E59: ADHD: Treatments Other Than Medications

[Music] Oh this is your brand new drug, this is from Pongpong City, I have just. So today, back to the season on ADHD, I'm going to start working through a treatment algorithm today and we're going to talk about the non-pharmacological treatments. So first, before we get into those, talk about what are the treatment goals? It's pretty simple, right? So you want to reduce the pervasiveness of the disease, frequency, and symptoms, and degree of impairment, improve quality of life, reduce disability short and long term. I mean, to me, that's kind of a generic treatment goals that you would have with any disorder, right? And then, let's talk about the treatment algorithm and children and adults. So, I'm going to go through in-depth all the medication stuff. So this is kind of how to step through it. And I'm going to talk about the non-pharmacological stuff today. And then, we'll talk about kind of the nuances of how to prescribe, like, what med depict, what dose, what timing, how to change it, like, how to deal with certain issues with it. And then we'll talk about the like 50 different medications. And their little literally are like 50 different, at least, formulations of a couple of different medications. So, with kids and adults, it's a pretty similar treatment algorithm. This is actually adapted from, this is a pretty old 1999, I don't know what this 1999 came from. So it says, "The Texas Children's Algorithm Project for ADHD from 2007." And then I've got the American Academy of Pediatrics ADHD Clinical Practice Guidelines from the Journal of Pediatrics 2011. I think this stuff is still pretty relevant, even though it's been, you know, 15 to 20 years since those dates. So, Stage 1 would be psychosocial interventions and Stage 0. We'll talk about Stage 0 today, the psychosocial interventions and the other, you know, all the stuff that could be out there and what you might want to consider that's not a medication related thing. Then, after you've kind of exhausted that, or that's, you know, that's not working out, then you move into medications. And Stage 1 would be ASTEMILIT. And then Stage 2 would be the other stimulant. We basically have two stimulants. We've got methylphenidate in all of its forms. And then we've got the amphetamines in all of their forms. And there's a lot of different forms that they come in. And we're going to go into depth on that probably in a month or two. When I, you know, get through a couple other things and we've got obesity stuff in there as well. We're flipping back and forth. We'll start talking about those. But for me, it's always first line is either methylphenidate or an amphetamine. And then the second line is the other one. All right. And then I've got Stage 3 here using an alpha-2 agonist or atom-oxetine, which is a norepinephrine re-optagon-hypoderm. But, you know, there's nuance to the stimulant 1 and 2. You might want to change to a different formulation of one of stimulant 1 or 2. You might want to do it longer or shorter acting. You might want to switch to a different form, you know, like Adderol versus Vivant, something like that. So you're not necessarily just going to go, you know, say methylphenidate 1, Adderol 2, atom-oxetine 3. Right. It's more like we're kind of, we want to prove that the stimulant, the two stimulants are not going to work before we move on to other stuff. So, yes, Stage 3. I've got alpha-2 agonist. So that's basically like clonidine or atom-oxetine, Intunive. We'd be in the category Stage 4. We're looking at bupropion or tricyclic. And honestly, I would never use a tricyclic. I don't know if people still do this. They have so many side effects and they're like so like not very effective and there's so many better options. Even, I see bupropion used first a lot of the time and I really don't care for that. Like if you think someone has ADHD, you probably should not be using bupropion first. It's more like something I would use if I didn't know what they had or I wasn't sure or I was using it for another use and thinking, well, it could also help with this kind of thing. I'm primarily looking at ADHD. And then also, am I going to use bupropion fourth? I'm probably going to try and get this other stuff to work first. I never use bupropion for ADHD. Like if I do, it's because I'm treating depression or smoking cessation and I'm like, well, you know, they've got a little bit of minor ADHD stuff going on. So that might be, you know, another thing there. But if I'm like, no, this person's ADHD, I'm not going to use bupropion. There's very, there's very few instances where I would do that or it might be they're coming in. They think they have it, but I'm not that convinced. That might be a time where I use bupropion, but like, I'm never going to like. And then also if they failed at all in methylphenidate, I'm not going to be like, well, they might be appropriate on my work. It's like, yeah, right. If those didn't work, then nothing's going to work. So I have treated this a lot in adults. And I can tell you that I've never used bupropion as a primary treatment. It's always been like I said. All right. And then I've got stage five here. Use something from stage four that you haven't used or a combination. I probably go with the combination therapy, honestly, before I would even go with like, bupropion and I would not use a tricyclic because stage five is saying use something not used in step four. So it's like if you use bupropion, use a tricyclic. Yeah, no, I wouldn't. I'm going to try it. Like, we have so many options on stimulants, so many. I think I like, I mean, we're talking about kids here. I'm going to talk about the adult one. It's a little bit different algorithm, but like, I'm going to be able to find some kind of stimulant that works. I've never not been able to. I've never had a problem with it. I've never had someone that I thought had ADHD. They want a treatment. And I could not find some kind of stimulant that, you know, I'll just, I'm going to address like, why did it not work? If it was ineffective, then something else is really, really not going to work. If it's some sort of side effect or, you know, tolerance issue, I'm going to figure out how to dose it differently or give them a slightly different type of medication that might address that. So we'll probably get into that at some point once we've learned about the meds. All right. So let's look at the adult algorithm. This one came from a CDC website. Probably not up there anymore, but that's where originally came from. So, let's look at the similar stage zero, psychosocial intervention stage one stimulant one stage two stimulant two stage three out of moxatine notice we don't have the alpha two on here. Those aren't, I believe those aren't approved for adults. And I think that's what I think is the most important thing to be recently that they may have gotten some, but at the same time might I consider it? Heck yeah, I might, why not? And the thing, the thing about like, like an alpha two agonist, that might be more likely to be something I add on rather than as a primary treatment. And then I think it was a little bit more likely to be a drug treatment. So I think that's what I think is the most important thing to be able to do is to get a treatment that's not something I would add on. I mean, I'm talking about out of moxatine. I believe out of moxatine don't quote me on this, but I believe it was the first treatment that was approved for adults. And then I think it was a little XR. But I could be wrong about that. I never use out of moxatine. I have. I mean, there's a reason why I never, the things I tell you that I never use, there's a reason why I don't. It's because I've used them in the past and just didn't find them all that useful. And now do I get patients that are on these? Yeah. And what's happening there is another provider is afraid to give the patient a stimulant because it's they're worried about all the potential adverse effects, which I'm not really worried about. And they want to give them something that's not a scheduled substance that doesn't have this potential of dependence. Right. And so I'll get patients that are on out of moxatine. And the thing is you may get a pay. Here's one where you might actually do this. If the patient doesn't want to take the stimulant, if they're like, "You know, I've heard about Adderall, I've heard about Concerna, and I'm afraid of them, I don't really want to take them." I'm worried that I'll get addicted. That's when I'll give them something else, right? If it's not going to be coming from me, I think in the majority of cases, it's coming from the provider that's afraid to give them the stimulant. When we're not afraid to give a lot of other stuff, and in my opinion, these are way less risky. There's probably people out there saying, "You're crazy." It's like, "I've treated hundreds of patients. I've never had people coming in early, asking me for stuff because they ran out of it, or they lost it." I mean, has that happened before? One or two times, and then I just didn't give it to them. You know, I'm very clear. And because it only happened one or two times, I think that maybe they did lose it. But at the same time, I don't want to set a precedent where that's going to happen. I had one guy who was really nagging me about it. I was just like, "This is the dose you're getting. This is how often you're going to get it, and this is how we're doing it." And if you misplace it, or lose it, or whatever, or run out before I think you should have, that's just something you're going to have to deal with. You don't need to take this every day. I can think of one patient I had that issue with, and I dealt with it pretty easily. He was like, on the dot every 90 days, asking for it again, and I'd give it to him. And because I'm in the military environment, which is also useful, these people are closely watched. And so I think his work and colleagues and stuff probably would have noticed if he was like downing the whole thing at once and acting like a crazy person. So that is another reason, like in the military, where I've done almost all of my practice. It's just a lot less risk that people are going to. And not that people in the military don't abuse things. It's just that there's things that they're more likely to abuse and less likely to abuse, and things that will be more noticeable if they do. And I felt very comfortable doing this the way I did it. And still do, because I still do volunteer and see a few patients. And I have actually one patient that I recently started on Adderall. And this is a case. This is a guy who was on well-buterin and Lexapro. And he actually does not have depression and anxiety. He has ADHD. And so I put him on Adderall and he quickly got way better. And then there's all these side effects he was having from these other. I mean, I replaced well-buterin immediately. I basically just. I cross-tapered him from well-buterin onto Adderall XR. And then. I'm weaning him slowly off of the Alexa pro right now. Because he was having adverse effects. We're not really sure if it worked. He did have depression. I think the ADHD had a lot to do with it. I think a lot of psych. A lot of social factors had a lot to do with it. Perhaps it was useful for a period of time. But he's doing better now. But he still has the ADHD. And I'd like to just have him on that. So that's a case of a patient who, you know, was put on Bupropre on for ADHD. It didn't really help that much. And there's something out there that helps way better. And he's doing really good with it. And then I can talk about another patient with the Adamoxetine. Came to me on Adamoxetine. And, you know, didn't really like it. Didn't like the nausea. But said. His comment was, "I don't like it, but I need it." And he didn't want to take a stimulant. I was like, "You know, if you say you don't like it, but you need it, and you're going to tolerate the negative side of it, and you don't want to try something else, that's a patient that I'm perfectly fine giving Adamoxetine too." And so that's. I mean, that's why I put it down third, fourth line. It's because it's not going to work as well. But if you have a patient that, for whatever reason, doesn't do well with the stimulant or is concerned about addiction issues, or you are actually really concerned about addiction issues. And we'll talk about this later. There's actually studies to show that people have addiction issues. Do better if you treat their ADHD with stimulants. Then if you just don't give it to them, then they go out and find amphetamines and meth on their own. It's. It's actually. There's actually a treatment out there for meth use disorder that's a combination of like methylphenidate and something else, to try and get them off of the amphetamines that they're refusing. So that's what I. That's what I experience, and that's what I have seen. There are patients that I will do the Adamoxetino. But we will talk about this more later. I want to get into the non-pharmacological stuff. So other things you can use for adults, but Daphnell off-label, unfortunately, can't really give it to kids because there is some signal of Stephen Johnson syndrome. We'll talk about this later, but that signal doesn't exist for adults. So that is an option. Clondin-guantacine intunidif right is in there. It's off-label. You can consider it for an adult who propryon vinla-faxine. I despise. So, you know, I would never use that. And then disappear. I mean, that's probably my favorite TCA because of the least side effects. But like I said, TCA is for ADHD or just not something that I'm wanting to do. Because it just is just not worth it. All right. Let's talk about the non-pharmacological strategies. Right? Because you've got a lot of folks out there and parents. And remember, this is stage zero. It's always in, you know, over in the obesity section that I'm covering, I'm in lifestyle medicine right now. So this overlaps very nicely. I always prefer a non-pharmacological treatment over a pharmacological treatment. I think it should always be tried first. I mean, unless if it's an emergency type of situation and you, like you need a heavier hitter. But like if you're in an outpatient situation and you've got time and it's not an emergency, it's always best to see if a non-pharmacological strategy will work or at least get us a little bit better to where maybe we don't need as high, maybe we need to use a med, but then we won't need as high of a dose when we get there. So there are non-pharmacological strategies to treat ADHD. And we're going to talk about it today. So first, the lifestyle stuff, right? I don't need to go into this in depth. I'm covering it in depth in the obesity medicine series. So listen to that. It's stuff like nutrition, exercise, avoiding substances. I'm going to talk about caffeine specifically today. As I mean, it's kind of a substance. It kind of falls into the lifestyle modifications. It's kind of a supplement. We'll talk about that. And then sleep, right? Sleep hygiene is so massive in ADHD. People with ADHD tend to have just bad sleep patterns at baseline. Like their brain just does it, right? It's not just the behaviors and what the disorder does to them. It's also just, it's kind of a part of the disorder that they have a sleep problem. And then we're giving a medication, a stimulant, that could then make that worse. And so it's very important to fall asleep hygiene stuff. And the other thing is, a lot of people might look like they have ADHD. But it's really their sleep deprived. Like, you know, and I'll tell you a story about that right now. Patient was sent to me for an ADHD evaluation. I end up determining, you know, because he had all the symptoms, concentration, like all the ADHD stuff is going on. But I'm doing my evaluation. Guys just like, he's waking up multiple times at night. So his sleep is poor. Why is he waking up to pee? Why is a 27 year old male waking up to pee so frequently? I'm not even exactly sure why. It wasn't because he was drinking too much fluids. He had this interesting symptom where he said that, not that it's semi related, but not, you know, have to be 100%. He was a gay man. And he said that when he would poop, he would get an orgasm. And so I had this theory that he didn't necessarily have an enlarged prostate, but that maybe the anatomy of his prostate, because I mean, to have an enlarged prostate, that age just is very unlikely. But maybe the anatomy of his prostate was such that it was pushing against his colon. And then, you know, if you massage the prostate, you can actually cause sexual arousal that way. And then also, if his prostate's kind of like blocking his ability to urinate, it's going to, you know, look like he has an enlarged prostate. So I don't know. I gave him flowmax, tampsilose, the alpha blocker, and just, just out of the idea that the crazy idea that I had that this might work. And it did. He, the concentration symptoms resolved, the sleep problems resolved, the pain all night resolved. I sent him to his primary, I consulted with the urologist and I was like, what do you think it could be going on here? You know, and they were just like, you know, If he's doing better on this med, then keep him on that med. And then I sent him to his PCM to have his prostate kind of physically examined, examined because I certainly wasn't going to do it as a psychiatrist. And they said that they didn't feel like it was like misshapen or like that there'd be, you know, of course we want to screen for cancer, right? Maybe you had some sort of weird cancer that was presenting at a young age or, but they examined it. They didn't find anything wrong. They stay on the flowmax and I sent him back to his primary care and I assume that he's taking that and it's reading his ADHD, right? So, I mean, this is just kind of an example, and especially when you're talking about kids, like if their sleep is messed up because of the ADHD or just because they're not getting good sleep and they don't have good sleep hygiene and they're not sleeping well, they're going to suffer with concentration issues, right? So, this is, that's a huge one. I would say out of all the lifestyle factors, sleep would be the one when we're talking about ADHD that would be the most important. Of course avoiding substances. I mean, if you're taking method night, you know, that's certainly not going to be helping either. Or if you're caught, I mean, if you're taking downers that like, you know, are the opposite of a stimulant, that's not going to help you, right? And then, you know, exercise is so important and I think especially for kids because it's, and especially for hyperactive kids, right? So, you know, if they're not getting that energy out somewhere, it's going to come out in inappropriate places. And this is why, you know, we need recess. When I was a kid, we had PE every day. We had recess every day. And I am still confused as to what has been added to replace that because I see kids doing things in like ninth grade that I was doing in sixth or seventh grade. So it's like, their academics appear to be even slower than it was when I was there. And they're only going to PE like one or two days a week and they never have recess. And their lunch is also like really short. This is a huge beef I have. I think I mentioned this in the previous podcast, but it's like bring back PE, bring back recess, bring back lunch. Kids need a break. They need to get the energy out. I mean, maybe one of the reasons why we're having more ADHD problems is because we're not using some of these lifestyle factors. Our nutrition has gotten worse. We're not letting these kids run around and get their energy out. They're not able to focus. You know, you can't have someone in school all day long trying to focus on things. Even if you don't have ADHD, that's a challenge. They need a break. And they need to be able to run around. And like, this is probably another reason why the obesity rate is going up because like, we're not letting kids exercise as much. So these lifestyle factors are huge, right? You let someone run around more, let them play sports. You know, you get them healthier foods, avoid substances, have better sleep. It's massive. And if you want to learn everything you ever wanted to know about lifestyle modifications, I already have my first episode on lifestyle medicine out from last week. And I'm going to, it's probably going to be about six more of those, all right? Maybe more. All right. Next, social interventions. Okay. So, what are some social interventions? You know, we talked a lot last time about adult ADHD. And I do focus on adult ADHD about like, you know, people in these people were drawn to these particular professions. Remember that was like stock trade or neurosurgeon? Try a lawyer, right? So it may be, you know, get the right job, you know, get the right degree or don't go to college. Be a mechanic, you know, a lot. In the military, what I notice, especially with adults, is that a lot of folks, maybe they had ADHD when they were growing up. And then they, you know, got off of it because you can't join the military unless you've been off of it for like two years or something like that. And then they do fine. And then they're in for a while. They get some leadership positions. They get some admin work. They're behind the desk. You know, they're like an enlisted E6 rank, you know, or E5 E6, you know, fifth or sixth level enlisted. And they're no longer turning cranks anymore. And now their ADHD comes out, right? Because now they're right. So it's like, get the right job. If they were still turning cranks and doing what they loved, like a lot of these people, they really complain. It's like they want to increase in rank because they want more money, right? They want more money and they want more respect, right? They want to call less people like they want to have to like address, they want to be respected by more people. And if you're a higher rank, then you have more people that are under you, which you know, feels better for your status, right? Makes sense. But I think this is part of the problem. It's like, why do we value the office worker and the manager more than the person that is doing the technical work? Like, why do they get paid more? Like, and here's the thing, we often promote the wrong people. We promote the people that were the best at doing the technical work. But these are not necessarily the people that will be good managers. And it's often the people that were not as good at the technical work that actually would be more suitable to be a manager. But then they don't get it because being a manager is a reward. It's like, oh, here's more money. Here's a promotion. Here's more benefits, right? And I'm going to give that to the person that was the superior performer. And it's not that, you know, this person is a superior performer because they try harder necessarily. It could just be because they were better at it and liked it more. And the person that didn't would be a better manager. But then they never get to that place. And so this is a huge problem with the society and the way it works. This is the whole get promoted to the level of incompetence, right? It's like, you just keep getting promoted because you keep performing well until you get in a job that you don't perform well in. And then they keep you there rather than moving you back down to the thing that you actually performed well at. And so, and in the military, it's kind of a problem because it's like, you can't keep turning cranks, you know, as you get higher in rank. I mean, I was in the Air Force before and I was a manager and I absolutely hated it, right? Like, I probably looked like I had ADHD and like I couldn't pay attention to meetings. I absolutely despised it. And so what did I do? I got the right job. You know, I still knew I wanted to be like an officer and I wanted to be a professional. But I wanted to turn cranks, right? Like I wanted to fix computers. That's, but I was supervising people fixing computers. So I said, you know what? If I go to medical school, I can basically be a technician but a professional at the same time. So that was a huge thing that led me into what I do, right? I like to be a technician. I don't want to manage things and go to meetings and deal with all this garbage, right? Like, I'm just not going to do well at that. It's probably why I didn't promote beyond what I did as a physician. But that's fine. I got to continue doing what I like, which was seeing patients and treating patients. And so it's, I mean, it is frustrating and I'm thinking, hey, these people like are less good at treating patients than me, but they got promoted maybe because they did whatever to get managerial positions. And then they're getting more money and I'm saluting them and stuff. And it doesn't feel great, right? But that's the way our society is organized. I'd like to think of everyone as kind of equal. And it's like everyone has their role in society and it's like, we need people doing this. And just because you're doing that and I'm not, doesn't mean that you're lesser than me. It's like, I wouldn't necessarily want to do that. Even if it might be considered an easier job, like, it's not easy for me. I wouldn't want to do it. I would hate it. But you may like it. And so I'm happy that you do because we need people to do that job. And so I think a huge thing with ADHD is. If you have, if people are in the right job and I think that if you have ADHD, there are certain types of jobs that you are going to enjoy more and you're going to excel at more. And you should figure out what that is. Do a search. And I just gave you some ideas. I think a lot of more technical work where you're solving problems with your hands or you're doing for me, solving with my mind, but like, there are like puzzles, right? Which is something that like I enjoy doing or someone else might enjoy it. They might enjoy trying to learn how to fix a truck or whatever. And they don't want to run through a check sheet and algorithm and follow all this stuff. That's boring. They want to get in there, look at how it's, and they can stay in there all day doing that with their ADHD with no treatment, right? So get the right job, right? So next social intervention. Be with the right person. That's another thing. You may love this person and you may be attracted to them, but like, are they someone desudable for you to be with with your ADHD symptoms? That may be why your relationship's not working because like your ADHD symptoms don't mix well with this person. So being with the right person, like, you know, this is why you got to be real careful about getting married. Make sure like, you know each other and they, you want to be with somebody. I think more importantly than anything that accepts you for who you are that's not looking to change you. And, you know, know, don't, and the message out out there at all those other people. People don't change in the way that you want them to change. People can change in certain respects, but in the way that like people in relationships want someone to change, people don't make those type of changes. They are who they are. If you don't like what's in front of you, then leave it. Or if you like something about that person, but don't like something else, accept the thing that you don't like. Say, you know what, I really like these things about this person, but I don't like these other things. They're not going to change. Can I live with this or not? Can I, can the positive qualities they have overruled this? If not, then go to a different relationship, right? And so I think it's really important in any relationship that you accept somebody for who they are. Because, I mean, this is the person you're spending the most amount of time with. Do you really want to be with somebody who you're forcing to not be what they want to be? And do you really want to be with somebody where you're having to change who you are around the person you spend the most amount of time with in order to keep them around? Probably not. And so, I mean, this goes for, this is like relationship advice for anyone, but like specific to ADHD, you know, this person needs to know that what your limitations are and accept them. Okay? So be with the right person. There's educational interventions we can do socially. So this applies more to like school age and college kids. So like, is this, this could be like giving them more time, you know, having like a 504 plan? I mean, is it called a 504 everywhere? And what is it? Individual education, IEP, right? So you've got IEPs and you've got 504s. So this is like, you have a diagnosis and then you can actually get like a little more time for an exam or maybe you get to fiddle around with like a fidget spinner or you can sit on a bouncy ball instead of a chair. I've heard it and seen all kinds of stuff. I don't deal with kids that much. Folks that do know more about that than me, but there's a lot of educational interventions. Honestly, I think it's probably gone a little bit too far. A friend of mine is a professor and she has been annoyed at the level of some of this stuff that's going on out there. I think it's gotten a little bit out of control. We need to have a little bit more uniformity, but I think a certain level of educational interventions for medical issues is definitely needed and that can help as well. And then parental training. So just like kind of educating and then this is for kids so that parents kind of understand what they need to know and deal with to handle and educate and raise a child with ADHD. So those are social interventions. Next psychotherapy, psychotherapy actually works for everything, even schizophrenia. I've even heard of psychodynamic therapy for schizophrenia and people might think that's crazy, but no pun intended. But yeah, it's actually out. I mean, it's not the same, but you can therapy. So meditation can be helpful. Coaching, I'm going to talk about. And then so some of these topics that I've mentioned, I'm going to dive a little deeper into. I'm just doing some broad strokes now and I'm going to I'm going a little bit more into depth into the ones I'm not going to talk more in depth about later. But yeah, once we get to these, I'm going to go more in depth on some of these topics. This is an overview. And then another one, many of you may have heard of EEG feedback. So that's electro and cephalogram. So like that's the thing that you know, neural just used to see if you have a seizure, but like it's like it's a feedback thing where like you see your own brain waves. But from what I've heard about this, it's really expensive and it's not that effective. It's something that's out there. I guess if you're wealthy and money is like, you know, not that big of a deal to you and you want to avoid meds and you've tried a lot of other things, it's something you can consider. I'm sure it does help and work for some people, but I think because of the access and cost of it, it's certainly not something that I would recommend for most. And then there's the trigeminal nerve stimulation. I think most of you have probably never heard of that. I'm going to go into more depth on that later. So I'll just kind of leave that as it is right now. And the digital therapies, another one I'm going to go into detail with later. So I will leave you in suspense for now on that one. All right. Let's talk a little bit about diet. There's a lot of stuff about diet out there for everything. But there's a little bit of evidence for some dietary recommendations. And I'm going to go over what those are. And I mean, I would say eating a healthy, mostly plant-based, whole foods diet and, you know, doing all the stuff that I'm going to talk about in the other season of obesity medicine would apply to 80, you can't go wrong with that stuff. It's just good in general. But specific to ADHD, let's talk about a couple of things. So a few things to avoid. Right. And so this isn't the news a lot right now. The artificial colorings. There is, and this is just in general. And my stance on this is that, you know, do we need these guys? I mean, I don't think there is bad as maybe people make them out to be. I think they're a very small piece of the problem. I would target other stuff before I would target dies. But like, do we have great evidence that they're bad? I mean, maybe a little bit. But at the same time, do they serve any purpose whatsoever? I think, perhaps, I mean, there's some things to say that like a color might help you identify something over something else. And that can be useful sometimes, especially in people that have maybe some perception issues, difficulty discerning certain things. So I've heard about, you know, color being used to kind of help people to know what things are, especially people that might have some sensory deficits. There's also, you know, it can make things more appealing that maybe we want to make appealing. And it's like there are people that have like issues with like eating certain foods and perhaps coloring it might help them to eat foods. We want them to eat. So like, there are some arguments that you could be in favor of food dies in like some small set of the population. But I think in general, dies are used to get you addicted to things that are ultra processed and bad for you. And most of the stuff that has dies in it are things that like I wouldn't recommend eating in the first place. So like, I mean, I say get rid of the foods that have the dies in them and then the dies go with them. And of course, when I say get rid of, I mean, like, if you want to fix your diet and eat healthier, don't eat the foods that have the dies in them because the foods that have dies in them are generally worse for you. I'm not saying that we need to ban them. People need, you know, people should have their choice about what they're going to put in their mouth, but they also need to have the information about how safe or good something is for them. But yeah, I would generally say when it comes to dies, I just don't eat the foods that they're in. And that kind of solves the problem. Am I that worried about the die? I'm much more worried about the ultra processed crap that the food is made out of than I am to die. But, you know, my as well, my as well not eat the die too. But let's let look with ADHD. There is there is some information that artificial coloring can worsen ADHD and cause hyperactivity in some kids. In fact, California, the California Environmental Protection Agency's Office of Environmental Health Hazard Assessment Report of 2021 made such a statement. So there are some reports out there that would suggest that avoiding artificial coloring. And it's not every color either. It's certain ones, but like there is some evidence. So I think if you're trying to do some natural things to help your ADHD or your kids ADHD, I certainly would say nothing's lost by getting rid of artificial colors because you're probably going to improve your diet if you're not eating foods with this in there anyway. And then you're eliminating this as well. And maybe it's a small factor. So why not? All right. Here's another one to avoid. Sodium benzoyte. So since sodium benzoyte, which is a preservative, I believe, rich beverage consumption is associated with increased reporting of ADHD symptoms in college students, a pilot investigation. This is a study from 2014. That was the title of it. So perhaps sodium benzoyte, I like to eat things that are fresh. Don't have it in there. All right. So once again, if you're eliminating processed food, ultra processed foods, you're probably getting rid of sodium benzoyte as well. But there is some evidence to suggest that ADHD symptoms might be worse in those that have a sodium benzoyte rich beverage consumption. All right, next. The effects of a double blind-- these is the name of the trial, right? The effects of a double blind placebo controlled artificial food colorings and benzoyte preservative challenge on hyperactivity and the general population-- a general population sample of preschool children from 2003. So this was one where they were taking both artificial food colorings and sodium benzoyte. And they found that hyperactivity was worse. And it was-- it's marginally worse. But if you're looking to get every little bit of juice out of that orange, why not eliminate these? And maybe there will be a slight improvement. And I think it'll probably better off overall anyway. All right, and then the last thing I have to avoid is-- here's a study-- study's name once again-- associations between exposure to biz phenol A and behavioral and cognitive function in children with ADHD-- a case control study from 2020. So biz phenol A-- it's something that could be in the environment. I'm not totally sure where this is. I mean, this is BPA. There's a lot of these things-- like these chemicals that are in plastics and things like that. I think that's what this is. They did show that there might be some increased ADHD stuff with the biz phenol A. And then let's look at some natural treatments. So these are things to avoid to maybe make a marginal difference. A lot of stuff has been looked at to help with ADHD. And I'm going to give you the list of things that have been looked at, but it didn't really show much benefit. So if you were thinking about using this, maybe you should think twice about spending your money on it to help with your ADHD. Kava Kava, Valerian Root, St. John's Wart, King Cobaloba, Jensing, Lyons main, Multivitamins, Tripdefan, Elkharnitine, Elthreanine, Amino acids. These are all things that are kind of marketed as helping with ADHD. And we just don't really have any evidence that they work. And so I'd probably save your money. But at the same time, if you're taking something like this and you feel like it's giving you some sort of benefit, go for it. I don't think any of this stuff is necessarily bad for you. I mean, St. John's Wart can have interactions with a lot of medications. So that would be one to be careful on. Valerian Root has some serotonergic quality so that could have some effects on other medications. And then Kava Kava, there's some lower grade Kava Kava that has been linked to liver problems. And so you might want to be-- So those three I would just be more careful with because they do have some risks attached to them. The other stuff, the only risks would be if they were tainted or not like what they actually said was on there. But I'm not aware of any risks associated. I mean, ginkgo buloba may have some drug-drug interactions, but the rest of that stuff is not really. So-- And I've got a couple of supplements here that show maybe some evidence. It's unclear. We don't know. But it's a maybe. Melatonin's one. I talked about the sleep. I wanted to get the sleep good. Melatonin might help us sleep in those with ADHD. It might be mostly placebo. It's probably mostly benign. So that's something that you could consider, especially in kids, but don't dose it too high. We'd be in other suggestion. And then magnesium is another one that's being looked at. If you want to know more about magnesium, I have a whole episode on magnesium, particularly all about it, but also about its treatment of depression. So in all the different formulations, so if you're interested in magnesium, just listen to that episode. It might help ADHD, but there's just not enough information to tell us that that's the case. And you know, I just wanted to bring this up because it's in the news. The whole Tylenol thing with autism-- I don't know if you remember a couple episodes ago, or I told you about this study. And it was a 2019 study from Johns Hopkins in JAMA psychiatry and the use of acetaminophenine pregnancy. And not only did it show an increased correlation of autism spectrum disorders between 2.14 and 3.62 times increased risk, ADHD also between 2.26 and 2.86 times increased risk. So you may remember that I actually talked about this report, and it's in the news now. And they're just talking about the autism part, but I also mentioned that the ADHD part was in there. But I just want-- I want to remind you of the qualifiers I said here, right? So the risk of fever that disrupts daily life, the risk of fever or pain that disrupts daily life gives you a higher risk of any of this than the acetaminophenine does. So don't avoid it at all costs, because fever and pain are probably going to affect your pregnancy more. Also not mentioned in the news, but the fact that this study said that they found no correlation for use of up to eight days. So eight days-- it was less than eight days did not show any increased risk. So if you used it for a week total, the correlation was nothing. It was 1.0. There was no correlation at all. Also, those that wrote this paper did not intend to have any kind of conclusions of such a high magnitude drawn from it. The authors actually have stated, we do not believe that a acetaminophen causes a-s-d. So even though they see this correlation, they're not really sure why it's there. They think it's probably not even that. And I've heard that there's some genetic factors that may explain this. But I just wanted to bring this up, because those of you that are listeners to the show may ever remember that I talked about this. And now that it became this massive thing in the news, I just wanted to make sure that I was clear about my stance on it, that my recommendations would be-- I wouldn't use it willy-nilly. I would limit the use, just to be cautious. But I would not forego it if it was needed. If this is what's helping with something you really need help with, especially fever, but pain that's disrupting daily life, and this is going to relieve that, take it. But if it's just kind of like you thought, oh, it's completely harmless, I've got a little bit of an ache. I'll take some Tylenol. But I probably could have just not done that. I think that's a good thing to do in all pregnancy related things, that if you don't need it for something that's moderate to severely impacting you, that you should probably avoid medications in general, unless you actually need it. If a doctor recommends you take it, I would take it. All right, so I just wanted to make that clear, because it does relate to ADHD as well, which is what we're talking about. And so let's get back to diet. So I mentioned melatonin and magnesium, where kind of maybe the supplement that we have the most evidence for is omega-3 fatty acids. I did a whole episode on omega-3 fatty acids, so if you want to know everything about omega-3 fatty acids, go listen to that episode, but I'm going to tell you about this trial in ADHD right now. So here's a title. Omega-3 fatty acids supplementation, but the treatment of children with ADHD symptomatology, a systematic review and metanalysis from the journal of American Journal of Academic Child Adolescent Psychiatry 2011. It was a metanalysis of 10 trials. There were 699 children in the study, in the metanalysis. However, many of the studies were poor quality and had poor blinding, so these were not great studies. All of them. The effect size was 0.31. And the studies that had higher EPA versus DHA actually showed a higher effect. So doses around 750 milligrams of EPA actually correlated with a closer to 0.5 effect size. So this is nowhere near what the stimulants are going to get us, which is closer to 1.0. I've seen everything between 0.65 and 0.8 and 1.0. And even higher, actually, 1.7 I've even seen. So the stimulants-- and we'll talk about that when we talk about stimulants-- stimulants are way more effective. But if you don't want to use stimulants, you want to give your kids stimulants you want to try other stuff, which I think you should do. That's state zero, remember? Omega-3 is something that you might want to consider. And I always say go with the real life. deal. Give them some salmon. We'll talk about Omega 3 rich foods in the lifestyle podcast as well. I'll talk about which fish are the highest. It's not just salmon. It's the smash fish. See if I can remember them off the hand. Salmon, macro, anchovy, sardine, and herring. To me, everything on that list except salmon is not appetizing to me personally. So I go with salmon. It's a little bit more costly. I go with the salmon. We'll talk about that more. So, yeah, Omega 3s is definitely does have effect. So it might not be enough, but it might be something definitely to think about. All right, next, next dietary item. The role of iron and zinc in the treatment of ADHD among children and adolescents, a systematic review of randomized clinical trials in the journal nutrients from 2021. All right, so in this one, we had ADHD symptoms correlated with low iron and zinc. So basically, people that have low iron and zinc seem to have more ADHD symptoms. We don't know if that's causing internaut. It's a correlation. Correlation is not causation. It's interesting. We need to study it more. There were with supplementing iron and zinc, not really anything was shown with iron, but there were some modest effect sizes seen. I don't have the exact numbers for zinc. So a little bit more evidence for zinc. Probably only if you were low in zinc in the first place, and pretty modest, but like if you're low in zinc, you should probably take it anyway. If you want to know about zinc, hey, I had a whole episode on zinc. Look at this. All the things that that I talked about in depression also are the ones for ADHD. We talked about magnesium. We talked about zinc. We talked about omega-3s. These are the ones I think are the most important for mental health. Iron is always important, but as we saw here, iron was not all that useful for ADHD. All right, here's a one last dietary study. It's called the effect of dietary approaches to stop hypertension. That's the dash diet. I don't like this diet because it's low in salt. I just find it tasteless. It's basically the Mediterranean diet without salt, with low salt. The approach with the dash diet on ADHD symptoms, a randomized clinical trial was in the European Journal of Nutrition from 2021. What they did was to diet a fruit, specials, fish, whole grains, nuts, beans, avoiding sugar, salt, saturated fats, cholesterol, refined grains. I'm down with all that except for the avoiding salt piece. Do not take my salt away. Do not take the punk rock psychiatrist's salt away or you'll get bit. That's one thing I'm not giving up as my salt. I will go to my grave with my salt. So yeah, all that other stuff I agree with. Next, the dash diet had significant improvements on multiple parent, teacher, and child related measures of ADHD after three months. There was about a two to three point difference from the control on a 30 point corner scale. Some sort of corner scale was like an adjusted corner. It was like corner scale and there was about a two to three point of course control always gets better too when you can people controls but there was a two to three point. They didn't calculate the effect size which is what I always like to see but there was a difference. So once again, I mean this makes sense to me. I would prefer the Mediterranean diet over the dash diet but like to each his own. This is a healthy diet. I would say it's healthy. I would say it's a flavorless salt, saltless diet but it's a healthy diet. And so you know here we're talking about eating eating healthy food makes sense and it was a marginal improvement, but an improvement. So there is a reason to eat healthy besides weight. It helps with mood depression, ADHD now we're seeing. Right. So this and we're going to see a lot in my other my other season about how it affects mental health. All right. And they also noticed that pro social behaviors were improved and there were few fewer conduct problems as well. All right. And then one more on the diet. So this is a Danish registry study. So the Scandinavian countries that keep track of everybody and everything we get great data from them because they have so many they have so many patients in their studies. So this is a 2025 study so this just came out. I'm at them. I may have mentioned this before in my updates episode. I can't remember. 60,000 mother child pairs assessed at age 10. The child obviously is age 10. And they were given a Western dietary pattern during pregnancy was associated with neurodevelopmental disorder in childhood and adolescents. Western dietary pattern otherwise known as the sad diet otherwise known as the SAD standard American diet a diet that I despise but that I grew up on and loved for many years and I have let go of. So it was associated with neurodevelopmental disorder in childhood and adolescents. There was a significant association with ADHD and autism diagnoses. So moderate shifts along this dietary spectrum associated with 66% increased risk of ADHD and 122% increased risk of autism. Remember correlation is not causation but like why not improve your diet and here this is suggesting that improving your diet could decrease the risk in your child of ADHD and autism. I'd probably like hold off on on the Tylenol if you need it issue but like why don't we why don't we report this why isn't this studying in there you know why is it why is Tylenol in the in the news but like eating a healthy diet isn't could it be because the food companies are strong arming everyone and they want us to eat garbage so they can make more money. Could it be I think it probably is. Tylenol is a big is owned by a big company too but this is just one tiny company with one drug. The food industry is massive. It's massive. It's everything people eat every day right so they probably don't want us reporting this but yes I recommend you eat healthy because it could actually decrease the risk in your child right so this is a mother child pair okay diets high in fat sugar and refined products this is what was in that western diet so high in fat sugar refined products low in fish vegetables and fruit and the association was strongest in early pregnancy so here we go don't give up your Tylenol during pregnancy but give up your western dietary pattern and eat healthy all right all right man I have a lot left to say I'm probably going to have to wrap this up sooner than I was wanting to but I do want to I want to I definitely want to talk about caffeine let's talk about caffeine because my theme song is about caffeine so I have to I have to cover this slide all right so a lot of people they think the caffeine helps with their ADHD symptoms so let's dig into it this could be a supplement hey maybe this you know people say oh I get I get my kid coffee in in their ADHD symptoms or better so how does how does caffeine work it blocks adenosine receptors in the brain and these adenosine receptors decrease dopamine so by blocking them we're increasing dopamine what are the stimulant medications do they increase dopamine and nor pernephrine so make sense it's a different mechanism caffeine is doing a similar thing to the stimulants and hey caffeine is a stimulant this is why it increases dopamine so this is making sense right helps with wakefulness vigilance cognitive and physical performance if you're going to the gym or doing a workout I recommend two things all those crazy supplements that people are selling for like freaking 30 50 dollars it can that last you like a month of those powders you can throw that stuff in the trash or don't waste your money finish it the only thing you really need is creatine and maybe some caffeine all right so also can help with physical performance it can worsen sleep this affects some folks more than others you know people metabolize metabolize things differently they have different issues with sleep some people have no issues with sleep and they can drink caffeine in the evening some people actually sleep better if they drink coffee because I don't know I guess it calms them and it calms them down and helps them get to sleep so everyone's different there was a study that showed 100 milligrams of caffeine worsen children's behavior withdrawal headaches can be severe if you like basically problem is caffeine doesn't last very long a couple hours and then it wears off and then a lot of people get withdrawal symptoms right so all the benefits they're getting go away they can get headaches and especially if you like drink coffee or caffeine every day and I would say coffee is a good thing generally. I'm - I'm - I'm two crores of I don't like coffee personally. I just don't like it so I don't drink it. But like almost every study that I see shows that coffee's good. And in fact, it's one of the only ways that the sad American diet gets any fiber into it. 'Cause people are not eating their fruits and vegetables but they're drinking their coffee and they're getting fiber through the coffee. So if they didn't have their coffee, they probably have even more unhealthy guts with unhealthy gut microbiome and difficulties going to the bathroom and so forth. But there are downsides, right? So withdrawal headaches can be severe. Some people, as long as they have their one or two cups a day, they don't get the withdrawal, right? But some people they get the withdrawal right after and they're drinking tons of cups all day long which is probably not a good idea. It can raise blood pressure by a few points which is similar to stimulants. A lot of people don't like the stimulants, go, "Oh, it raised my blood pressure." Barely. Bupropreon probably raises it more. So the stimulants, they have a little bit of an impact about the same as caffeine. It can work similar to stimulants for attention but tend to have more adverse effects and higher doses are needed than the stimulant for the same effect. So it's like, "Why would you use caffeine when you could just use a stimulant?" They're doing very similar things but you're having to drink more caffeine, more often, more impact on sleep, more side effects, just take the stimulant, okay? And so a lot of folks are on stimulants but they're also on caffeine. And so if you combine caffeine and stimulants they can synergistically cause these adverse effects. And so when you add the stimulant, one reason why they're not tolerating it could be because the caffeine combined with it, right? And so the answer may be, decrease the amount of caffeine. And then sometimes if somebody decreases their caffeine, we may need to increase the stimulant dose to counteract the fact that the caffeine's not in there. So just kind of keep this in mind and caffeine works very similarly but it does not work as well. It just doesn't last as long it causes more adverse effects. The stimulant is, and it causes basically all the same problems and more. And so I would advocate for the stimulant medication over the caffeine but like it's something, everyone's different. If you like caffeine and you're tolerating it well and it works for you, then go for it. All right, I'm gonna make this episode a little bit longer so I can finish this up. All right, so this will be a little bit longer episode. Let's talk about some coaching strategies, right? So coaching is different than therapy 'cause like these people don't have to be licensed therapists. They don't need the masters or grease and stuff. They're just kind of like helping somebody that are like a mentor, all right? I remember on sign felt there was an episode where like this woman that I think George was dating or maybe Jerry was dating and she had like a mentor, kind of which is basically like a coach. And he found this kind of strange and he thought that, and then he tried to replace the mentor with himself and I think the mentor may have been a man. He was threatened. So when I think about coaching, I always think about that episode and then he found that he like didn't like the role he had taken on. But what are some coaching strategies, right? You can coach as the psychiatrist or psychologist or whoever's listening to this show or I can coach you patient who's listening, right? So what are some things we could do? Set up time in your schedule to take care of specific tasks. So people have difficult time organizing with ADHD, they have a difficult time being on time. And so it's like set up times in your schedule to take care of tasks. Like have a schedule, put it in your phone, put it in a planner, whatever works for you, right? Use a planner, stick to the plan. And things that other people might just get to on their own that you don't say, you know, do this thing at two o'clock in the afternoon on Tuesday. And then you knock that thing out because other people, they're just getting stuff done. But you might need to actually schedule that. Okay, there's nothing wrong with that. And in fact, you can become more efficient than those people because you do have this plan in schedule. So set alarms. I mean, I've already admitted to you that I think I probably have touch of ADHD. I don't take medication. I've tried it before. Didn't really work. It kind of felt like it made it worse. So I manage with a lot of this stuff. I have a lot of spreadsheets. Like I've told you before, I'm highly organized. But my highly organized behavior is all like computer assisted. I use databases. I use Excel spreadsheets. I use Word documents. I use the notes in my phone. I have a list. I have a grocery note that says, anytime I see that I'm running out of something or remember I need to buy something, I open it up, I get the note, I go to the grocery note, I add the thing. Every time I'm at the store, I look at the list. That way I, and of course I forget things all the time. And I always kick myself. I'm like, that's why you look at the list every time. You didn't think there was anything on there, but then you forgot that you would add something. And then as soon as I get it, I delete it from the list. So I've got a grocery list. I've got it to do list. I have a check sheet note with the little radio buttons that you like check things off. Every time I take a trip, pack your bag, do your laundry. Do you need a plug converter for the place you're going? Make sure that you've sorted out your garden stuff. And you've prepared for a typhoon, comes while you're gone. I basically have this huge list. And if there's anything specific, like I'm visiting someone and I'm bringing them a gift, I'll add it. I'll be like, make sure you pack this because you'll need it on this trip. And I leave it on there until I've had that trip and then I'll delete that item off. I have lists that I do for everything, because I forget things so easily. And then I have alarms. And then I put things in the calendar. Everything goes in my calendar, my phone. And then I have-- like I said, I have alarms. I use the notes. I use the reminders. The reminders I use for if it's a specific time that I want to take care of something. The note is like, if I'm in the grocery store, if I'm packing or if I'm doing something, it's a check sheet of things to do. And if I adhere to this, I maintain control over this inability to remember anything. I remember to task wise, I remember nothing. And so my entire life is scheduled. I have an Excel spreadsheet for what my activities are all that I do during the month. Anytime I do a trip, I have it all. Like what dates? So you just-- these are all ideas that I'm giving you. And I don't know. This probably sounds overwhelming. But the fact is, you build this up slowly, and you integrate it into your life. And it ends up saving you a tremendous amount of time in the long run. And you have to stick to it, because that ADHD thing in your brain is going to say, I don't need to look at that list. I don't need to check. I've done the list a million times. And then you forget something. Or I don't need to add this. I'm going to remember. I really need it. And then you go to the store, you don't get it. You come home and you kick yourself. And I know it's annoying. And it's like you feel like a baby. But it works. Trust me. When you have the thought, write it down. And write it. And you write it down the form you need. If it's something you need to do by a specific time, put it in something that's going to set off in a lot. If it's something that you need to do when you go to a certain place and you have a check sheet for that, have a note check sheet for that. If it's something that you don't need on the go all the time, don't have it on your phone, have it on your computer, and reference it whenever you're doing something. A task, it's like, OK, I'm doing this task. I'll reference this thing. I made it on my computer and I'll look at it. Because some things are maybe too big or complicated to put it on a phone. So make short term, intermediate term, long term plans. What do I need to do in the next month? What do I need to do in the next year? What do I want to do long term? Have a list of things to do. My to-do list, I haven't broken up by time periods. And some of those things are things are just like, if I get to it, I get to it. These are just ideas. Like, if I'm bored and I don't know what to do and I'm trying to think it's something, I've got it on the list. Oh, let's look at my list. Oh, yeah, I was going to do that. Why don't I do that today? It's not important, but it's something to fill my day. Or I might-- I lost the trade thought there. But just keeping these lists of things that you can remind yourself of. In fact, I should look at my phone right now. I'm going to open it. Right here on the air with you, it's going to be a long episode. So I've got it to do note. I have a grocery note. I have a thing when I go back to the US of products I can't find right in Japan where I live. It's a list of things to buy at the grocery store and bring back with me. I've got my prep for leaving list. I've got a password list. I've got podcast list. This is like when I have ideas about the podcast to put it in there. And then once I put them into my stuff, I take it off of there. I've got to do list with my kids. So it's a shared list. So if they want me to do something, I want them to do something we add that to a list. I've got a cheese I like list, so there's a cheese store I go to, and he makes all these really interesting cheeses, so every time I really like one of the cheeses, I add it to a list, so when I go to the store, I'm like, do you have this one? Do you have this one? That way I always get the cheese I want. I've got a movie list. It's like a list of movies that, when I feel like watching a movie, it's ones that I want to see. Then I've got a phone list of how to call certain kinds of numbers over here. Just to give you an example, and then I've got my reminders. It's to cancel a couple of credit cards by a certain date, so I don't get charged the annual fee. These are just some examples of how to plan your life out and keep it worldly. I have people's birthdays programmed in my phone, so they remind me I have. When I play hockey in there to remind me, all my flights that I take, all of my hotel stays, all that goes in the calendar, and I have a doctor's appointment tomorrow, that's in my calendar. I'll scan the week and see what's in my calendar every day so that I don't forget to do things. I know this may sound insane, but when your brain works the way mine does, and the stimulants just aren't your thing, it's good. Right? So have the planner, use a paperbook, wall calendar, you know, an app, I've got some paper stuff that I'll stick things on, and you know, it's a combination. Figure out what works for you. Another thing is to stay organized, right? Because those are the best with ADHD, and I think I'm probably one of them. We forget things all the time. So everything you own needs to have a place, and always keep it in the same place. That's why it kills me when someone in the house moves one of my things, because like I always have my stuff in the same place, right? So that I do not forget about it. Right? Because I will, and then if I take it out of that place, I better darn well put it back, or I will completely lose track of where it is. So it's really important to kind of organize your space to where you have a place for things and you keep them there. Other strategies, use your words to benefit yourself and those around you. All right, so that's something maybe more to teach younger people, hopefully older people learn that. Automatic bill pays, people that have a hard time remembering to pay bills, use the automatic pays. Anything that you can automate, the better. Reminders and alarms on apps, clocks, smart watches, sticky notes, kind of talked about that, but those are some other ways of doing it. Have things delivered to save time shopping. So if you're like short on time, and it's something that you order a lot, do like the automatic order thing, that way you don't have to forget to get it, and you don't have to waste time going to the store to pick it up. Creating a system for managing electronics. So this would be like not using your electronics all the time. So have a place to put your phone at night and time to turn off electronics, because that's going to affect your sleep. All right, so those are some coaching strategies. Hopefully you glean some cool stuff from that. I just have two more things that I want to talk about. I want to tell you about the external trigeminal nerve stimulator. So this is a device. It's made by Monarch ETNS system. It was FDA approved in 2019 as the first and only medical device for ADHD. It's only approved for ages 7 to 12. You wear it on your head. The trigeminal nerve, medical folks, you guys know what that is. It's the fifth. I hope I got that right. Fifth cranial nerve. It's the sensory nerve of your face. That you know, you can get trigeminal neurology, which is like a chronic pain of the area that that nerve innervates. It's really, really extreme. So you wear this thing. It's connected to a little kind of handheld device. And it delivers low-level electrical pulses. The patch is attached to your forehead. At bedtime, the trigeminal nerve near your eyebrows is a, you know, you've got the trigeminal nerve. It's like three. It's like trigeminal nerve one, two, and three. And the one on the forehead. So near the eyebrows is a significant pathway to critical brain regions associated with attention, mood, and self-control. And so you guys have probably never heard of this thing. Like, how well does it work? Well, I looked at the trial results, but of course, it's probably by the company who did it. It showed a decrease in a scale. And the scale that they, I mean, I don't have good details on, like they don't have the effect size, but what I have is what numbers they went from and to. Right? So folks started that used the ETNS system, started at 34.1, went down to a 23.4. Those that used placebo started at 33.7. So about the same went down to a 27.5. So it's about a four-point difference. So it seems like it probably provides some benefit. So those that don't want their kids on medications, this is another option for you. I don't know how much it costs or like, how easy it is to get this prescribed or whatever. But this is another option. And it, like a lot of the things I've talked about today, none of this stuff works as well as stimulants, by the way, none of it. So this is because we're trying to avoid using a stimulant. What are other options? Right? Are non-medication options that are not as good, but could be enough? Right? Like I said, I think the coaching strategies I told you about are enough for me. So there are some warnings. If they have a pacemaker, active and plantable, neuro stimulators or insulin pumps, it's recommended. It's not just recommended. Don't use it. All right? So that would be something that would permit you from using it. And then let's wrap up with the digital therapies. So this is like, these are like video games that are supposed to help you with your ADHD. There's a couple of them. There's this one called Endeavour RX. So it's Endeavour, but it's like, prescribable. It's a video game. It's FDA authorized. It's for ages 8 to 12. That came out in 2019. And then the Endeavour OTC came out in 2024. And it's authorized for adults. And that one's available in AppStorage without a prescription. But the Endeavour RX, you need it. You actually have to download it and then get a prescription from your doctor and then use that to unlock it so that it works. And I found a study on this. And it wasn't done by the company, but it was a meta-analysis. So it probably includes the studies done by the company. So it's titled "Effects of Game-Based Digital Therapeutics on ADHD and Children and Adolescents as assessed by parents or teachers, a systematic review of meta-analysis from the European Child Adolescent Psychiatry Journal from 2024." And they showed that in their study, medications improved in attention with an effect size of 0.62, which I think is on the low side of what meds actually do, but it's still a pretty good effect size. And the game was 0.28. So, I mean, zero would be no effect. So I mean, it's a pretty low level effect. But like everyone's different. Some kids may get a better effect size than others. That's just the average. And then on hyperactivity, they didn't have something for meds on that one. And it was also a 0.28 effect size for the endeavor game on hyperactivity. So it actually does do something. It's like you play this game and you accomplish these tasks and things. And it's supposed to help your brain learn how to multitask and do things better like that. So another option, right? It's just another option out there. And it might help. And then the last one I have is another digital therapy. It's called Skyler's Run. Also came out in 2019. It's a video game. It's not FDA-clear. It's kind of neat, though. I don't know how good it works. But you wear this thing on your head and you use your own brainwaves from an EEG headset to control this character's Skyler. And apparently that's supposed to help. Hey, I don't know if it does. I don't have any studies on this one because it's not FDA-clear. There's not much information on it. That other study was on the endeavor system. So it was a meta-analysis. So it was a few studies that had been done combined, probably all by the company. But regardless, we talked about a lot of things. And these are probably effect sizes between 0.3 and 0.5 at the best. Which is maybe half as good as meds at best. But hey, we talked about some diet stuff. You know, magnesium, melatonin, avoiding artificial coloring and some preservative. Omega-3 fatty acids might help sink. It's a possibility. A Mediterranean diet or a dash diet. Caffeine we talked about is potential. I actually think it's probably best not. I do not recommend caffeine. We talked about it. talked about some coaching strategies, we talked about the external trigeminal nerve stimulator, talked about some digital therapies, and these are the things I would say that could potentially work. And so there's a lot of options out there, and I think we only think about stimulants, but like if I'm gonna give someone a med, I'm gonna go with the stimulant, but best not to give them a med and maybe try some of this stuff, all right? So today's song that I have selected is Black Coffee by Lesson Jake. I picked this song because we talked about caffeine, all right, that was basically why I picked that song. And it's a great song from, it's from their first major studio album, Pescore. So recommend the band. I've used a lot of their songs. That's an early album, there's like all their stuff. I like the early stuff, they're late stuff, they're great. So I hope you enjoyed the episode, you learned a lot, you really feel like, hey, I'm gonna, I'm gonna give some different treatments out there, and maybe I'm gonna fix my freaking diet and exercise and stuff, and maybe we're gonna get PE back into the school. I'm gonna advocate for my school to put that stuff back in there. You know, 'cause that's gonna help kids. So thank you so much for listening, and I'll see you next time. ♪ We don't make it, but I'm trying ♪ ♪ Wanna sing the name ♪ ♪ That was the meaning of what's in it ♪ ♪ The meaning of what's in it ♪ ♪ Dr. Dan C. ♪ ♪ That was the feeling ♪ ♪ Don't let me, what's in it ♪ ♪ The way ♪ ♪ The way I think ♪