Improve Focus With Behavioral Tools & Medication for ADHD | Dr. John Kruse

ADHD diagnostic clue: forgetting to eat all day is a red flag

People with ADHD often forget to eat entirely, miss interoceptive cues, and struggle with time management and emotional regulation.

"But never did anyone who was coming in for OCD or depression or PTSD show up at the front door. And I gave the instructions at the same time. And sometimes I didn't know beforehand that the person was coming in for ADHD because they didn't know. But if they showed up at the front door, that always made me, you know, uh-oh, I better make sure I ask specific detailed questions about the ADHD possible component. So the other sort of real-life diagnostic test I had, if someone during the evaluation would say something like, or in a subsequent session, oh, it was 4 o'clock yesterday, and I just realized I hadn't eaten all day. Ding, ding, ding, ding, ding. I mean, I have people who diet, I have people who have fasting regimens or others, but they're not forgetting to eat. And it's not that everyone with ADHD does that, but either not getting the right intero-receptive cues from your body or not paying attention to them is something that's been measurable in people with ADHD. So having a regular meal schedule. So having a regular meal schedule. And again, getting back to the COVID in workplace. I had lots of people in tech who really lamented, now I have to work for home. They were giving me lunch, a healthy, nice lunch each day at work. They're scrambling to even use the home meal delivery systems because getting that organized and set up is just too overwhelming for them. And again, these are bright people who are succeeding in most parts of their life. Are these people with ADHD sometimes also starting a meal, taking a few bites, and then going back to work? And then like the meal never really ends? It just sort of fragments into the rest of the day? Yeah, that can be one variation. But it's often just completely forgetting or being oblivious to it. I mean, the other ways ADHD can play a role is I was meaning to have breakfast before I left the house, but always when it's time to leave the house, you forget that you hadn't done this, and the kids' shoes need to be tied, and, oh, do I need a new toothbrush? I better go check upstairs before I go out because I'm going to the CVS store. I mean, time management is a problem with ADHD, an executive function problem. Interestingly, it's not one of the 18 symptoms in our official checklist. So our official checklist is sort of a crude clinical attempt to map out a lot of the aspects of ADHD, but it misses a lot. So there's emotional regulation problems. We know something like 60% of people with ADHD acknowledge having that emotions explode or come up bigger or stronger and are harder to regulate. And that's nowhere acknowledged in our official diagnostic symptomatology. I'd like to take a quick break and thank our sponsor, AG1. AG1 is an all-in-one vitamin, mineral, probiotic drink with adaptogens. I've been taking AG1 daily since 2012, so I'm delighted that they're sponsoring this podcast. The reason I started taking AG1 and the reason I still take AG1 is because it is the highest quality and most complete foundational nutritional supplement. What that means is that AG1 ensures that you're getting all the necessary vitamins, minerals, and other micronutrients to form a strong foundation for your daily health. AG1 also has probiotics and prebiotics that support a healthy gut microbiome. Your gut microbiome consists of trillions of microorganisms that line your digestive tract and impact things such as your immune system status, your metabolic health, your hormone health, and much more. So I've consistently found that when I take AG1 daily, my digestion is improved, my immune system is more robust, and my mood and mental focus are at their best. In fact, if I could take just one supplement, that supplement would be AG1. If you'd like to try AG1, you can go to drinkag1.com slash Huberman to claim a special offer. They'll give you five free travel packs, plus a year supply of vitamin D3 K2 with your order of AG1. Again, go to drinkag1.com slash Huberman to claim this special offer. So we've got sleep, eating, exercise, or movement, and relaxation. Maybe before we start talking about some medications and some other factors that modulate ADHD, if we could maybe step through each of those and you could share with us some of your favorite tools that you give your patients and that you teach online. Realizing, of course, that each one of those is a vast topic that we could do entire, we have done entire podcasts on, but I'm curious about your favorite go-to tools. We were talking about a few of these before we started. So sleep, regular to bed and wake up times? Matthew Walker and his great book on sleep. One of my favorite things about it is he really emphasizes this point, that quality sleep isn't just about eight hours. It isn't just duration. It's getting quality sleep. And the timing of your sleep is every bit as important as the duration. So if you're used to sleeping midnight to 8 a.m. and you're staying up dancing or partying until 4 a.m. and you say, oh, it's a weekend, I can sleep until noon, you may still get those eight hours, but they're not restorative to the same extent as if you had slept at your regular time. And it's, I mean, my PhD research was on circadian rhythms. We had realms of data back then, so this was 40, 30 plus years ago. We had every bit as much data then that the timing of sleep was as important as the duration, and yet every public service announcement just says, get your eight hours of sleep. Why are we leaving out this other piece? We've known for decades that people with ADHD have a strong propensity to being night owls, to have a different chronotype where they're maybe more effective or functional later in the day, a tendency to stay up. For many years now, we've actually known that this is strongly genetically controlled. So we do have, you know, there are genetic markers affecting sleep timing that are overrepresented strongly in the ADHD community. So some of it is you are pushed that way, but some of it is the nature of ADHD, that if you, you know, procrastinating is part of ADHD. If you procrastinate, you're going to push things off until the end of the day. Some people, the end of the day is a better time to work because there's fewer distractions."

Caffeine is a lousy stimulant at equivalent doses -- more jittery, more cardiac risk

At equivalent doses to prescription stimulants, caffeine causes more jitteriness and cardiac toxicity. Most people use it at much lower doses.

"But associated with higher levels of angriety, higher levels of jitteriness, higher levels of cardiac toxicity if you were to use it at an equivalent dose. But most people are using it at a substantially lower dose. And the ADHD experts sort of historically have fallen into two different camps. Some of them have said it's going to interact with your stimulant or other medications. It's complicated. We don't want it messing up the picture. Stay off of it. And the other half say it's a stimulant. Lots of people are using it with these other stimulants, both full-blown stimulants and non-stimulant ADHD medications. And as long as you know it's part of the picture and you're trying to be constant with your dosage or aware of it, then fine. And maybe it helps you get away with the lower dose of the prescription. The one little piece I'd add in there is that often you don't know what dose you're getting. So people have the common experience. As I was saying earlier, I've only had three cups of coffee in my whole life. So this is all anecdotal or research, not personal experience data. But lots of people have the experience, go to their local Starbucks or something and say, whoa, that feels way stronger than usual. And then invariably they say, oh, that must just be me. I'm more anxious already. I'm jacked up. Because they think Starbucks, you know, seven billion stores around the country, everything's automated and precise, they must be. Starbucks isn't, you know, they control for the aromaticity, how many minutes each bean is cooked, which side it gets flipped over on. They're not controlling for caffeine intake, which is wild to you. So a University of Florida study, and this is several years ago now, went into a Florida Starbucks, bought the same drink every day for three weeks, and compared the caffeine content, the highest day compared to the lowest day was a three-fold difference. Wow. And that's Starbucks. Who knows what smaller... So one is you may think you know what you're giving and maybe the bane of coffee drinkers and maybe Sanka in a teaspoon that you're dissolving may be the most consistent there. But one of the risks with caffeine and with pretty much any over-the-counter drug is you may not know what dose you're getting. Very interesting. I mean, as I've said several times in this podcast, I think caffeine is a wonderful drug mostly because I love the things that comes in. Yerba mate being my preferred source of caffeine, but also coffee. And it certainly increases my focus. It's a narrow plane though. You know, two sips too many, and I can start feeling myself veer toward more lack of focus. It doesn't seem to have a very pervasive effect and dosing it on an empty stomach versus after eating. I mean, I'm not that precise about it, but I don't see it as a very reliable stimulant. It's more to get to a plane of just normalcy for me, given how much I've been drinking it since I was a teen, really."