting because what it means is that

children with ADHD, adults, with ADHD

or people with normal levels of focus

that want to improve their ability to focus

can do so through a training that involves

learning how often to blink and when,

and how to keep their visual focus on a given target

and it turns out this study has actually been done.

There's a study again, I'll link to the study,

entitled "Improvement of attention

in elementary school students

through fixation focused training activity."

I won't go through all the details,

but what they found was a short period of

focusing on a visual target,

allowed the school children to greatly enhance

their ability to focus on other types of information

and a significant component of the effect was due

to the way that they were controlling the shutters

on their eyes, their eyelids, and controlling their blinks.

So what they did in this study is they had these kids

focus their visual attention

on some object that was relatively close,

like their hand for a minute or so,

which actually takes some effort if you try and do that,

they were allowed to blink.

However, it's known from other work

that if people can consciously override the desire to blink,

at least to the point where they feel like they have to,

or else their eyes were dry out,

that actually can increase attention even further

and they had conditions where they would look at a point

further across the room and even further across the room.

It only took a few minutes each day to do this

30 seconds in one condition, or maybe a minute

and then at another station

of looking a little bit further out

and a little bit further out, however,

there was an important feature of this study

that is definitely worth mentioning,

which is before they did this

visual focus, task or training,

they did a series of physical movements with the kids

so that the kids could sort of eliminate or move out

some of their desire to move

and would thereby enhance their ability to sit still.

Now it's long been known that kids need a recess,

they need time to run around and play and roll around,

do whatever it is that they do

in order to be able to sit still at all.

Adults probably need this too, frankly,

but kids need it more because the circuits in the brain

that control reflexive movements and as we say,

kind of rhythmic undulating behavior and things like that,

that's an active suppression

and kids have less of that circuitry built up

until they hit about age 15 or 16.

So they had the kids move around a bit

and then do this focus training.

That brings me to another treatment

that's actively used nowadays in schools for kids with ADHD,

but also is starting to be used by many kids

and by parents in order to keep their kids focusing

and not going crazy in the car or not acting out in general

and that's the prevalence of these so-called fidgeter toys

or things that kids can do actively

and repetitively in order to move out

some of their underlying reverberatory activity

in their nervous system.

So what you will find is that some kids with ADHD

are now given a rubber band on their desk,

literally a rubber band that's attached to their desk

and they're able to pull on it,

even snap it against the desk,

if I had done that when I was a kid,

I think my teachers were throw me out of class,

but I think it's great that they're allowing them

to do this now as a way of moving

some of their physical energy out

or engage their physical energy, rather,

as opposed to trying to sit

statue still all the time and attend

and it turns out that does enhance these children's ability

to focus mentally when they have some physical activity

to attend to and it turns out it also can work for adults.

I'll share with you I related anecdote

because it illustrates the underlying mechanism.

I've had the great privilege of being able to do a number of

surgeries, brain surgeries during my career.

So one thing you find when you do brain surgeries,

is that the brain's pretty small

regardless of the species that you're working on

and you're in there and you're trying to do

something very specific and the more you try

and hold your hands really steady,

the more they want to shake, all right?

So it's not natural for any of our limbs

to sit perfectly still,

depending on how much coffee you had,

how well rested you are

and your sort of baseline level of autonomic arousal.

Some of you may find that you can hold out your hand,

absolutely rock solid, others will shake a little bit more.

It doesn't mean you're if you're shaking,

doesn't mean you're calm if you're still.

What it relates to

is the amount of what we call premotor activity,

the number of commands to move

that are being sent through the system

and that's what I mean by reverberatory activity

and it does seem that kids with ADHD and adults with ADHD

have a lot of reverberatory activity

in their nervous system

and so that's that constant desire to move

it's hard for them to sit still

and therefore it's hard for them to attend,

to harness their attention.

When you do a surgery

and you find that your hands are shaking,

what you learn from your mentors,

which I did and what works extremely well,

whether or not you're doing a surgery or not,

is that you simply tap your foot

or you bounce your knee a little bit,

which you might think would make your hand shake even more,

but provided that it's subtle.

What it does is it actually shuttle some of the activity

from those premotor circuits to elsewhere in the body

and then you're able to sit much more still with your hand,

you're able to perform the surgery with much more precision.

You are able to write with much better handwriting

and for those of you who engage in public speaking,

if you ever too nervous,

that's why pacing while you public speak helps

if you're nervous,

that's why bouncing your knee behind the podium

works as well.

That's why nodding your head and gesticulating can help.

It's not a matter of,

"Moving energy out of the body."

That doesn't actually happen,

what it is you're engaging those premotor circuits

that are sending through commands.

It's like trying to stuff,

a bunch of stuff through a funnel,

and it creates this tension,

so you're giving it an outlet for the neural circuitry

to be able to move something

so that you can keep other components of your body

and your mental attention engaged

and locked onto something what we call focus.

One thing related to this whole business of blinking

and focus and training yourself to focus

and not blinking, et cetera, is that most all of the drugs,

Ritalin, Adderall, and recreational drugs

that increase dopamine,

even coffee and tea and other forms of caffeine,

they tend to make us blink less

and when we get tired, we tend to blink more.

Now this is sort of a duh, right?

But being wide-eyed with excitement or fear

or with your eyes, barely being able to keep them open,

now it should make perfect sense that these shutters

on the front of your eyes,

they aren't just there for winking

and they aren't just there for cosmetic purposes.

They are there to regulate the amount of information

going into your nervous system

and they're there to regulate how long

you are bringing information into your nervous system

and in what bins, how widely or finely

you are binning time is set by how often you blink

and how widely or specifically

you are grabbing attention from the visual world is set

by whether or not you're viewing things very specifically

like a cross area through a soda straw view like this,

or whether or not you were in this panoramic

sort of whole environment mode,

this kind of fisheye lens or wide angle lens mode

and in fairness to the pharmacology and the circuitry,

while dopamine and heightened levels of alertness

and excitement tend to make us blink less and attend more.

There's actually a study that's looked at

the other neurochemical systems

and drugs and how those relate to blinking

and so this will all be obvious by the title of the paper

I'm about to share with you.

This is a paper entitled,

"Decreased spontaneous eyeblink rates

in chronic cannabis users,

evidence for stride or cannabinoid, dopamine interactions."

Okay, I'm not going to go into all the details here,

but one thing that is somewhat surprising is that

many people with ADHD use or abuse cannabis,

you might think, well, why would they do that?

Because I thought that a increase in dopamine

is actually what's going to lead

to heightened levels of attention

and that's what these people in children crave.

Well, it turns out that cannabis also

increases dopamine transmission in the brain,

but because of the other chemicals,

it increases namely serotonin

and some components of the cannabinoid and opioid system,

it creates that kind of alert, but mellow feel

and again, here I'm not a proponent of this,

I personally am not a THC or cannabis user.

It's just not my thing

and obviously it's illegal some places

and so you have to determine that for yourself

it does have medical purposes in some places it is legal,

but THC increases dopamine and increases neurochemicals

that can also create a state of calm.

So it's that sort of middle ground

and this paper has a beautiful demonstration

whereby not just while people are using cannabis,

but depending on how long they've been using

cannabis across their lifespan,

the rates of eye blinking change.

So if you look at the number of years

that people have been using cannabis on a regular basis,

either daily or up to excuse me, weekly, or up to daily,

what you find is that for people

that have not been using cannabis at all,

or have only been using it for about two years,

their rates of eye blinks are much higher

than people who've been using it chronically for 10 years.

In other words, people

who may be using cannabis for 10 years,

don't blink very often at all.

Now cannabis has well known effects in depleting memory,

but it does seem to engage the focus

and blinking system in a way that increases focus.

So basically what I'm saying is

marijuana seems to increase people's focus,

but then they can't remember what they were focusing on.

Something I'd like to discuss just briefly is the so-called

interoceptive awareness that's present in people with ADHD,

both children and adults.

Interoceptive awareness is one sense

of one's own internal state heartbeat,

breathing contact of skin with a given surface, et cetera.

For a long time, there was this hypothesis,

this idea that people with ADHD,

were just not in touch with how they felt

that somehow they weren't registering

all the stuff that was going on inside them

changes in heart rate and so forth

and so they were behaving in a way

that was dysregulated or appear dysregulated,

and that if they could just learn to attend

to their internal state better,

that somehow they would function better in the world.

Now, before we described a process,

literally a 17 minute interoceptive exercise

that does seem to lead to improvements

in one's ability to focus for a longer period of time.

However, it's very unlikely that that was due to

increasing interoceptive awareness per se.

It probably wasn't because people gain a much heightened

or improved ability to understand

what's going on internally.

In fact, you can imagine how that might actually

prevent one's ability to pay attention to things

in the outside world.

So while there is benefit to just sitting there

and being in stillness, as they say,

or focusing on one's breathing and internal state

for sake of then accessing information

in the external world,

a really nice study called interoceptive awareness

and attention deficit hyperactivity disorder

explored whether or not interoceptive awareness

was different in people with ADHD or did not have ADHD

and the findings were essentially that there's no difference

that people with ADHD, children, and adults,

they are aware of what's going on inside them

just as much as anyone else's

and the typical measure of interoceptive awareness

is one's ability to count their own heartbeats.

This is actually challenging for some individuals

and very easy for other individuals,

regardless of their attentional capacity.

Some people just can really feel their heartbeat

without taking their pulse other people cannot

and these studies are pretty straightforward to do.

You ask people to sit there and to count their heartbeats,

and then you are monitoring their heartbeats

and you get to gauge how accurate they are.

So it's important to understand that people with ADHD

are in touch with how they feel.

It's really a question of whether or not

they can take the demands that are placed upon them

and enter a cognitive state of mental state

that allows them to access the information

they need to access

in other words, whether or not they can focus,

but it is absolutely wrong to think that

the child that's getting up 11 times during a short

six minute interaction at the table,

or whether or not a child who

somehow has to venture off every moment

or a coworker of yours

who's an adult who's constantly fidgeting

or moving things around that somehow they are unaware

that they are oblivious,

they're not oblivious to how they feel.

Chances are they're very challenged in the situations

that they're in

and they're doing everything they can to try

and regulate their attention.

So I think it's an important study to highlight

because it really underscores the fact that

something else is going on

and that something else has everything to do

with this ability to coordinate

these tasks directed networks,

and to coordinate that in the proper way

with that default mode network

and that is a process as you now know,

that's regulated exquisitely by certain neurochemicals

and in particular the neurochemicals, dopamine,

norepinephrine and serotonin,

and a fourth one I'd like to throw into the mix,

which is acetylcholine,

which is very vital for cognitive focus.

So now I want to switch back to talking about

some of the drugs that are typically used

to access those systems, prescription drugs

and I want to talk about some of the new and emerging

non-prescription approaches

to increasing the levels of dopamine,

acetylcholine and serotonin in the brain

using various supplement type compounds,

because several of them are showing

really remarkable efficacy

in excellent peer reviewed studies.

So before moving to some of the newer atypical compounds

and things sold over the counter,

I'd like to just briefly return to the classic drugs

that are used to treat ADHD.

These are the ones I mentioned earlier,

methylphenidate also called Ritalin,

Modafinil or armodafinil is another one and Adderall,

again, all of these work by

increasing levels of dopamine and norepinephrine.

Typically they're taken orally in pill form,

or sometimes in capsule form

the dosages that are appropriate vary,

according to severity of the condition

for a given person and the age of the person.

This is a complicated landscape for each individual.

They have to figure out the pharmacology

that's best for them.

Some individuals are even layering long

or time to release Ritalin with Adderall in smaller doses,

it can get quite complex or it can be quite straightforward

if you are really interested in these drugs

and how they work

and you'd like to get a glance at a table of all the results

from all the studies of which there are now hundreds,

there's an excellent review about these drugs and their use

and their comparison to similarly structured drugs

in particular MDMA and cocaine and amphetamine,

meaning Street Amphetamine

to really illustrate the similarities

of action and some of the problems associated

with long-term use.

I don't expect you to read this article in full

I'm here so that you don't have to go read these articles,

but in case you want a ton of information,

the paper is Esposito et al Frontiers and bio-sciences,

it's an excellent, excellent

review of the entire literature.

It is quite long.

I can put a link to that study in our caption,

and it essentially describes all the studies

that have been done, peer reviewed and published,

and it refers to these drugs in an interesting way.

It doesn't just refer these drugs as for treatment of ADHD.

It actually refers to them using language that ordinarily

I'm not very fond of, but I'll agree to here,

which is so-called smart drugs or nootropics.

It also covers caffeine, which again as I mentioned earlier,

increases dopamine norepinephrine

and to some extent serotonin,

but what I like about this review so much is that

in putting, these drugs of abuse,

methamphetamine, and cocaine, right alongside these drugs,

like Ritalin and Adderall and also caffeine,

we start to realize that the distinction between

drugs of abuse

and the distinction between drugs of treatment

is actually a very fine and sometimes even a blurry line

and in thinking about whether or not one wants to use

these prescription, I want to emphasize prescription,

not drugs of abuse,

but prescription drugs

for treatment of one's own attentional capacity.

I think it is important to understand

the extent to which they all carry

more or less the same side effects.

The one exception being caffeine caffeine side effects

can be anxiety if you ingest too much of it, insomnia,

if you drink it too late in the day,

but typically it will not cause the major side effects

of the other drugs,

such as high propensity for addiction and abuse.

Amphetamines of any kind as well as cocaine

can cause sexual side effects

because they're vasoconstrictors.

So, men have trouble achieving erection,

there can often be the intense desire or libido for sex,

but an inability to actually perform.

So that's an issue with any kind of stimulant.

So these drugs are not without their consequences.

In addition, and here I'd lump caffeine back into the mix.

In addition, they almost all carry cardiac effects, right?

They increase heart rate,

but they also have effects on constriction of blood vessels

and arteries and veins and so forth in ways

that can create cardiovascular problems.

Now, caffeine is a bit of a complicated one.

I talked about this on a podcast long ago,

but I'll just remind you that it turns out

that if you are caffeine adapted, in other words,

if you are used to drinking caffeine

then the ingestion of caffeine,

most often will cause vasodilation who actually allow more

blood flow through.

However, if you are not caffeine adapted,

it will cause vasoconstriction

due to an increased stress response.

So if you're familiar with caffeine,

caffeine can actually have a little bit more

of a relaxation response

although if you drink enough of it,

it will make you amped up.

These other drugs, almost always lead to vasoconstriction,

increased heart rate dilation of the pupils, less blinking,

heightened levels of attention,

which looks very much like stress

and at its extremes looks very much

like the effects of street drugs,

like cocaine and amphetamine.

Because of the large amounts of

dopamine that released in the brain.

People tend to crave that state over and over

and yet with each subsequent use

are able to get less and less

of that euphoric feeling

or that really, really focused feeling.

So one thing that's being explored quite extensively now

in the treatment of ADHD are drug schedules.

Whether or not people should take Adderall every day

or every other day,

whether or not they should take it

only every once in a while,

whether or not young children can take it just a few times

and engage in behavioral training of the sort

that I talked about before, where they're doing,

maybe it's a 17 minute meditation type exercise,

but more likely it would be the movement

followed by the visual focusing,

cause that's only done for 20 or 30 or 60 seconds.

Why would you do that?

Well in a chemically enhanced state,

your brain is more plastic.

The circuits are able to modify and learn better.

That's the optimal time to engage in focus

in a very deliberate way.

So just taking a drug and expecting

focus to just work at any point

and being able to turn focus on and off at will,

that's an unrealistic expectation, right?

More likely the best use of things like Adderall, Modafinil,

armodafinil and Ritalin is going to be

to combine those treatments with behavioral exercises

that actively engage the very circuits

that you're trying to train up and enhance

and then perhaps I want to highlight perhaps

tapering off those drugs

so that then one can use those circuits

without any need for chemical intervention.

So despite any controversy that might be out there,

I think it's fair to say that

the consumption of omega-3 fatty acids

can positively modulate

the systems for attention and focus.

So then the question becomes how much EPA,

how much DHA does that differ for,

what's helpful for depression, et cetera

and actually it does differ

in reviewing the studies for this

it appears that a threshold level of 300 milligrams of DHA

turns out to be an important inflection point.

So typically fish oils or other sources of omega-3s

will have DHA and EPA

and typically it's the EPA

that's harder to get at sufficient levels,

meaning you have to take quite a lot of fish oil

in order to get above that 1000 milligram

or 2000 milligram threshold to improve mood

and other functions.

But for sake of attention,

there are 10 studies that have explored this in detail

and while the EPA component is important,

the most convincing studies point to the fact that getting

above 300 milligrams per day of DHA is really where you

start to see the attentional effects.

Now, fortunately, if you're getting sufficient EPA

for sake of mood and other biological functions,

almost without question,

you're getting 300 milligrams or more of DHA.

So that usually checks that box just fine.

What's interesting is that there's another compound

phosphatidylserine that has been explored for its capacity

to improve the symptoms of ADHD.

Again, I don't think this is any direct way,

but rather in a modulatory way,

but it appears that phosphatidylserine

taken for two months for 200 milligrams per day,

was able to reduce the symptoms of ADHD in children.

It has not been looked at in adults yet as,

at least as far as I know,

but that this effect was greatly enhanced

by the consumption of omega-3 fatty acids.

So now we're starting to see synergistic effects

of omega-3 fatty acids and phosphatidylserine

again that was 200 milligrams per day.

This is something that sold

over the counter in capsule form, at least in the U.S.

there were two studies,

both were double-blind studies.

I carried out for anywhere from one to six months on both

boys and girls and it really was boys and girls,

not men and women.

This was kids age one to six or seven to 12,

and it was a fairly large number of subjects.

So 147 subjects in one case in 36 in the other,

the takeaway is that getting sufficient levels of EPA

and particularly there's 300 milligram threshold of DHA,

plus, if you are interested in it and it's right for you,

200 milligrams of phosphatidylserine

can be an important augment

for improving the symptoms of ADHD.

You'll also find literature out there

and many claims about so-called Ginkgo Biloba,

which has been shown to have minor effects

in improving the symptoms of ADHD,

not nearly as effective as Ritalin and Adderall.

Ginkgo Biloba is not appropriate for many people.

I am one such person, I don't have ADHD,

but when I'd taken Gingko, even at very low doses,

I get absolutely splitting headaches.

Some people do not experience those headaches,

but it's known to have very potent vasoconstrictive

and vasodilating properties that vary depending on

when you took the compound.

So for those of you that are exploring Ginkgo Biloba,

and you will see a lot of claims about Ginkgo Biloba

for attention in ADHD definitely take the vasodilation

vasoconstriction headache issue into consideration.

So I'd like to talk about the drug Modafinil

and the closely related drug armodafinil

that's AR Modafinil.

Because Modafinil and armodafinil

are gaining popularity out there,

both for treatment of ADHD and narcolepsy,

but also for communities of people

that are trying to stay awake long periods of time.

So it's actively used in the military by first responders,

it's gaining popularity on college campuses

and people are using it more and more as an alternative

to Adderall and Ritalin and excessive amounts of coffee.

It does increase focus and to a dramatic extent,

Modafinil typically was very expensive,

I don't know if it's still this expensive,

but when one has a prescription for it,

it could still cost as much as eight or $900

even $1000 a month.

Armodafinil is a far less expensive version,

that's chemically slightly different than Modafinil.

Regardless of price

people are taking Modafinil and armodafinil.

Want to emphasize that unlike Ritalin and Adderall,

Modafinil and armodafinil are weak dopamine

re-uptake inhibitors,

and that's how they lead to increases in dopamine.

So, whereas Ritalin and Adderall, amphetamine,

and cocaine lead to big increases in dopamine

also through re-uptake mechanisms and so forth

Modafinil is a weaker dopamine re-uptake stimulator

and so what that means is that it leaves

more dopamine around to be active at the synopsis,

the gaps between neurons,

however, it also activates other systems.

It acts on the orexin system,

which is actually a peptide that we talked about

in the episode on hunger,

because it regulates hunger and appetite,

and it regulates sleepiness and feelings of sleepiness.

In fact, the, excuse me, orexin

also called hypocretin system,

the orexin hypocretin system

is what's disrupted in narcolepsy.

That was the important discovery of my colleagues,

Emmanuel Mignot and Seiji Nishino

at Stanford some years ago,

they identified the biological basis of narcolepsy

and it's a disruption in the so orexin hypocretin system

and Modafinil is one of the

primary treatments for narcolepsy.

It also has these other effects on the dopamine system

and on the norepinephrine system,

even though it doesn't lead to quite as intense levels

of dopamine and arousal and focus,

it does have the property of raising levels of attention

and focus, and that's why people are using it.

So it's a somewhat milder form of Adderall.

Armodafinil for some people works as well as Modafinil

and as I mentioned before,

it's much lower cost for other people it doesn't.

I have an experience,

meaning I do have an experience

that I'll share with you with armodafinil.

A few years ago,

I was suffering from jet lag, really terribly

and I was traveling overseas.

I went to a meeting to give a talk,

I took half of the prescribed dose of armodafinil.

It was prescribed to me.

I took that half dose and I gave my lecture

and then I stayed around to answer questions

and then four hours later,

a friend of mine came up to me and said,

you've been talking for four and a half hours,

and they're only a few people still here.

Luckily there were still a few people be a lot weirder,

if the room was completely empty,

'cause it wasn't being recorded.

So I have firsthand knowledge

of the sorts of cognitive effects that it can create.

I personally would not want to be in that state

for sake of studying or learning

or for doing this podcast, for instance

and I can honestly say that today,

all I've adjusted is some coffee

and some Yerba latte tea and some water.

I'm not on any of the compounds that I've described during

the course of today's episode.

You might ask why I took half the recommended dose

of armodafinil and the reason is that I'm somebody who's

fairly hypersensitive to medication of any kind,

what you find if you look in the literature,

is that about 5% of people

are hyper hyper sensitive to medication.

They require far lower doses of any medication

than other people in order to experience the same effects.

I'm somebody that I think has,

or modest a hyper if that sort of oxymoronic statement,

but a modest hypersensitivity to medication.

So I've almost always been able to get by,

on taking less of whatever was prescribed for me

and feel just fine

or in this case to feel like it was still too much,

it turned out that the right dose of armodafinil for me

was zero milligrams.

Now you may notice that

I haven't talked much about acetylcholine.

Acetylcholine is a neurotransmitter

that at the neuron to muscle connections,

the so called neuromuscular junctions

is involved in generating muscular contractions

of all kinds for all movements.

Acetylcholine is also released from two sites in the brain.

So a little bit of nomenclature here again,

feel free to ignore the nomenclature,

but there is a collection of neurons in your brain stem

that send projections forward,

kind of like a sprinkler system

that's very diffuse to release acetylcholine

and those neurons reside in an area or a structure

that's called the pedunculopontine nucleus, the PPN

and then there's a separate collection of neurons

in the basal forebrain called

unimaginatively nucleus basalis the nucleus at the base

and they also hose the brain with acetylcholine,

but in a much more specific way.

So one is sort of like a sprinkler system

and the other one is more like a fire hose

to a particular location

and those two sources of acetylcholine,

collaborate to activate particular locations in the brain,

and really bring about a tremendous degree of focus

to whatever is happening at those particular synapses.

So it could be a focus on visual information

or auditory information,

if you're listening closely to what I'm saying right now,

and you just heard closely

step out from the rest of my sentence,

no doubt there was acetylcholine

released at the sites in your brain

where the neurons that represent your recognition

of the word closely occurred, okay?

So now you have an example and you have an understanding

and hopefully a picture in your mind

of how all this is working,

not surprisingly then drugs that increase cholinergic

or acetycholine transmission

will increase focus and cognition.

One such compound is so-called alpha GPC,

which is a form of choline and increases acetycholine

transmission dosages as high as 1200 milligrams per day,

which has a very high dosage spread out,

typically it's 300 or 400 milligrams spread out

throughout the day have been shown to offset

some of the effects of age-related cognitive decline,

improved cognitive functioning

people that don't have age-related cognitive decline

that's a very high dose.

Typically when people are using alpha-GPC to study

or to enhance learning of any kind,

they will take somewhere between 300 and 600 milligrams

that's more typical.

Again, you have to check with your doctor,

you have to decide if the safety margins

are appropriate for you

obviously you'll want to check that out,

but alpha-GPC is effective in creating

more focused by way of this cholinergic system,

It stimulates acetylcholine release

from both of those locations,

the PPN in the back of the brain and nucleus basalis

in the front of the brain.

There are two other over the counter compounds

that are in active use out there for treatment of ADHD

and in use for simply trying to improve focus

and the first one is L-Tyrosine

it's an amino acid that acts as a precursor

to the neuromodulator dopamine

and now knowing everything you know about

dopamine, attention and the circuits involved,

it should come as no surprise as to why

people are exploring the use of L-tyrosine for that purpose.

L-tyrosine does lead to increases in dopamine.

They are fairly long lived and L-tyrosine can improve

one's ability to focus, however,

the dosaging can be very tricky to dial in.

Sometimes it makes people feel too euphoric

or too jittery or too alert that they are then

unable to focus well.

So the dosage ranges are huge,

you see evidence for 100 milligrams

all the way up to 1200 milligrams.

It's something that really

should be approached with caution,

especially for people that have any kind

of underlying psychiatric or mood disorder,

because dysregulation of the dopamine system is

central to many of the mood disorders such as depression,

but also especially mania bipolar disorder,

schizophrenia, things of that sort.

So it's something that really should be approached

with caution, nonetheless, in exploring what's out there

and even some studies online

that were done in either animal studies or human studies,

it's clear that L-tyrosine is being explored for that

purpose as is PEA and Phenethylamine,

which is a essentially PEA, but some related compounds.

So there's a whole class of dopaminergic

or dopamine stimulating supplements

that people are using to try

and get their dopamine levels up and again,

it's kind of a fine line between too little enough

and too much.

If you want to get the literature on

those two compounds there, I will refer you to

this great website at examine.com just as it sounds

and you can put in L-tyrosine or PEA,

and you can get the details on that.

But I highly recommend also going to their section on ADHD

to see how those particular comment OENs relate specifically

to ADHD and cognitive focus.

And last but not least

in terms of these different compounds,

I do want to mention the Racetams.

These are somewhat esoteric

and probably most of you haven't heard about them,

but some of you probably know a lot about them

and they are becoming more popular.

They go by names like New pepped and things of that sort.

The Racetams. are illegal in certain countries.

They are gray market in other countries,

and they are sold over the counter in this country,

in the U.S. so they have different margins for safety

you definitely need to consult your doctor,

especially if you have ADHD,

but new pepped has been shown when taken,

at 10 milligrams, twice daily can be more effective

than some of the other Racetams.

What is Noopept? Noopept taps into the cholinergic system,

the acetylcholine system in ways, very similar to alpha-GPC,

but seems to have a slightly higher affinity for some of the

receptors involved and can lead to those heightened states

of cognitive capacity

and there are these studies one in particular,

comparative studies of new pepped,

Racetams in the treatment of patients

with mild cognitive disorders

and brain diseases of vascular and traumatic origin.

That's a mouthful.

What this study basically points to

is the fact that people who are experiencing some degree

of inability to focus due to prior concussion

or some vascular event, a stroke or a schemey of any kind,

because neurons need blood,

when the blood supply is cut off to neurons,

or when there's a bleed in the brain.

Subsequent to that, often

there are challenges in maintaining focus.

This is very common for people who have done sports,

where there's a lot of running into each other

with your head like rugby football, hockey, and so forth,

but also people who have experienced head blows

or often overlooked is the fact that

most traumatic head injury is not actually from sports,

even football it's from things like construction work

from high-impact work of that kind.

So there does seem to be some efficacy

of new Pepped and Racetams. and things like it.

It's an emerging area and as I mentioned in the U.S.

these things are sold over the counter.

Again, you have to figure out if it's right for you,

but they are beginning to show some promise,

and I'm intrigued by them because of the way

that they tap into the cholinergic system,

which is both directly involved in focus,

and the ability to focus,

but is also important for things related

to age-related cognitive decline.

So a decline in cholinergic transmission or acetylcholine

as we call it in the brain is one of the things

associated with cognitive decline

and it does seem that increasing cholinergic transmission

can offset some of that cognitive decline

and perhaps even more so in conditions

such as vascular damage or concussion to the brain.

If you're interested in atypical treatments for ADHD

compounds or improve focus and related themes,

and you like reading about this stuff,

there's an excellent review article

that I can refer you to it's

by Ahn et al, AHN it was published in 2016

so it's a little bit behind the times,

although it's surprisingly comprehensive given that,

which lines up all the various drugs that I've discussed,

Racetams., and Adderall and Ritalin,

and various forms of dopaminergic agents

and cholinergic agents spells out whether or not

they are sold over the counter by prescription,

and really lines them up in all their effects,

their drawbacks, et cetera.

I'll refer you to that study.

It's available in its full length form online for free

it's Hen et al the journal is neuro plasticity,

neural plasticity, 2016

should be very easy to find if you put those keywords in,

and while it is a review,

it is a very comprehensive review

and if you're really into this stuff,

and you also want to learn a thing or two about

how these things interact with neurofeedback, et cetera,

there's some information in there as well.

I know I've already covered a lot of information,

but there is one more category of technology

for the treatment of ADHD and for enhancement of focus

in anyone that I would like to emphasize

and that's transcranial magnetic stimulation.

Transcranial magnetic stimulation also called TMS

is achieving increasing popularity nowadays

for the treatment of all sorts of neurologic conditions

and psychiatric conditions.

It is a non-invasive tool,

it involves taking a coil it's a device with a coil

that's placed over particular locations in the brain,

and then sends magnetic stimulation into the brain

and it can actually pass through the skull

without having to drill through the skull

and nowadays can be used to both

lower the amount of activity

or increase the amount of activity

in specific brain areas.

It's spatial, precision is not remarkable.

That doesn't mean it's not of use,

but it is not a super fine green tool, okay?

It's not a canon, but it's also not a needle.

It is somewhere in between.
It can direct the activity of particular brain regions

at particular depths and as I mentioned,

it can increase or decrease that activity.

So for instance,

I've had a TMS coil placed on my head,

not for therapeutic purposes, even it was,

I wouldn't tell you, but rather just for,

well, I'm a neuroscientist

and I worked in a lab with one for entertainment,

exploratory purposes, please don't do this at home.

It was placed over my motor cortex,

which generates voluntary action

and it was a coil that at that time

could only inhibit neurons

and so what I was doing as I was moving objects

around on a table, just like I am now,

it was actually a pencil, not a pen

and I was tapping the pencil

and then the TMS coil was turned on and for the life of me,

I could not move that pencil, okay?

Because it was inhibiting my upper motor neurons

in the portion of my cortex

that controls voluntary activity.

As soon as the coil was turned off,

I could return to tapping the pencil again,

nowadays it's possible to stimulate motor cortex

or any area of the brain with some degree of precision

that could create the impulse to move

without actually making the decision to move.

So you can literally engage certain neural circuits

and therefore behaviors and certain thought

and emotional patterns

by way of transcranial magnetic stimulation.

This has far reaching and vast implications,

as you can probably imagine

in discussing ADHD with a colleague that uses TMS,

what they are doing is they are taking the TMS coil

to children and adults that have ADHD,

and they're using it to stimulate the portions

of the prefrontal cortex that we talked about earlier

that engage task directed focused states.

So rather than using a drug

that generally increases dopamine,

and some of the other chemicals involved

there you using directed TMS stimulation of the circuits

and fortunately, I was quite relieved to hear this,

they are combining that with a focused learning task.

So they're literally teaching the brain to learn

in a noninvasive way, no drug at all

and right now there are experiments clinical trials

going on, comparing TMS of this sort

to the drug treatments of the sort that we described earlier

that engaged these circuits

through pharmacologic mechanisms.

So very exciting times for TMS,

very exciting times for pharmacology related to ADHD

and for enhancing focus in general

and when I say very exciting times,

I mean, no drug is perfect,

but the constellation of drugs that's out there

is getting much larger,

but because they tap into different aspects

of their circuitry,

I do think that we are well on our way

to identifying the ideal combinations of drug treatments,

technological treatments,

and behavioral paradigms for increasing focus in both

children and adults with ADHD.

And as a final final point,

I also want to mention something about technologies

that are making it harder for all of us to focus,

regardless of whether or not

we have pre-existing ADHD or not.

You can probably guess where this is going.

Everybody nowadays seems to have a smartphone.

I'm sure there are a few individuals out there

that don't have a smartphone.

Nonetheless, most people have them.

Most kids want one, as soon as they can get them

and they are small, they grab our attention entirely.

But within that small box of attention,

there are millions of attentional windows

scrolling by, right?

So just because it's one device that we look at

does not mean that we are focused,

we are focused on our phone,

but because of the way,

in which context switches up so fast within the phone,

it's thought that the brain is struggling now

to leave that rapid turnover of context, right?

Many, many shows, many, many Instagram pages,

many, many Twitter feeds many, many websites.

Basically the whole world,

at least in virtual format is available

within that small box.

Unlike any other technology

humans have ever dealt with before,

even though there are trillions

infinite number of bits of information

in the actual physical world,

your attentional window,

that aperture of constriction

and dilating that visual window

is the way in which you cope with all that

overwhelming information typically.

Well within the phone,

your visual aperture is set to a given width

it's about this big,

typically the phone seem to be getting bigger,

but nonetheless, it's about that big

and within there,

your attentional window is grabbing it near infinite

number of bits of information, colors, movies.

If a picture is worth 1000 words,

a movie is worth a billion pictures,

the brain loves visual motion

and so the question is,

does that sort of interaction on a regular basis

lead to deficits in the types of attention

that we need in order to perform well

in work, in school, relationships, et cetera

and the short answer is yes, it does appear so

we are inducing a sort of ADHD

and while the studies on this are ongoing because prominent

use of smartphones really took off right around 2010

and we're only in 2021 longstanding studies take time,

which is essentially to say the same thing as long standing.

There are some studies and one in particular

that I'd like to highlight

one was actually carried out pretty early in 2014.

This is a study that explored smartphone use

at the time they called it mobile phone use,

but smartphone use and inattention,

difficulties in attending in 7,102 adolescents

that's a huge study,

a population based cross-sectional study

and you will be probably surprised and somewhat dismayed

to hear that in order to avoid this decrease

in attentional capacity,

adolescents needed to use their smartphone

for less than 60 minutes per day,

in order to stay focused and centered on their other tasks.

Otherwise they started to really run

into significant issues.

So 60 minutes is not much,

I've a feeling that most young people

are using their phone more than 60 minutes per day,

I know I am.

I think for adults,

the number's probably higher meaning if you're an adult,

I'm going to just extrapolate from what I read in this study.

It seems that probably two hours a day on the phone

would be the upper limit beyond which

you would probably experience

pretty severe attentional deficits.

I'm a big fan of Cal Newport who wrote the book "Deep work."

He's also written an excellent book,

"A world without Email."

I've never met him, but I'm a huge admirer of his work

and I will paraphrase something that he said

far more eloquently than I ever could,

which is that the brain does not do well with constant

context switching, meaning it can do it,

but it diminishes our capacity to do meaningful work

of any other kind.

And so Cal, as I understand is very

he's our computer science professor

at Georgetown, by the way,

is very structured and very disciplined

in his avoidance of cell phone use.

I think we're all striving to do that.

I'm not here to tell you what to do,

but I think whether or not you have ADHD or not,

if you're an adolescent limiting your smartphone use

to 60 minutes per day or less

and if you are an adult to two hours per day or less

is going to be among the very best ways to maintain,

just to maintain your ability to focus

at whatever level you can now and as I always say,

most of the things that we get recognized

for in life success in life, in every endeavor,

whether or not it's school relationships, sport,

creative works of any kind are always proportional

to the amount of focus that we can bring that activity.

It is important to rest of course, to get proper sleep.

But I stand behind that statement

and I leave you with that study about attention

and cell phones and how cell phones are indeed eroding

our attentional capacities.

So I realized I covered a lot of information about ADHD

and the biology of focus and how to get better at focusing.

We talked about the behavioral

and psychological phenotypes of ADHD.

We talked about the underlying neural circuitry.

We also talked about the neurochemistry

and we talked about the various prescription

drug treatments that are aimed at that neurochemistry

and aimed at increasing focus in children

and adults with ADHD.

We also talked about over the counter compounds,

the role of particular types of diets and elimination diets

and we talked about interactions between these various

features in dictating outcomes for ADHD

and enhancing focus in general,

we also talked a little bit about emerging neurotechnologies

and how certain technologies like the smartphone

are no doubt hindering our ability to focus

and put us at greater risk of developing ADHD at all ages.

I do acknowledge the irony and somewhat the contradiction

of doing a two hour plus episode on ADHD

If indeed, people who are watching this

have challenges with attention,

I want to emphasize that this podcast,

like all of our podcast episodes

are timestamped for a specific reason.

They are designed to be digested

in whatever batch one chooses, right?

You don't have to watch or listen to the entire thing

all at once however,

if you've gotten to this point in the podcast,

I want to thank you.

I do hope that you've learned a lot about this condition.

I hope you've also learned a lot

about your own capacity to focus

and things that you can do to enhance your focus.

We even talked about a tool that takes just

one 17 minute session to enhance your ability to focus

thereafter, presumably forever.

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And finally,

I want to thank you for your time and your attention,

and as always thank you for your interest in science.

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