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

Andrew Huberman: Welcome to the Huberman Lab podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Dr. John Kruse. Dr. John Kruse is an MD, PhD, and practicing psychiatrist who specializes in the treatment of ADHD in both kids and in adults. As you'll see during today's episode, Dr. Kruse is among the world's top experts in understanding the various treatments for ADHD and tools for helping to overcome non-clinical issues with focus and attention. We, of course, discuss the drug treatments for ADHD. So those include Adderall, Ritalin, Vyvanse, Modafinil, Wellbutrin, basically all the drugs that are used to treat ADHD, and we cover their relative advantages and disadvantages. We also talk about the use of caffeine for focus and how caffeine can interact with those various drugs. Dr. Kruse also educates us on how specific behaviors like our sleep timing, so not just the amount of sleep we get, but when we sleep, as well as our meals, our exercise, how all that can shape our levels of attention and focus. And that, of course, is relevant not just to people struggling with attention and focus or who have ADHD, but to everybody. Dr. Kruse isn't just a psychiatrist. He also has a background in circadian biology research, and he offers the intriguing idea that ADHD and other deficits in focus may, in many cases, be the consequence of a misregulated circadian rhythm. He tells us how to test that idea and potentially how to fix it. By the end of today's episode, you'll understand what stimulants do, the possible origins of ADHD in both kids and adults, and both the behavioral and drug treatments and non-prescription approaches to overcoming brain fog and focus challenges. So by the end of today's episode, you'll be armed with a ton of new knowledge, and you'll have a lot of practical tools you can apply. Before we begin, I'd like to emphasize 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. In keeping with that theme, this episode does include sponsors. And now for my discussion with Dr. John Kruse. Dr. John Kruse, welcome. Dr. John Kruse: I'm glad to be here today. Andrew Huberman: Let's talk about ADHD, and probably best if we start off by just laying out what it is. Is the H, is the hyperactivity component always in there? Childhood ADHD, adult ADHD. Maybe if you would just give us the top contour of this, and then we can get into ways to combat ADHD depending on different circumstances, different needs, this sort of thing. Dr. John Kruse: I'll just start out by saying that like most things in neuroscience and psychiatry, we have some definitions, and we have lots of different thoughts and frameworks to approach things. So I'll start with our diagnostic category or how we diagnose ADHD, and that is there are 18 different symptoms. Nine of them are hyperactive-impulsive, nine of them are inattentive. So the inattentive ones are things like forgetting to follow through on things, losing items, being easily distracted. The impulsive and hyperactive ones are cutting people off in conversations, blurting things out, running around, fidgeting. But the definitions themselves were designed with a child population in mind because until roughly the mid-'90s, it was dogma that this was a neurodevelopmental disease of childhood, and that every child who had it outgrew it. That is dramatically wrong. Some kids do. Most kids don't. The latest work suggests that most adults fluctuate in time with the severity of their ADHD symptoms. So jumping back to the definition. So we have these 18 different symptoms. As an adult, you need to have at least five of them, and when we say have them, all of these are things that normal people can display at any time. So any of us might interrupt someone, might have trouble sitting, might have trouble attending to a task. But to meet the criteria, these have to be displayed in excessive amount of time or to an excessive degree to the extent that they're causing some dysfunction or distress, and that they have to be displayed in multiple realms of life. So if it's only at work that you have trouble completing your task, that might have something to do with your boss or an uncomfortable chair or something. So these have to be traits that are displayed in multiple realms of life. They have to cause, again, distress or dysfunction. They have to be to an extent that's beyond what a normal person does. And what's strange is often ADHD has a stigma it's not a real diagnosis, partly because there isn't some, a fancy word, pathognomonic, some classic symptom that's characteristic exactly of that. So with schizophrenia, we have hallucinations. Most people aren't having hallucinations. If you have those, you might have schizophrenia or a drug effect, but that's unusual. Again, with ADHD, they're all usual behaviors. It's just to an unusual extent. So the diagnosis comes under a lot of stigma and questioning. Isn't this just normal behavior carried to a ridiculous extent? Andrew Huberman: So you mentioned that there can be a lot of environmental dependence. One thing that I, and I know a lot of people wonder about, is with the advent of more people working at home, and certainly during lockdowns, kids were at home for school as well. But is it the case that when somebody with ADHD is in their home environment where they're Typically, more options of things to do that the symptoms get worse, as opposed to when they go to, say, a restaurant or to school or to play a sport or to work where sure, there are multiple things you can do in those environments, but they're more constrained in terms of the different sides of oneself, the different activities that one tends to engage in. Is that common? Dr. John Kruse: Yeah. So back up a little bit. Like all of our other mental health or psychiatric conditions, there's clearly both a biological component to ADHD and clearly a social environment, or the nature and nurture question isn't which is it, it's always both. So with ADHD, we know there's a very strong genetic component. The heritability factor is around 0.8, which is about as strong as the heritability factor for height or for schizophrenia. Andrew Huberman: So does that mean that if you're an identical twin and your twin has ADHD, that there's a sort of essentially a 0.8 probability that you'll have it as well? Or is this through the- Dr. John Kruse: Yeah. Heritability is a little more technically- Andrew Huberman: Sure Dr. John Kruse: ... sophisticated, and it's about the variance due to gen- Andrew Huberman: Sure Dr. John Kruse: But it's high likelihood. Andrew Huberman: Mm-hmm. Dr. John Kruse: So this tends to run in families. But again, it has a social-- You're not just a brain in the world, you're a brain interacting with the world. And with ADHD, we like to frame it as both structure is important and demands are important. So one of the aspects of ADHD, separate from the official how we categorize it or diagnose it in terms of symptoms, we most often are understanding at this day and age as a problem with executive functions of the brain, how the brain's working memory works, how selective attention works or doesn't work, how emotional regulation is working or not, how impulse control is working. And essentially, the ADHD brain is less able to provide the structure it needs, so it's more reliant on an optimal structure in the outside world. So getting the home versus working in a office environment, part of the problem is if you're in a traditional office environment, you're starting a specific time. Everyone else is doing their work at a certain time. When you go to lunch, it's clear. You may have people checking in or seeing you in the hallway. "Larry, how far along are you on this coding project? Are you going to be ready for it on time?" When you're home, you don't get any of that reinforcement. You don't have any of that structure. So, structure is a Goldilocks issue. It's not just more structure is always good, because if you put or impose too much structure on someone, so most people with ADHD are really lousy assembly line workers. They don't want to be just picking up one bolt, screwing it on the side of a Lexus or whatever, and watching the car move down the line. That's too stultifying, too limiting, too structured. So you need the optimal amount of structure, and with COVID and working from home and kids being at the home, so one thing it created is less structure for the day, but it also increased the demand side of the equation. So the cognitive demand, not only did you have to manage your own time and schedule now, in addition to doing your work, you had to schedule it, but you might have had screaming kids in the other room, or you might have had your partner who wants to use that room for their quiet meetings some of the time when you're trying to do it. So the demands increased for many people, and the structure decreased, and that was sort of a perfect storm for creating more ADHD. And what's really interesting from a mental health perspective, at the very start of the COVID epidemic, public mental health figures said, "We know if this is a massive epidemic, and we're going to have to do quarantine, and people-- We know depression's going to go up. We know anxiety's going to go up. We know alcohol and substance abuse is going to go up. We know PTSD and domestic violence is going to go up." They claimed suicide would go up. That was incorrect, and we can get into that, but I think there's an ADHD reason why it didn't go up. Nobody that I heard was mentioning that ADHD would go up. And part of it is because partly to hold onto its legitimacy as a real psychiatric diagnosis, both many patients and many researchers in the field hold so strongly to, this is a biological condition. Why would it change? We can understand why PTSD, more people are being traumatized. Uncle Joe just died from coughing his lungs out from COVID. PTSD, it's easy to see. Or depression. You've just lost your job and your whole industry. You're a restaurant worker, that's not coming back. So we could easily relate stories as to why these other conditions were going to go up, but there was no prediction, again, mostly because I think the defensiveness of the ADHD community and not wanting to acknowledge as much that there's a real nurture component and not just a nature component. And yet what we've seen, just looking at prescriptions, and the media's jumped all over this, not only have ADHD diagnosis gone up considerably, but also prescription stimulants have shot up dramatically in the last few years.