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Bert Martinez:
Today on the show, John Cruise, MD, PhD John Cruz. Dr. Cruz is a neuroscientist and psychiatrist. He’s been working and helping adults with ADHD for more than 30 years. Dr. Cruz, welcome to the show.
DR. JOHN KRUSE :
I’m delighted to be here talking with you today.
Bert Martinez:
All right, I want to jump into this because you’ve been doing this, like I said, for, for a while. What was the inspiration or the motivation or the catalyst that got you into not just mental health, but this niche of ADHD?
DR. JOHN KRUSE :
Good question. So I had finished a PhD in basic neuroscience. I was actually on circadian rhythms and biological clocks. I had done my medical school and I finished a residency program in psychiatry, University of California at San Francisco. And in four years of training, and this was considered one of the best departments in the country, there had not been a single mention that adults could have ADHD. And then one of the very first patients that was referred to me was a guy who was 40 years old. He was above average intelligence. He was already on disability when I first met him because he had not held a job for more than six weeks.
DR. JOHN KRUSE :
And, and he had held more than 100 different jobs by the time he was 40. And furthermore, his psychiatrist, who was a Freudian, analytic psychiatrist, said, I’ve been working with him for seven years. He’s a smart guy, he’s a nice guy. We’ve made no progress. Could he have ADHD? And he referred, and I’ll call this guy Frank Frank, to the university clinic and they did three days of neuropsychological testing. And they said, if you were an 8 year old boy, you would have ADHD because he’s talking nonstop, he walks around, he blurts things out, he gets off track, he has trouble starting things. But that doesn’t exist in adults Here. We’ll turf him off to you, the young recent graduate of the program, and you figure out what’s going on.
DR. JOHN KRUSE :
There were some elements of depression, there were some elements of substance abuse going on as well. But it was so clear pretty quickly that he had full blown ADHD symptoms and that that was the essence of his inability, is to function well in society. So I had to. And, and right about that time, there were other researchers and clinicians finally getting a clue that, you know, the dogma was every kid who has ADHD outgrows it by the time they’re an adult. Part of why that persisted is how fragmented our health care is that who would the kids see? They’d see either a child psychiatrist or they’d see a pediatrician and when they turned 18, they didn’t see that person anymore. They were out into the world again. If you were an adult psychiatrist and you don’t even think ADHD exists, you don’t see it when it’s in front of you. Started changing right about the time I started working with Frank.
DR. JOHN KRUSE :
And what was striking over the next years was how often people who were often trapped in our mental health system for years with depression or anxiety that just wasn’t responding had full blown robust ADHD symptoms that weren’t being recognized. So that’s what led me to work more and more with that population.
Bert Martinez:
You know, it’s interesting to me that it took so long for adult HDAD to be recognized. It just seems like that would be a no brainer because we know that you don’t always outgrow your childhood, whatever diseases or whatever. It’s just like some people outgrow, what do you call it, the asthma, right, the old asthma inhaler. A lot of kids outgrow that, but not everyone outgrows that. And I even had two friends of mine who, when we were in high school, both of them, all three of us, wore glasses. They outgrew both of their glasses. Somehow their eyesight became 2020 without doing anything and they didn’t need their glasses anymore. I wasn’t that fortunate, but it just.
Bert Martinez:
Did that just strike you as odd that it took so long for people to recognize this adult version?
DR. JOHN KRUSE :
I haven’t ever linked these before, but you just reminded me of something. One of, we have twins who are they just finished college this fall, but one of them, the first two years of her life, was a projectile vomiter. This sounds off course, but when her, when my niece and nephew, who are three years and six years older, came and visited, they actually knew how far to stand, like four and a half feet to be outside of the range. And the doctors never found a cause. It was just. It wasn’t. It was most days, at least some. But my husband and I reassured ourselves it’s like we don’t know any 16 year olds that are doing projectile vomiting like this.
DR. JOHN KRUSE :
She will outgrow it. So are, you know, maybe less so in the behavioral mental health run. But there’s a host of childhood conditions that absolutely people outgrow. But the other bigger thing it sort of highlights is that believing is seeing. If you don’t believe something exists, you don’t see it, you come up with other reasons to explain it, or you don’t even notice it, or you don’t register it. So that’s part of the value of, of recognizing ADHD as a condition because it helps you make sense of patterns of behavior that otherwise don’t make a lot of sense.
Bert Martinez:
Yeah. To me, it’s just so interesting that it took so long to be recognized. And something that you said, which I think something I’ve never thought about, and that is our health system is so disconnected. As you mentioned, you might have a set of providers when you’re in that peak, what is it? Younger age, you outgrow them, but somehow that. I don’t know. I don’t know. If they don’t ask for records or they figure, okay, well, you’re 18 now, so we’re going to start the whole chart stuff over. I don’t know.
Bert Martinez:
But it does make sense to me that sometimes those, those records get lost.
DR. JOHN KRUSE :
Yeah. I think an adult doctor would look at 88, you know, 30 years ago, would have seen ADHD and would have treated it like seeing diaper rash on the chart. Okay. They had diaper rash. They outgrew it. So getting back to. Part of how the field became more aware of it was actually through ADHD clinics where the clinicians at clinics treating kids would notice, hey, wait a minute, I’m also treating kids with bipolar and depression and eating disorders. Their parents are remembering to pick up the medication.
DR. JOHN KRUSE :
Their parents are the ones showing up on time. Their parents are the ones who, you know, don’t miss appointments. And it was finally being aware that. Wait a minute, a lot of these parents. Because there’s a strong genetic component, a lot of these parents of kids with ADHD are displaying ADHD symptoms themselves.
Bert Martinez:
Yeah, that’s, that’s tremendous. All right, so let’s talk about this in case somebody is listening or watching and they’re going, this might sound like me, but so, so what are, so what are the symptoms or what are the traits that we should be looking for for an adult having ADHD?
DR. JOHN KRUSE :
So the official Mental Health Classification Systems criteria for ADHD consist of 18 symptoms, nine of which are inattentive symptoms. So missing details and making careless mistakes because of that. Trying to think. I’m blanking right now.
Bert Martinez:
Real quick. On the, on the, on the mistake there you’re talking about, but this is. You’re talking about someone who’s consistently making these, these simple mistakes. Right. It’s not like a one off because.
DR. JOHN KRUSE :
All of us make mistakes. So part of what’s difficult about ADHD is that all of the behaviors are within the realm of normal, and it’s that they have to be excessive. For that person’s age and cultural group and that they have to be interfering in some meaningful way with life function. So there’s inattentive symptoms, there’s also hyperactive or impulsive symptoms. And with a kid, some of the hyperactivity could really be running around in circles. Most adults, even with bad adhd, don’t run around in circles. But Frank, when he would come in the office, you know, he would often get up and pace around the office. And it wasn’t because he was that anxious, it was.
DR. JOHN KRUSE :
So some amount of hyperactivity can be there. It can be more subtly fidgeting with fingers, drumming on desktops, shaking your feet, things like that, for the hyperactivity. And then impulsivity can include things like blurting things out spontaneously. So it’s the one person when the. At the group meeting, the boss asks for, did anyone have problems with this? And someone will blurt out, yeah, this was really stupid because you did this and this. Whereas everyone else knows, don’t say that to the boss, even if you’re thinking that. So it’s troubles with impulse control. So our diagnostic criteria are these symptom lists.
DR. JOHN KRUSE :
But increasingly, over the last decade plus plus, we’ve been thinking about more conceptually that ADHD is an issue of what we call executive functions of the brain. And the executive functions of the brain aren’t just your memory storage or your knowledge, but it’s how you are handling information. So it’s how you are handling attention. And attention isn’t just sustaining attention for a long period of time, it’s switching it when it’s appropriate, it’s directing it to what’s appropriate in the environment, rather than all the extraneous things other executive functions have to do with. Things like time management have to do with how you initiate a task, how you organize the task in the sequence of events, how you complete a task. It has to do with working memory or keeping that knowledge that you need for the next 10 seconds before you don’t put your lunchbox in the dryer because you’re changing clothes out of the washing machine at that time. So we think of ADHD sort of more conceptually as an issue of executive functions. And a couple things that does.
DR. JOHN KRUSE :
One is that so much of the earlier ADHD research and sort of thoughts about it focused on the kids not doing well in school, or the young adults or even older adults not doing well in the work environment. So it’s sort of productivity organ oriented. And an important part for at least 2/3 of people with ADHD is poor emotional regulation, which is an executive function. But it also brings up the. ADHD has a huge toll on social life. And that starts in, you know, grade school. Again, the kid who’s not paying attention and slams into his classmates. I saw this on the playground when I was a chaperone, that this was a progressive San Francisco school, and they had just started a program about communication and pacifying, aggressive conflicts.
DR. JOHN KRUSE :
And this kid is a girl who was in a judo class, and she was just on the playground not paying any attention, doing some judo moves. And another kid. So both these kids had. Were on the ADHD spectrum. First kid kicks the other girl full in the chest, and half the playground rushes over to start this intervention. What were you thinking of? What could have you done as an alternative? And both kids were completely mystified because both kids got it. I wasn’t trying to kick. This wasn’t anger or aggression.
DR. JOHN KRUSE :
This was, I’m not paying attention to my environment. I’m doing something cool that I like doing. And the other kid was. She’s not angry at me. I just walked into the wrong place at the wrong time. So part of that, again, gets at. If you don’t understand really what’s going on, you’re going to come up with horrible solutions for treating it. And, I mean, it also highlights.
DR. JOHN KRUSE :
Hyperactivity can be a part of ADHD in girls as well as boys, because that’s a common myth that girls are never hyperactive, they’re only inattentive. There’s a third point there, and I just dropped my drop the ball on that third point to. That our anecdote was trying to be.
Bert Martinez:
But that’s all right. Okay, so I want to talk about this real quick, because I think not always, but many times when. When, you know, you have ADHD or ADD or, you know, there. I think there are some hidden gifts. And so I wanted to ask you this because, again, you’ve worked with thousands of patients over your. Your lifespan, your. Your career span there. Have you found that sometimes, you know, that there’s a hidden gift with, you know, with this adhd?
DR. JOHN KRUSE :
It’s a loaded question because some experts particularly yet don’t let. I mean, there’s. There’s a part of the ADHD community that boasts of superpowers, and the superpowers they most often associate with that are creativity or sort of thinking outside the box, which overlaps with creativity. It’s often high energy and enthusiasm, which can be infectious. If you’re really into something that I call the sort of the Eternal Freshman syndrome, where it’s like, hey guys, look at this, this is really cool. I mean, not everyone with ADHD is like that, but it’s a common trait associated with it. Candor is one. And if you don’t want me to go into political situations, I won’t.
DR. JOHN KRUSE :
But I’d say there’s certain, I mean, in the older eras, if you said something wasn’t true or was a mistake, you had a big penalty for that as a politician. So politicians in general tended to be people who carefully scrutinized and were careful of what they said and, and came across as very scripted and controlled. Right. In our more modern era, there’s certain prominent people who seem to be, have multiple symptoms on the ADHD spectrum and they just blurt out whatever at the top of their mind and they’ve used that candor. The difficulty, or my problem with it is that they are blurring candidates. Candor with honesty. You can be completely candid and say what you’re thinking. Doesn’t mean it’s right, doesn’t mean it’s true, it doesn’t mean it’s accurate.
DR. JOHN KRUSE :
But there’s a refreshing quality to that that clearly some politicians have used as a big asset. So candor, I mean, has it cost lots of people lots of jobs and others? So candor. Many of the ADHD traits are sort of double edged swords.
Bert Martinez:
Yeah, Yeah. I think that one of the things that I, that I hear a lot is I can multitask, which I think is I know that people love to use that word multitask, but I think it’s been proven time and time again that you’re not necessarily multitasking. You’re doing one thing and then you’re stopping for a brief second to do something else and then you’re coming back. So it’s very difficult to really do multiple things at the same time. And, and so I think that, but again, I know that a lot of people in the ADHD community, you know, they, they feel that those, that’s a strong suit for them. And, and it, and I could see their point, but I think creativity is definitely good.
DR. JOHN KRUSE :
You know, the research data on the double tasking or multitasking is pretty much along the lines of what you said. I mean, certainly can most of us walk into gum at the same time? Both of those are tasks that don’t require active attention, concentration. For tasks that are requiring active attention and concentration, nobody double tasks. Everyone is switching off and it might be at a microsecond level, but you’re Switching back and forth. And, and virtually every study has shown that’s less effective, that’s less efficient than doing the two together. And there have been studies of people with adhd, and they are actually not any better at multitasking in terms of actual accuracy of results or efficiency of producing things. But part of it is that they may be more practiced at it. I mean, they’re doing it more of their lives because they’re distracted.
DR. JOHN KRUSE :
They may recover better, or they may present to the world better, or they, you know, may be better at signaling, yes, I’m following you when I’m typing on my iPhone under the table. And, and they’re creating the impression because they practice it better that they’re following you. But the actual data, and not that in a lab situation, we’re always capturing everything about real life. But, but they are not any better in study after study at multitasking.
Bert Martinez:
Yeah, and. And that’s kind of what I’ve seen as well. I mean, I, I believe that I probably have some level of hdh, adhd, you know, some of the symptoms you talked about. You know, my leg, My leg is constantly going. If I’m, you know, my leg seldom stops. And, and yeah, so now I want to kind of talk. Talk about. I think now here in 2025, things have gotten a little bit better.
Bert Martinez:
I think that we as a society are starting to be a little bit more tolerant about people who act differently or think differently. But I know for a while there, and I don’t know if you still see this in your practice, there was a lot of doubt and shame and, and just a lot of criticism around adhd. Do you still find that when you work with people.
DR. JOHN KRUSE :
Yeah, it’s still there. And it’s still. There’s even people within the mental health field who just insist it isn’t there, or, I say, even more weird or unhelpful as people insisting and popular authors that there’s no such thing as adhd. It’s all complex trauma. These are all people who have been traumatized. And trauma can cause some of the executive function deficits of making it harder to concentrate, making you more distracted, making you more emotionally volatile. So there’s certainly overlap. You can develop a complete ADHD like, picture from trauma.
DR. JOHN KRUSE :
But we know, one, that there’s a strong, very strong genetic connection to adhd. Two, people with no documented history by not just their own recollection, but family members and others, can have full, robust adhd. Three, and this may sound weird too, but trauma in America seems to actually gone down substantially over the last several decades. And if trauma were causing all of adhd, ADHD rates have been going up, trauma’s been going down, down again. Is there still too much serious trauma than there should be? Absolutely, absolutely. It clearly can’t be used to explain all or even most cases of adhd.
Bert Martinez:
Yeah, I, I just find it interesting that some people still do not accept adhd. Like, like you said, there, there’s some perfect, you know, some professionals out there that, that don’t believe it exists. And again, looking at my family, genetically speaking, my parents didn’t have any ADHD that I’m, that I ever saw. You know, my, both of my parents were academics and, and my dad wrote multiple books. And I bring this up, and my mom was in the. Like I said, she was an academic as well, and she taught me. And, and those tend to require a certain level of, of a, you know, of having good attention spans for long periods of time. And as far as I know, I was the only, I was the only kid in my family that had ADD and then adhd.
Bert Martinez:
And so for those who are listening, yeah, you don’t have to have a genetic disposition. It just happens, right?
DR. JOHN KRUSE :
Yeah. I mean, there are some environmental causes which are tightly linked to it. So one that’s much less of an issue than it was in the 60s and 70s was lead. So in that area era, we had substantial amounts of lead entering people’s lungs and bodies from leaded gasoline particularly. That was the biggest source. But lead paint was another major source. And so in mid-1970s, about the time the EPA tried to pull or and started demanding pulling lead out of gasoline, the average lead blood level in kids in the mid-70s was about 15 micrograms per deciliter of blood. I’ll just say 15.
DR. JOHN KRUSE :
We have lots and lots of studies showing a good correlate. So right now the average level is less than one, and the EPA’s guidelines or level of concern is as low as three and a half. And there’s some experts who say even any lead is some risk. But we can see much higher rates of ADHD as you go from 1 to 15 micrograms. We see other intellectual problems as well. But, but again, lead is one clear environmental factor that make. And again, everyone who had lead in their blood above a certain level didn’t. Everyone didn’t have it, but the rate of developing it was strongly correlated with it.
DR. JOHN KRUSE :
And so environmental exposure, at least to lead. There’s certainly reason to think that many of the plastics are contaminating our World with now also are affecting that prefrontal cortex where the executive function circuitry is stored. So part of it is. And head trauma, the prefrontal cortex, it’s there right in front of your forehead. It’s vulnerable just because it’s head front and center and it’s a big area. And we know that there are some people who develop ADHD symptoms without having previous symptoms as a direct result from head and drama.
Bert Martinez:
Interesting, interesting. Let me ask you this because again, you talked quite a bit about the executive function and our ability to, to focus and regulate ourselves. And I was wondering, in today’s world where social media is constantly pulling, you know, almost kidnapping our attention, how is that altering our executive functions? Have you noticed anything there?
DR. JOHN KRUSE :
So. Well, I am fairly sure there’s a direct cause and effect relationship. Part of what’s hard to tease out is a lot of the studies just establish correlations. So what they show is kids and adults who spend way much greater number of hours on social media or engaged in it, have more distractibility, have greater difficulty sustaining attention. And, and that’s been much of the discussion around it. But there’s even again, these other executive functions like emotional regulation is measurably worse. Impulse control impulsivity is higher in this population. So what’s interesting and getting much less attention is it’s a full range of ADHD symptoms that at least are correlated with higher exposure to social media.
DR. JOHN KRUSE :
And it’s. So part of the difficulty of doing a study is how can you deprive someone of social media for, you know, weeks or months? I mean you can, but then there are a multitude of other factors and ex life experiences they’re missing out on. And it makes it harder to know. Is it, you know, is it actually social media? Is it being disconnected from friends? Is it feeling different and deprived? Is it that of fear of missing out? Is it. But there’s also sort of shorter terms. I mean, so there’s a MIT study that got a lot of attention just a few months back where they had students writing essays on several occasions. And they either did it completely from their brain, that was called one group. A second group could use Google to look things up or as a resource.
DR. JOHN KRUSE :
And third group was looking at, was using AI, you know, large language systems to essentially write their reports for essays for them. And they looked at EEG as measuring brain engagement. And not surprisingly, the group that was most engaged, the group that actually felt most closely ownership of these essays, the group that could remember what they had actually written best, was a group who just used their brain. And the group that relied most entirely on AI was worst at all those categories. And there seemed to be some. So there were acute, measurable effects that there. They could be pretty clear that it was, again, they weren’t segregating out for long term. Over the course of your life, how much time you spent, it was just on this specific task, it seemed directly relevant.
Bert Martinez:
Yeah. That’s interesting. You know, it’s so funny because again, this AI, which you mentioned, large language models, you know, and, and a lot of people are saying, hey, this isn’t real AI. This is as close as we can get now. It, it’ll, it’ll, it’s. As it upgrades, it’ll change either way. I see, I see. It’s going to get to a point where, where again, communication is going to be hampered because it’s going to be, hey, John, I’ll have my AI contact your AI and we’ll get together for lunch kind of a thing.
DR. JOHN KRUSE :
Right. Well, what’s, I mean, in terms of talking, what I’ve friends who are school teachers everywhere, from middle school up through college level, and the ones that have been in the field for a while say, is so striking, is that they’ll walk into a classroom and in your era, in my, my era, growing up, you know, kids are. There might be rowdy classrooms, there might be fairly sedate, but kids are talking to each other, kids are interested and they will go into a classroom and there’ll be 20 kids, if it’s an elementary school or 100, and nobody’s talking to each other. They’re all sitting at their desks and no one’s know. They’re not throwing spitballs, they’re not causing disruptions, they’re just not interacting. And, you know, maybe some of them are interacting even with kids in the same room, you know, via text. But it’s, it’s. We are engaged in a vast experiment which no one’s given informed consent to, and we don’t know how much this is going to be affecting brains and communication and empathy and all sorts of skills like that.
DR. JOHN KRUSE :
I think there is reasonable reason to be worried.
Bert Martinez:
Oh, yeah, absolutely. There’s reasonable reason to be worried. I think everybody should be worried. Okay, so let me ask you this. When you’re working with your patients, what do you tell your patients who are trying to navigate a world designed to distract them every second? Right. So do you tell them to stay away from social media? Do you give them some other kind of advice as far as distractions go? So any Thoughts there?
DR. JOHN KRUSE :
Yes. So I’m a physician so I can and do prescribed medications and there’s and medications for ADHD 50 years of research says are the single most potent intervention in terms of reducing symptoms to the greatest extent and likely to help to the most help the greatest number percentage of people with ADHD and help reduce symptoms to the greatest extent. On the other hand, one, they’re never completely curative. Two, lots of people for very good reasons either don’t want to take them or can’t take them. But again three, they are never the complete answer. So there’s always more that one can do. And the simple message is what’s important is making your environment fit your strengths and weaknesses. And part of what deficits in executive function imply is that it’s much harder for you to generate the structure and organization that other people may be able to generate themselves.
DR. JOHN KRUSE :
So it’s seeking it from external sources. So the two biggest non medication things that I recommend are having a schedule and a task list and learning how to use those. And that can be again particularly challenging for someone with adhd, but particularly useful. And two, in terms of the daily living other stuff, it’s getting good sleep because sleep deprivation itself, what part of the brain is it impacting most? It’s the prefrontal cortex. It’s those same executive functions. Being sleep deprived makes you more distracted, makes you more irritable, makes you more more impulsive. It, it replicates all of the symptoms of adhd. The good thing is you get a good night’s sleep and that’s gone.
DR. JOHN KRUSE :
But given that sleep deprivation itself, by most studies and surveys for the last 20, 30 years, 20, 30% of Americans, adult Americans are not getting adults and adolescents are getting insufficient sleep. So the, the worry is these are all having cumulative effects on the brain. Again, the prefrontal cortex, which houses and some of this I’m oversimplifying a little bit, houses the executive functions is unique in two special ways. One is most of our brain isn’t readily fatiguable. We don’t even think about this much. You look through your eyes, you might be awake 16 hours today, 17 hours at 18. If it’s a long day, your eyes might be tired, particularly if you’re just looking at a screen and staring at a set focal distance. But at the end of the day, colors haven’t started to fade.
DR. JOHN KRUSE :
You’re not seeing fuzzier edges to things. The visual cortex doesn’t fatigue. Same with the motor cortex. It sends signals to your muscles if you’ve Been exercising. The muscles might be tired. They may do less well, but your ability to say, flex this, move my finger here, that doesn’t fatigue. So what’s unusual is the prefrontal cortex, executive function circuits. Most of those are fatiguable.
DR. JOHN KRUSE :
If you are told to pay attention and concentrate on this, that’s time limited. You start failing the longer it goes on. And emotional regulation, too. You may hold it together for the first part of your commencement speech that you’re giving to everyone, and then, but you see enough other people and tears or something, you burst out. So all of our emotional executive function prefrontal circuitry seems to be fatiguable and even more not alarming. But why so many of these symptoms wind up going together is that they bleed more into each other than others, than other parts of the brain. Again, oversimplifying a little bit, but our visual cortex is the back of the head. There’s auditory processing centers nearby.
DR. JOHN KRUSE :
But people don’t start again when they’re tired or anything else. Mixing sound. I mean, there are some people with somatic seizures who are processing information in different senses differently than the norm. But normally you don’t start getting into overlap when one system is getting tired. I mean, you don’t start. Whereas in the prefrontal cortex, if you concentrate too hard or too long and you’ve depleted that system, you’re more likely to have trouble controlling your impulses, and you’re more likely to have emotional regulation problems, and you’re more likely to not being able to switch out your attention when you should need to be able to do that, or you have more trouble estimating time. All sorts of these executive functions are more likely to wind up being affected together, which is why adhd, I think, is a unit, is a helpful unifying concept. But it also means it’s a concept that adhd, like symptoms, can show up under a lot of other conditions, including just stress and fatigue.
Bert Martinez:
Yeah, no, absolutely. And I think I’m so happy, I should say, I’m so glad that you brought up the whole sleep thing, because not only are we all sleep deprived, but I think to. To make things worse, there’s this massive push by marketing companies to push the energy drinks. You know, and. And you hear about again, somebody who down two or three different energy drinks. And when I say somebody, I mean a young person, 17, 16, 17, 18. They’ll, they’ll take two or three pro. I mean, energy drinks, and then they pass out or they’re rushed to the hospital or whatever.
Bert Martinez:
But it’s Crazy how much I see caffeine pushed massively. These energy drinks are pushed massively. And, and nobody’s thinking, or let’s say normal sleep is not being promoted as much as these other, these other alternatives. And so we’re not getting enough sleep. We’re wired on, on caffeine and other energy products. So it’s this vicious circle in the course when, you know, when you’re on energy drinks, you have limited attention span. Right. You’re kind of a spaz.
Bert Martinez:
But it’s interesting to me, I just noticed that in media lately, it’s just been a. I shouldn’t say lately, I want to say for the last 10 years. It’s just, you watch a cop drama and the cops are all swigging tons of caffeine, or there is a show not too long ago where the good guy was, was a computer hacker. You constantly saw him, you know, blazing the keyboards with an energy drink. So it’s just being promoted left and right. And I think it’s, it’s such a terrible combination.
DR. JOHN KRUSE :
I’ll jump back to the sleep part first. And I like when you said enough sleep. But the other key element that we tend to ignore all the time is that the quality of sleep is every bit as important as the amount. So to back up, most adults do need close to eight hours. There’s some variability in some people, but lots of people brag about how they can function well on four or five hours. Every single study that I’m aware of that’s made people who are sleeping that little sleep closer to eight hours. And you do really simple tests, like look at this paragraph, cross out the word the. And how often, how accurate are you? How accurate are you at adding up a string of numbers? These people who felt I’m functioning fine were doing poorer than when they were forced to sleep eight hours.
DR. JOHN KRUSE :
But the other thing, and this is how weekend screw with us, is it’s not just getting your eight hours. So if you’re used to sleeping close to midnight to 8am and hey, there’s a cool party or you’re going to a film festival or something and you’re on Saturday night, you sleep, sleep till noon. You’ve still got your eight hours, but you do not wake up as refreshed or restored when you’re waking up at noon. So the circadian where you. The consistency of sleep seems to be every bit as important. And there’s some research out of my undergraduate and medical school college, University of Rochester in the last decade that identifies probably a big part of that for years we didn’t know what the brain’s garbage system was, how it got rid of chemical and toxic waste. I mean, there’s a lymphatic system in the body and that drains most of the body and feeds into the venous system and gets rid of garbage. And it took them until the last decade to find what they call the glymphatic system in the brain.
DR. JOHN KRUSE :
And the interesting thing about the glymphatic system, I mean, one is it actually involves flushing fluids through the brain which makes connection and the space between brain cells increases, the brain cells actually shrink back. And so there’s less efficient brain going on that time, which is why it’s happening at sleep. But it isn’t just happening randomly during sleep when you shut your eyes, it’s only happening during deep slow wave sleep that’s occurring during normal sleep time. So if you have deep wave sleep during a nap in the middle of the day, your lymphatic system isn’t turning on, you’re not flushing out those toxins. And I oversimplified it a little bit, but again, I’m, I’m trying to make the big point. Being consistent is, is every bit as much as getting enough sleep in terms of quality of sleep. And I mean, not only are we promoting the monster drinks, but there’s still, and it’s particularly a part of sort of bro hacker culture of glorifying, oh, I’m getting by on four hours of sleep. And it’s.
Bert Martinez:
Yeah.
DR. JOHN KRUSE :
Factors that’s associated with developing dementia. I would say getting that good sleep is way better for you than guzzling two or three energy drinks.
Bert Martinez:
Yes. And unfortunately, you know, it’s, it’s, it’s, it’s one of those things that I’ll say the young and inexperienced, they don’t have to go through it, but they’re going through it. You know that, you know, when you’re 16, 17, even in your, you know, 20, you know, you’re, you’re caught up in whatever. Yeah, whatever.
DR. JOHN KRUSE :
And that’s part of ADHD is time discounting is that it’s harder to think of the negative consequences of your actions. Oh, gotcha. See what’s right in front of you. So one of the little tools or tips I use particularly with sleep is I tell people, you know, the next time you’ve pulled an all nighter or slept these weird hours, take a picture of yourself that next morning when you’re looking hungover, when you’re looking bedraggled or spaced out or whatever. It is. And take a picture of you on the night after you have a good sleep day and keep them with you so the next time you’re tempted to stay out late, you can see it. So when pictures are much more evocative, much more motivating, much more emotionally stirring than just telling yourself the lesson and making it personal. So it’s not just a general, people shouldn’t do this, but you can see the effects for yourself.
DR. JOHN KRUSE :
It doesn’t work always, but it’s a helpful, powerful way of reminding people of what they need to be reminded of and they’re not likely to think of in the moment that they need to think of it.
Bert Martinez:
Yeah, I like that idea, I really do. Because if anybody stayed up, you know, or had a, you know, what do you call it yet pulled an all nighter, like you’re talking about the next day, you do feel a little hungover. And yeah, it’s, it’s not, sometimes not a very pretty sight. Especially the older, the older we get. Your, your skin recovers much, much list. Let me ask you this a little bit more. I guess going down this, this practical road, let’s say somebody I don’t know, it’s just being diagnosed. They’re 30, 40, 50, and they’re being diagnosed for, with ADHD.
Bert Martinez:
What’s the very first step they should take, not just to manage the adhd, but maybe the, you know, love themselves or treat themselves with some compassion. So maybe, I guess that’s maybe two questions in one.
DR. JOHN KRUSE :
So back, I mean, the question highlights one thing I tell people. I say, why do we even bother diagnosing this? And I’d say with ADHD and other mental health issues, it’s not that different than the rest of medicine. There’s three big reasons to make a diagnosis. One is so that you understand what’s going on. If you know that your heart pain is not heart pain, it’s indigestion, that’s important. If it’s really a heart attack, that’s important to know too. If you are distracted just because you’re tired, that’s one thing. If you’re distracted chronically because it’s adhd, if it’s in another.
DR. JOHN KRUSE :
If you’re distracted because you’re really anxious right now about this performance, again, knowing the label, that it’s accurate and fitting helps you understand what you’re dealing with. Second thing beyond understanding is prediction. It allows you to predict what’s likely to be a problem. If your distractibility right now is just from fatigue and you’re planning on getting good rest, that’s not a worry. If it’s ADHD and you’re an adult, so, you know, you’re likely to become dealing with this as an ongoing issue. And, and even if you’re ignoring it, that’s one way of dealing with it. But, you know, it’s likely to continue, and it’s likely to have effects in these different dimensions. And then three is treatment and finding treatment that’s specific to that condition.
DR. JOHN KRUSE :
So that’s why we diagnose. So getting back to your hypothetical person, it’s hard for me to give a general answer, because my general answer would be, what are the symptoms that you’re dealing with that are causing most distress or dysfunction in your life? And, you know, for some people, it might be punctuality. For some people, it might be mouthing off to the boss, even though they know they’re right and the boss is wrong. But if that costs them the job, that might be a high price to pay. If it’s, you know, forgetting to bring home the milk and do the other things your wife is counting on you doing each day, and she’s getting annoying, annoyed, and think you’re being lazy. And so, so it’s. The starting point is sorting out what’s going on in your life that feels most in need of fixing and, and then targeting that. And, and that may go any number of different directions.
DR. JOHN KRUSE :
And again, although medication may be part of it, it’s almost never the full answer.
Bert Martinez:
Absolutely. I can tell you there is, at least in my experience. It just came down to the point where I said, okay, these are the things I’m challenged with. You mentioned being on time. That used to be one of my biggest challenges. And so it is very disrespectful. Some people take it as a personal insult when you’re 15 or 20 minutes late constantly. And so, you know, if that’s, if that’s one of your symptoms that you’re dealing with, I just, you know, I made a.
Bert Martinez:
Not only a personal goal not to be late, but then I, I looked at, okay, how can I avoid being late? Well, all right, so luckily, there’s some tools now that can remind you. Okay, hey, your, your appointment is coming up. And, and, and so I have reminders in place. So I leave 30 minutes, you know, earlier than I need to, just because you never know, traffic might happen. You know, you catch a flat tire. I just, I just rather get there early and wait versus the other thing. But that took. I want to say that took a lot of time.
Bert Martinez:
For me to finally wrestle with and find a system that works for me. Right. Because my system may not work for somebody else. You mentioned having a to do list or writing things down. Again, I’m a big believer in doing that, having a to do list. And if I’m in a meeting, especially if it’s going to be a boring meeting, because not all meetings are boring. I found that taking notes works really well for me. So I can focus on taking notes and it kind of helps me keep engaged as to what’s going on.
Bert Martinez:
And again, it’s different for everybody. But I, I know you have to have that. You have to sit down with yourself and, and kind of make a list of the things that are hindering your, your life. And if it’s. And then figure out a system. And, and to your point, medication will not solve all of those things. So if you’re not used to writing things down, medication isn’t going to fix that. And if you’re constantly being late, medication is not going to fix that.
Bert Martinez:
You have to sit there and make a conscious effort to say, okay, I’m going to stop being late. And it takes time. All right, let me ask because. Because let’s see, you’ve been again in this field for 30 plus years. You’ve seen what works and what doesn’t. Since we’ve been talking about things of this nature, do you have any kind of daily practices or mindsets that you found that make a big difference over time?
DR. JOHN KRUSE :
Again, we can re emphasize sleep or just pass on it, but that I’d say is the number one lifestyle component that if you don’t have that in place, even if everything else you’re working at, it’s going to keep undermining you. So there’s a big school of talking therapy called cognitive behavioral therapy that focuses less on feelings and childhood origins, but more on what are the behaviors, what are the thoughts going on, what are the actions you’re doing and how can we regulate them and make them more healthy? And the CBT approach for adhd, several people independently sort of came up with it, that the schedule is the center of that. And if you don’t have a daily schedule, it’s going to be really. And this is, I mean, it’s, this isn’t just an ADHD recommendation. You go to 12 Steps for a successful businessman and having a schedule is there. It’s just, it’s more important for someone with ADHD because again, they’re not generating as well. And what I tell people who are clearly solidly on the ADHD spectrum, I say put the, I mean, most people say, okay, I’m ready. I’m going to put the biggest test day on the schedule.
DR. JOHN KRUSE :
It’s, you need to have what I call the big four on your schedule first. And the big four are sleep, eating, movement or exercise and relaxation, me, time, downtime, because those are all essential to sustainable life. If you’re not taking care of those, your life isn’t going to be working. Well, we talked about sleep. I’ll just say one or two words about eating. You know, I have people who have eating disorders. I have people who consciously are on restriction schedules so they’re not eating. But the only time I have people in the office who are saying, oh my God, Yesterday it was 4 o’ clock and I suddenly realized I hadn’t eaten all day.
DR. JOHN KRUSE :
It’s like, okay, ADHD meter is going off. Some of it is probably less connection with internal body signals, interoceptive signals. Part of it is just getting distracted. Oh, I had the lunch out and I, or even put it in the microwave and. But when the timer went off, I was doing something else. And it’s been there for four hours now. So scheduling hunger. If you’re feeling hungry, you’re behind the ball.
DR. JOHN KRUSE :
Hunger is telling you you’re already operating at a deficit. We don’t eat in society because we’re hungry. We eat to prevent hunger. So having sleep, having meals, physical activity. So one, you know, some bouts of rigorous activity every week is essential to keeping, and I call it activity rather than exercise because even though I, you know, I run a hundred marathons, so I’m a big fan of exercise, but I know lots of people aren’t right, make it fun. So not just some regular vigorous activities scheduled in there, but also breaking up, sitting for more than two hours and maybe even an hour is probably not good or healthy. Even if you’re really focused on this coding problem, or X, Y or Z, you should get up and get your body moving. And then the fourth time is making sure that there is some downtime, fun time.
DR. JOHN KRUSE :
Whether it’s actual meditation, which I think there are good, there’s good value to that beyond just the restfulness of it. So. But meditation is something that’s particularly difficult for many people with ADHD. But actually knowing okay, at 4 o’, clock, when work is over, I really do have an hour to play or watch my video game now helps you focus more on the task between two and four instead of thinking, when am I ever going to get a break? When am I Ever. No, I can’t keep doing this forever. And is it ever going to happen? Oh, I should just do it now. But if you knew. Again, it takes some practice.
DR. JOHN KRUSE :
So I recommend getting the big four in there and then for most people, scheduling happens best as a weekly event or usually on the weekend, mapping out what are the real important either tasks in my own life or tasks for the boss or tasks for the spouse or things I need to take care of for the kids or whatever it is blocking those out. And I usually recommend blocks of time between 15 minutes to 2 hours. So longer than that. Again, most people can’t be productive. Shorter than that, you’re likely to be micromanaging. You know, an hour for many things works, but, you know, if you just need to desperately buy shoelaces, I wouldn’t schedule an hour for shoelaces if the shop is right around the corner. So. So it’s blocking out time and then it’s combining your task list and so some other things about a calendar schedule, whether it’s old school, day planner, pen and paper, or most people these days, it’s a something on their phone.
DR. JOHN KRUSE :
It needs to be mobile. And it needs to be mobile because you might be out there and run across Bill and you want to have a social, you know, get together with them, or you might want to have, you know, be consulting him for work or something. Hey, if you don’t have your schedule, you’re sort of lost and scrambling there. So it should be mobile, it should be simple to use. It’s good if at the end of the day you can at least glance at it so you know what you’ve actually accomplished. Because one particularly people who are we often the things we haven’t accomplished loom larger in our minds and we dwell on those and the things that we’ve already finished. Why should you think of it? It’s done and gone. But that can leave a very skewed assessment overall of what we’re actually getting done or not getting done in our life.
DR. JOHN KRUSE :
So it’s sort of weekly, filling out the calendar and then each morning or sometimes the night before, reviewing what do I really. What’s really important to get done today and what would be good if I get done and what are the things left over from yesterday or others that I thought were essential and still aren’t done that I have to put in today. And. And again, combining the schedule with a task list where the recommendation is, you know, yes, it might be nice to have a list of books you want to read and a List of things you need at the grocery store and to have 17 lists but then organizing consult, you know, which, oh, I took the grocery store list when I was clothes shopping and okay, I gonna buy two pairs of carrots to wear for my daughter. No, that’s not gonna work. So it’s having one task list. And everything doesn’t have to be ranked from 1 to 213 on the list. It’s.
DR. JOHN KRUSE :
It’s sort of chunking that task list into three big components. The A group are the things that are really both urgent and important. They really have to happen today. You know, if you have street sweeping and your car is going to get towed on Tuesday, moving the car on Tuesday has to be on that list. The B list are the things that are important, but they’re less urgent. If it happens today or tomorrow, it doesn’t matter. And the C list are all the everything else. And so often, particularly with adhd, it’s like, oh, I’m not, I’m feeling, I’m unproductive.
DR. JOHN KRUSE :
I can go and buy those shoelaces today. And if you don’t really need them, great, you have the shoelaces, but you didn’t pay the taxes or move the car or buy the wife’s anniversary present and you’re in big trouble because of that. So part of it is, is each day and week making sure that the A, the urgent and important are scheduled or get done and then working on the Bs. And then if there’s time and energy, you can go on to the Cs. And sometimes now the shoelaces might have been item 433, but if you’ve now broken both shoelaces and tied them so much that with the knots you can’t retie your shoes, that one might become an A over time.
Bert Martinez:
That’s right. I like that. But it’s true. I like to follow that system as well. And you know, I always talk about, you know, you’re driving to one of your important appointments and all of a sudden you get a flat tire. The, you know, all sudden that flat tires become urgent and important now because again, life has changed so much. You could, you could pull over and then grab an Uber and, or a Lyft and get to your appointment and worry about the car later. So all of that is, is, you know, you can juggle that stuff around.
Bert Martinez:
But I do, I do believe in having the urgent important. Usually if you take care of those, everything else kind of just takes, not necessarily takes care of itself, but it’s Easier to dovetail right into your system.
DR. JOHN KRUSE :
That’s the big issues.
Bert Martinez:
Yeah, Take care of the big issues. Everything else kind of, you know, settles itself. All right, so again, I want to talk about your book real quick. I want to mention the book. It is called recognizing adult ADHD by Dr. John Cruz. K R U S E Let me ask you this. When somebody, let’s say, gets your book, they go through it.
Bert Martinez:
What is it that you want them to walk away with most? What ideas or thoughts or what would you like? What’s a home run? If somebody walks away with your book and they’re thinking X, what should that X be?
DR. JOHN KRUSE :
So. So one is when it’s. And this is where I might decide to censor some of my response, but that’s okay. So there’s lots of very good books out there for people with ADHD, but most of them are written for people who already know they have ADHD. And my hope was to write a book that would be read by people who don’t usually read mental health books or self help books, and they would either recognize them themselves or others around them that ADHD was really having a role in their life. The subtitle of the book is, the book is Recognizing Adult ADHD What Donald Trump Can Teach Us About Attention Deficit Hyperactivity Disorder. I won’t go into the politics, but in terms of the 18 symptoms of ADHD, and you only need five as an adult, robustly to make the diagnosis, he has more than a dozen of them that are unequivocal, again, not depending on whether you like his politics or not. So my naive thought is, you know, when I was growing up, the mainstream media was fairly a shared community.
DR. JOHN KRUSE :
You know, if, if someone talked about a famous football player or famous rock star, most people knew who they were and knew what they acted like. There’s very few people short of the press in the United States who can say that, you know, I know Taylor Swift’s name. I don’t think I’d recognize a song she wrote. I don’t know if she’s distracted or ditzy or organized or what she’s like, but people. So my hope was that people would be able to see his symptomatology and that would tell people, teach people about that. We could use this as a teaching moment. And again, that, that he would resonate where people weren’t thinking about it or in themselves or others. I mean, it turns out, and maybe with different marketing it might, and it still might turn out differently.
DR. JOHN KRUSE :
He’s toxic enough to many People that it turned off many people in the ADHD community who wanted to say he is nothing like I am. Even though, I mean, part of why I wrote the book was during the 2016 campaign when he and Hillary were both on the stage. People my ADHD patients were saying, she’s organized, she’s calm, she’s methodical, she’s thinking before she’s talking. He’s blurting things out, he’s pacing around the stage, he’s fiddling with his hands, he’s answering irrelevant questions. That’s what I look like, isn’t it? And they’re sort of self revelation and horrified. But that’s what, you know, this is a teaching moment, right? So.
Bert Martinez:
No, I love it. I love it. And so yes, the, the, what do you call it? The, the complete title of the book is Recognizing ADHD what Donald Trump Can Teach Us About Attention Deficit Hyperactivity Disorder. And it’s. I like the book jacket. I’m gonna, when the guys edit this, they’ll put it up here and, and I’m gonna put a link in the show notes. So people want to check out the book. They, they certainly can.
Bert Martinez:
And John, what’s the best website, if somebody wants to know more about you, what’s the best website for people to reach you at?
DR. JOHN KRUSE :
So I, I mean, probably my YouTube channel. So the YouTube channel is under Dr. John Cruz. I have more than 200 informational videos. Most of one or two get into the book and, and the certain leader we just mentioned, but most of them are on different medications for ADHD or scheduling for ADHD. So they’re informative, 15 to 30 minute videos. That’s a free channel. So that’s.
DR. JOHN KRUSE :
And every Tuesday at 10 o’ clock West coast time, I’ve been doing a question and answer session. So people who have questions can call in, write in. It’s writing along the chat and I try to answer them. And they can be ADHD or broader mental health questions or focused on the videos I released that week. I also write on medium.com There is a paywall there, but many of my articles are linked to that from the YouTube channel. So you can get behind the paywall for specific articles. And I’ve just finished writing, it won’t be out till next year, a book called tentatively called the ADHD Spectrum, which is highlighting that although the official definition is categorical, you have ADHD or you don’t. What we absolutely know is ADHD exists on a spectrum of severity and many people slip back and forth between full blown clinical ADHD and sub threshold clinical or sub threshold ADHD.
DR. JOHN KRUSE :
And conditions like head trauma or long Covid or other or new trauma can push them more firmly or too much immersion in social media and computer technology can push people further along the spectrum so their ADHD symptoms are more of a problem.
Bert Martinez:
Yeah, I love it. I love it. So I will I’m going to on the show notes, not only will I link to your book, I’ll link to your YouTube channel as well. Like Dr. Cruz just said, it’s got tons of great information. Now every Tuesday is a Q and A.
Bert Martinez:
Well, I want to thank you so much for stopping by. You know, this is such a neat topic and affects it affects so many people because if you don’t have hd, if you don’t have adhd, you probably know somebody who does who may be affecting your life. And I think, you know, again, putting politics aside, I think Donald Trump is a great example of what we all see with ADH people, DHD and adults. Right. He’s all over the map, you know, and but yet he’s been fairly successful.
DR. JOHN KRUSE :
Part of the last part of my the book you you cited emphasize point that even if you don’t, where if your leader has it, whether you like it or don’t, if you don’t comment on whatever position or comment he made right now, he’s on to the next one. So that is instilling impulsivity, you know, quick reaction time without thinking it. We are in a culture in a time when there are a lot of feedback loops pushing all of us further along the spectrum.
Bert Martinez:
Well, thank you for stopping by. Looking forward to have you back again. Maybe next year when your next book comes out, we’ll bring you back.
DR. JOHN KRUSE :
Great.
