Huberman Lab
Improve Focus with Behavioral Tools & Medication for ADHD | Dr. John Kruse
Mon, 10 Mar 2025
My guest is Dr. John Kruse, M.D., Ph.D., a psychiatrist specializing in treating people with attention-deficit/hyperactivity disorder (ADHD). We discuss the many stimulant and nonstimulant ADHD medications available, covering both their potential benefits and risks. We also explore behavioral approaches to managing ADHD, the key role of maintaining a consistent sleep-wake schedule, and the impact of exercise, fish oil supplementation, and video games on ADHD. Additionally, we examine the genetic and environmental factors contributing to the rise in adult and child ADHD diagnoses and offer various options to consider if you or someone you know is struggling with focus. Read the full episode show notes at hubermanlab.com. Thank you to our sponsors AG1: https://drinkag1.com/huberman Eight Sleep: https://eightsleep.com/huberman Joovv: https://joovv.com/huberman LMNT: https://drinklmnt.com/huberman Mateina: https://drinkmateina.com/huberman Timestamps 00:00:00 Dr. John Kruse 00:02:11 Attention-Deficit/Hyperactivity Disorder (ADHD) 00:05:37 Genetics & Environment; COVID Pandemic & ADHD Diagnoses 00:11:43 Sponsors: Eight Sleep & Joovv 00:14:26 ADHD, Interest & Careers 00:20:40 Social Media & Distractibility; ADHD & Lifespan Effect 00:27:39 Hyperfocus, Flow States 00:33:45 Tools: 4 Essential Behaviors for ADHD; Regular Meal Schedule 00:41:06 Sponsor: AG1 00:42:21 Tool: Regular Sleep Timing; Stimulants & Sleep 00:48:06 Insomnia; Tools: Bedtime Structure, Exercise, Phones, Breathing 00:52:30 Nighttime Waking Up; Cyclic Sighing 00:56:35 Exercise; Addiction, Risk, Kids & Stimulants; Catecholamines & Focus 01:04:32 Ritalin, Stimulants, Amphetamines; Amphetamine-Induced Psychosis & Risks 01:16:46 Sponsor: LMNT 01:18:03 Adult ADHD & Medications; Stimulants & Cardiovascular Risk? 01:26:06 Adult ADHD Medication Choices, Psychosis, Cannabis 01:33:49 ADHD Symptoms, Nicotine; Caffeine, Energy Drinks, L-Theanine 01:43:28 Fish Oil, Cardiac Effects & ADHD, Tool: Fish Oil Dose, EPA vs DHA 01:49:38 Sponsor: Mateina 01:51:04 Gut Microbiome 01:52:56 ADHD & Cognitive Behavioral Therapy (CBT), Tool: Task List System 01:57:52 Video Games, Neurofeedback, ADHD Benefit?, Tool: Technology Restriction 02:02:26 Guanfacine, Clonidine, Hypertension, Effects & Timeframe 02:10:13 Modafinil, History & Forms, Dependence 02:19:02 Drug Holidays; Short- vs Long-Acting Drugs, Addiction, Vyvanse 02:28:56 Time Perception, ADHD, Circadian Rhythm Disruption, Phototherapy 02:35:39 Zero-Cost Support, YouTube, Spotify & Apple Follow & Reviews, Sponsors, YouTube Feedback, Protocols Book, Social Media, Neural Network Newsletter Disclaimer & Disclosures
Chapter 1: What is ADHD and how is it diagnosed?
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. 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. 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. 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
an 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 fancy word as pathognomonic, you know, 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 know, 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?
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 there are typically, you know, 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
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Chapter 2: How do genetics and environment affect ADHD?
But it's high likelihood. 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 it this way. 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.
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 an 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 is 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, I mean, 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 the 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 demand's
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, we know depression is going to go up.
We know anxiety is 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.
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Chapter 3: What are the effects of social media on attention?
that the timing of sleep is 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 your push 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 gonna push things off till the end of the day. Some people, the end of the day is a better time to work because there's fewer distractions. You know, if everyone else is asleep finally, no one's gonna come in and interrupt your work or ask what your thoughts on this project are. But again, getting regular sleep, and regular and sufficient,
doesn't mean it has to be what I'd say normal. If it works for you, if you can build your career and your social life around sleeping from 2 a.m. till 10 a.m. every day, I'd say go for it if you can be consistent with it. So what are the things that help with getting regular sleep? One thing paradoxically for many people is actually being on stimulant medications.
So stimulants do have as a side effect, some people have insomnia, some people stay up later.
But more people with ADHD tend to, either because the drug is wearing off at the end of the day and there's some crash in alertness or energy, or because they're being more productively expending energy and are more tired at the end of the day, or it's just helping synchronize circadian clocks by getting a consistent start early in the day. We don't know the mechanism by which it works.
There's lots of plausible and overlapping ones, but Again, daytime alertness medications can help.
Can I run something by you in that context before we jump back? I don't consistently take stimulants except caffeine, and I limit my caffeine intake to prior to 2 p.m., and I stack it pretty heavy in the early part of the day. But on occasion, I'll take 25 to 50 milligrams of Welbutrin. which, as you know better than I, is slightly dopaminergic, but certainly triggers noradrenergic release.
So epinephrine, norepinephrine, it's a stimulant. On the days when I take that, which again is very rare, and I track my sleep every night, I notice a significant improvement in my sleep and significant increase in my rapid eye movement sleep. It's extremely consistent. So from that, I sort of reverse engineered the major effect being norepinephrine.
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Chapter 4: Can ADHD individuals experience hyperfocus?
Like have for some people it's breakfast, lunch, and dinner for some people like myself, it's lunch, snack, dinner, whatever it is, keeping a regular schedule. Um, Exercise, aside from encouraging people to not exercise too late in the day, certainly not caffeine and exercise late in the day.
Are there any data about specific types of exercise being better for ADHD independent of effects on sleep? I realize they're hard to tease apart.
Yeah, there's a few studies looking at acute aerobic exercise. Part of it is that it's hard to study people when they're exercising during many exercises. I mean, you're not going to wire someone up when they're swimming, for example. Right. So there's not a lot of studies in any one approach, and there's so much diversity that often it just gets lumped together.
So there do seem to be some acute effects of measurably improving some of the executive functions associated with better attention from acute exercise, and there seem to be some more general or longer-term benefits from people who are consistently actively exercising.
having you know being able to concentrate longer being able to switch attention more appropriately or effectively and there's a huge body of sort of clinical literature of patients reporting you know i know i feel much more alert the day i get my workout in the gym in or i feel better or the week i took off from that was a big mistake.
But I would say identifying at what's the most valuable or what's the best duration. I ran through the data about a year or two ago, and I would say that we can't make any conclusions. And I would say at some level, try it and see what works for you. And that's what's important. It isn't what works for everyone.
Is there a relationship between ADHD and addiction because of the impulsivity component?
Yes. And so the answer is, and these are really rough statistics. I actually, one of my pet peeves is people who quote, oh, the rate of this is 27.43%. Well, It might have been in that study, but that's looking at one population at one set. So I use ballpark figures.
The ballpark figure is Americans in the last 20 years, more than that, about 20% of Americans run into some addiction, substance addiction problem, either alcohol or drugs. People with ADHD have a rate that's almost double that, and it's higher in men than in women. Double? Almost double, almost 40% risk.
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Chapter 5: What role does sleep play in managing ADHD?
But even though they were paranoid, even though they were severely impaired enough that each of them wound up in a psychiatric inpatient hospital, which is pretty hard to get into in this day and age or even 20 years ago, they all liked something about the experience enough that they all wanted to get back on. And all of them knew enough to lie about this past.
So they didn't tell me about, you know, they presented. All of them also had ADHD. You know, they presented with ADHD. They'd say, I've been on stimulants before, and I'm not working with that doctor because my insurance changed or they had moved to the area. So they gave plausible histories, and most of those, within a month or two of restarting it, wound up back in the psychiatric hospital.
I had one guy, bright computer programmer, late 20s, calling me from inside the psychiatric hospital to try to get me to prescribe more Adderall to him. And not only that, he had convinced his inpatient psychiatrist that this was a good idea, that this was important to treating his ADHD and helping him retain his job. Wow.
So these are, as you said, straight white males who have psychotic episodes on their ADHD meds and continue to seek those meds because they, quote unquote, like the experience. It feels like a manic high, the high dopaminergic state.
Yeah. And you put the word mania in there, manic, and lots of people define this as amphetamine induced mania rather than psychosis.
I don't because one is uniformly and maybe other people are seeing more that these people were paranoid, they were worried, they were anxious, they were delusional, but they weren't overtly enjoying it, they weren't having a great time, they weren't saying I'm gonna party with all you friends and I'm only worried about the people there.
And yes, they were talking more loudly, they were sleeping less, which could be characteristic of mania, but there was no positive affect that I or police reports or often families give you extensive history of everything that was going on, that there was nothing euphoric they were describing about it.
I mean, I think the second piece is how much of they... It's unclear how much they actually remember or recall or... either through psychological suppression of it or physiologic. They're in a different enough state that didn't register properly. It's not clear. But they tend not to recall the paranoia. And by paranoia, it's persecutory delusions. I have people who,
assaulted family members thinking that they were being spied on, manipulated when they were the parents trying to take care of their kids.
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Chapter 6: How can exercise and diet impact ADHD symptoms?
Do you recall if the study of that device or the study of that video game has a conflict of interest? Was it run by the company?
Yeah. Yeah. So almost all of them have been run by the company. I mean, it's good people at UCSF who are at least partly involved in it. Oh, is this Adam Gazelli's group? I think so.
Yeah. I should just say that I've... followed his work for some years. He's a neuroscientist. I know people who have been in his lab. He's known for doing very, very high quality and stringent work.
Their product and some of the others can clearly show you get better at their product and you get better at tests that look exactly like their product. But in terms of real world, how much is this really helping ADHD symptoms on a day-to-day basis? Not a lot of data at all. So again, that doesn't mean it doesn't work.
And I'm going to go sideways in talking about neurofeedback because there's lots and lots of neurofeedback companies across the country that are making Lots and lots of money. And there was an article in the American Journal of Psychiatry in the last year. I'm not remembering which group did it. And it was another failure to find a significant impact from neurofeedback.
And again, I'm not saying it doesn't have an effect, but I've had lots of people saying, writing me, should I keep spending hundreds of dollars each week because my insurance isn't covering this? And the doctor saying, oh, maybe 20 more episodes will retrain your brain. So this gets back to a topic you brought up earlier, how much are we retraining our brains with immersion in social media?
And the evidence is we are rewiring our brains. So maybe anything pushing in an opposite direction or maybe this is reinforcing some of the bad things we don't want. We're in a messy world without clear answers yet.
I've made it a point to put social media on a old phone. So those apps are only on that phone. I don't even know the number to that phone. If I need to post something, I airdrop it onto that phone. And this has helped tremendously in segregating that activity and limiting it.
It also means that if people send me something which would otherwise direct me to social media, it's much more difficult for me to go look it up. It's helped tremendously. I just pass it on because it's one of the things that's really allowed me to restrict my social media time. And yet still be, you know, in keeping with the fact that I think social media has its uses. I post there, et cetera.
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Chapter 7: What are the risks and benefits of ADHD medications?
Chapter 8: Is there a link between ADHD and addiction?
Yes. Getting back to the scheduling. I mean, what I recommend to people and one of my weakness, I don't know the specific apps, but there are apps that will help shut you out of. Facebook or Discord or TikTok or whatever it is, if you can't exert your own willpower, which again is harder to do if you have ADHD.
And if the app approach doesn't work, the next level up is there are all sorts of companies making lock boxes and physical devices where you can lock yourself out of your device for certain hours of the day. And I think that's a good idea for lots of people.
I do too. And I think it also helps, at least in my experience, to do things that are very different than social media as well but still consuming content. So I make it a point to read from an actual physical book. a bit each day or night. Also, because I was raised doing that and writing by hand, it's just sort of in keeping with the way that my brain was wired.
So maybe that's more specific to me and my generation. But I find that when I'm doing those other activities, when I go onto social media, it feels more like a departure from the rest of life as opposed to the other way around. But in any event- I'd like to talk about some compounds that are not so typical, meaning some people may have heard of these, but most people probably haven't.
And they are somewhat novel to me. The first one is guanfacine. What is guanfacine and why is it sometimes used for ADHD?
So guanfacine and a related drug called clonidine, which can be confused with Klonopin and others. So clonidine and guanfacine are both alpha-2 agonists. So they work on a subset of the norepinephrine system. They're both originally antihypertensive for lowering blood pressure. And it was actually studies first in clonidine that suggested this could be helpful with people with ADHD.
And I think it was just a serendipitous initial discovery. It wasn't seeking out its mode of action to see if that really worked. One difference between the two of them is clonidine jumps off the norepinephrine alpha-2 receptor really quickly. And for people who skip a dose with their blood pressure medication or stop abruptly, it's not uncommon to have rebound hypertension.
And not to smile, but way higher than what you're being originally treated for to dangerous levels. guanfacine leaves the receptors more slowly and there have been formal studies trying to see if this is a problem or issue there.
And particularly given that people with ADHD forget their medication or run out and don't fill it in time or just don't remember to take it, the rebound hypertension does not seem to be nearly as common with guanfacine and that's part of why the research has moved more towards the guanfacine. So there's extensive work by, I'm going to blank on her, Amy Arden, she's at Yale. Oh, Arnston.
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