5 Simple Tricks to HACK Your ADHD - Dr James Kustow

Dr. James Kustow 0:00 Don't forget the D of ADHD automatically implies that the person has significant impairment Dr James Kustow

Alex Partridge 0:07 The brilliant mind behind How to Thrive with ADHD I think I'm getting better at unmasking. Do you have any advice for someone who's spent years and years and years pretending to be someone that they're not?

Dr. James Kustow 0:19 When you are super sensitive to rejection, there are personality shifts that take place, and they fit into three main categories as far as I can see. One is people pleasing. You don't wanna ruffle feathers because you don't wanna get rejected. The other one is avoidance. If I don't do it, I won't be judged on it. If I don't go to the party, no one will reject me. The third one is perfectionism, and I think that is to protect yourself from being judged negatively

Alex Partridge 0:42 I know for a fact that there, there's gonna be lots of people listening, nodding their head at what you just said. But what's the solution?

Dr. James Kustow 0:48 One of the solutions is, uh, and when you stop beating yourself up and not feeling guilty all the time and shameful all the time, there's nothing to feel shameful about

Alex Partridge 0:58 This episode is dedicated to anyone who can give someone their perfect eye contact or their undivided attention, but never both at the same time. [upbeat music]

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Dr. James Kustow 3:34 My pleasure. Good to be here.

Alex Partridge 3:36 I'm incredibly excited about this episode because your book, How to Thrive with Adult ADHD, I think is going to genuinely help so many people. Um, and I'm excited to hear you share some of your tips today. Before we get into the meat of the episode,

Alex Partridge 3:53 I want to reveal your ADHD item.

Dr. James Kustow 3:57 Okay.

Alex Partridge 3:57 I ask all my guests to bring in an item that most represents ADHD for them, and you've chosen an owl.

Dr. James Kustow 4:07 A night owl.

Alex Partridge 4:08 A night owl.

Dr. James Kustow 4:09 I have indeed.

Alex Partridge 4:10 So we're gonna talk about that a little bit later on.

Dr. James Kustow 4:12 Okie dokie. [laughs] That's fine. I'm enjoying seeing the rest of the items here. It's great.

Alex Partridge 4:16 These are all the p- items of past guests, and the owl will, will, will join those.

Alex Partridge 4:21 Is there a displacement of energy in someone with ADHD in which they use energy in places that a neurotypical person might not? And is there a knock-on effect of their physical health because of this?

Dr. James Kustow 4:35 It's amazing. You know, I talked, um, well, I think it was before we went on, on camera, but, uh, I have developed a model for understanding ADHD, I think much better than the existing model which we use, which is actually the model that we use to diagnose ADHD, which is different from how best to understand it. Uh, my model's, um, called the den- 10 domains of dysregulation. It's basically understanding ADHD as a, a, a disorder. Um, and I use that word cautiously. I think, I believe that ADHD when it's, when it causes problems is a disorder. I know a lot of people don't agree with that. I also see it as a, I can see it in a, from a sort of social construct perspective as well. But, um, you know, I, I often see people who have a lot of disorder in their lives. Um, but when you see it as a, a, an issue of regulation, and I've, like, highlighted 10 separate domains that get dysregulated, and one of them, interestingly, the last one, is energy expenditure and arousal. And again, it's an area that we don't really talk about a lot in ADHD, but many people with ADHD have a sort of boom and bust pattern. They, like, really push it hard and that the brakes aren't on again, and then exhaust themselves and then crash. I'm always amazed actually at the staying power of people with ADHD.

Alex Partridge 5:58 [laughs]

Dr. James Kustow 5:59 It's unbelievable. Um, but without a doubt, the way energy is managed, um- Partly because of the excitability and the impulsivity and the hyperactivity and the dysregulation, it all feeds into, uh, dysregulated energy, uh, the way the body deals with energy

Alex Partridge 6:19 The, the boom and bust cycle there you mentioned, very relatable. I think m- lots of people listening will have, you know, a graveyard of domains. They've, uh, got very excited about an idea, a business project, whatever it might be, a new hobby, perhaps spent a fortune, but the energy has fizzled out. They've gone all in, but they're, uh, they've been unable to sustain that momentum, and there is humor there occasionally, but I think what we see is a lot of shame and a lot of guilt when that pattern repeats-

Dr. James Kustow 6:51 Mm

Alex Partridge 6:51 ... especially as, as you enter into adulthood and you sort of can see this trend, this boom and bust cycle, and you lose confidence in your ability to, to see anything through because you've got all this evidence behind you.

Alex Partridge 7:02 Have you s- seen undiagnosed ADHD impact a person's mental health and their, their, consequently their physical health?

Dr. James Kustow 7:10 Have I seen it? I think ADHD that, don't forget the D of ADHD automatically implies that the person has significant impairment, and that impairment, f- functional disturbance, that impairment can be in a whole wide range of domains, and it, it's, you know, it's often expresses itself in the form of other mental health problems. There's a characteristic cluster, depression and anxiety disorders and other neurodevelopmental disorders. But without a doubt, and particularly untreated ADHD, I think that people use up a huge amount of energy to stay on par with their peers, their colleagues. They, um, will stay up much later at night to get work done, and there's a huge amount of energy used in masking. And I, I, I don't know anyone with ADHD that doesn't really relate to that concept of masking. Now, in your teens and your 20s and even in your 30s, that energy expenditure, that sort of extra compensatory, you know, um, energy usage, uh, you know, is absorbed. It's like you can cope with it. But I think as you get towards the end of your 30s and into your 40s, I think the strain starts showing in lots of people.

Alex Partridge 8:36 When you were talking about masking, I was reflecting on my own journey of what I now know to be masking, and I look back and I can see infinite occasions where I completely change who I was, shape-shift, m- completely mirror someone's personality, their interests, their tone of voice sometimes. There was no awareness of self, really, and I think the consequence of that is you don't have any self-confidence, because how can you have self-confidence if you don't know who you are? I'm, I think I'm getting better at unmasking. Do you have any advice for someone who's at that stage in their journey? They, they, they might just be coming aware that they've spent years and years and years pretending to be someone that they're not. They're exhausted. They want to peel back some of the layers. Where does someone start when they're at that stage?

Dr. James Kustow 9:34 First of all, I think it's better to think of, well, like, you know, the ana- an orange is the analogy. Rather than layers, like taking the orange peel off and revealing the true self, I'm much more excited the concept of segments, that you have different parts of yourself, and in different situations, you express those parts, um, in different ways. You know this feeling, you know, when you're with certain friends, you're really funny and you can, you know, and other friends, you're really serious and depressed. [laughs]

Alex Partridge 10:03 [laughs] Yeah.

Dr. James Kustow 10:04 Um, so, uh, I think very, very often this, this, uh, these mini traumas that people collect along the way, um, in a life with ADHD, unrecognized ADHD, many of those traumas are underpinned by s- an exquisite sensitivity to rejection. And I think, um, this is only just emerging now as a thing, and it, it's not actually a thing yet either because it's not been studied or proven in any shape, but it's a concept, rejection sensitive dysphoria, and I think one of the, the reason I'm bringing it up now is because when you are super sensitive to rejection, I've s- I've noticed, I've seen, I've experienced that there are personality shifts that take place, and they fit into three main categories as far as I can see. One is people pleasing, and you get into the habit of taking the leat of re- le- the route of least resistance. You don't wanna ruffle feathers, you don't wanna... Because you don't wanna get rejected, so you make it really easy for the people that you're around, and you neglect your own, um, needs. The other one is avoidance. If I don't do it, I won't be judged on it. If I stay away, if I don't go to the party, no one will reject me. The third one is perfectionism, and so many adults, so many, everyone with ADHD, [laughs] um, will understand this, th- this idea of needing to get it really perfect, and I think that is to, to protect yourself from being judged negatively. And I think over time these cause problems. Like in the short term it feels like, um, the right thing to do. You know, you protect yourself. But what I've learned is that any time there's a fear or a phobia of something and you avoid it in whatever way, the phobia grows, the thing gets worse. And I think, um, I think the simply understanding that sensitivity to rejection issue goes a huge way to sort of make, ah, this is RSD And then suddenly you can avert it, you can pick up the early signs of it, you can, um, you can actually share that you have this funny thing, uh, with, with people. Because otherwise you go, you spiral into this, either this sort of dissociated, freaked-out state that can last for hours, full of anxiety or cut off, or get really angry with yourself for letting yourself down or with other people for shaming you or showing you up. It's a really big problem, and I think so many of the, um, so much of the emotional baggage that gets collected along the way is linked to that. And it's amazing, the emotional symptoms, the emotional dysregulation symptoms of ADHD, they're not even in the criteria for diagnosing ADHD. That's how unfit for purpose they are.

Alex Partridge 12:59 I know for a fact that there, there's gonna be lots of people listening, um, nodding their head at what you just said and thinking, "That's me."

Dr. James Kustow 13:06 Mm-hmm.

Alex Partridge 13:06 And this is probably a very oversimplified question, but what's the solution?

Dr. James Kustow 13:12 One of the solutions is knowledge, understanding that this is what happens. Um, uh, and look, I think it's about surrounding yourself with people who get you, um, and establishing a really solid mindset, and I refer, it's the first of seven pillars. It's, um, basically, uh, nurture a growth-oriented mindset. So you need to know that you're gonna trip up regularly with ADHD. There's no doubt about it. You're gonna have mishaps and mistakes and, and I think how you deal with that is so important. If you pick yourself up and go, "Oh, well, there you go. My- that's my ADHD again," and dust yourself off, and then stride on confidently, having learnt a lesson, that I'll do it differently next time. And most importantly, I will not beat myself up. I'm not gonna give myself a hard time, and I'm also not gonna tolerate anyone else giving me a hard time. And I'm definitely not going to use it as an, ADHD as an excuse. If people really need to understand why I messed up, then I'll explain it, I'll explain it, but not excuse it. So, um, having a really, uh, a, having a mindset that, that never, ever cr- ever self-deprecates. There's no self-deprecation, um, in my life anymore, ever. And it's one of the first things I'll teach the people I work with, is it's just not acceptable to just, those little art- you know, th- those, um, what's the word? End of, end of a little sentence, "Oh, I'm such an idiot," or, "What a fool," or, "Oh, there I go again." It's none of it. It's not, it's just not good for you. And when you stop beating yourself up, you start carrying yourself with more pride and not feeling guilty all the time and shameful all the time. There's nothing to feel shameful about. You know, this different brain has pros and cons, and, um, you just need to learn to work with it, like any instrument.

Alex Partridge 15:22 The rejection sensitivity dysphoria, for me, it's been, at various stages of my life, completely debilitating.

Dr. James Kustow 15:31 Mm-hmm.

Alex Partridge 15:31 And I, like you, don't like the word disorder, but there are some times in my life, relationships, jobs, family encounters, that in those situations, because of RSD, it has been very disorderly [chuckles] and very debilitating. If someone's relates to that, and they really struggle in their relationship with rejection or perceived criticism to the point where it really causes explosive arguments, real big problems, if someone's in the, in the moment, they've just been triggered, the partner's, they've taken something, a comment the wrong way, do you have any advice for someone in that very specific moment, just as they're feeling that intense internal visceral reaction?

Dr. James Kustow 16:15 Hmm. So I think it's important that the individual with ADHD and their partner have discussed this issue and learnt about it first. And then the moment it's activated, even to have, like, a co- [chuckles] a code word, just to sort of flag up, "I've been, I've been triggered." I, I often will, like a switch, "I've been triggered. I'm gonna, I'm gonna take some time out." Changing state, like changing room, going outside, getting fresh air. Not set, not like closing down the issue. Saying very clearly, uh, you know, "We need to talk about this, but I'm, you're not gonna get the best of me right now." Go and have a state change. Glass of water's sometimes quite good. I really like tapping, um, a technique that I introduce in the book, um, for regulating emotions is, without doubt, without doubt, all my years of learning so many different approaches, it's the, it's the most quick and effective tool for changing your state. I will go off. I will go off somewhere quiet. I'll do some tapping. I'll breathe. Um, and I'll come back. But what's really also very interesting about this scenario you describe, and it, I mean, relationships, uh, are complicated anyway, but a relationship where one individual has, um, ADHD or, or, or other forms of neurodiversity can be super challenging, and very characteristic patterns develop. Um, but the, um, the, one of the most important things to recognize is that when, uh, when people with ADHD get aroused in a sort of angry way, in a stressed way, that adrenaline that's being released is actually treating their ADHD in a, in a slightly unhealthy and, um, inefficient way. But that burst of adrenaline that comes with the anger and the shouting- It might not feel very nice in that moment, but the calm after the storm's what they're after. And they have no idea that it's not about the dustbins. It's about recognizing unconsciously that by getting aroused or angry or into an argument, that in about 15 minutes later, I'm gonna feel focused, regulated, and calm. And again, once you know that, then you can s- stop yourself from using up all that energy, and, you know, you don't really wanna be activating your stress system continually in order to treat your ADHD-

Alex Partridge 18:51 Mm-hmm

Dr. James Kustow 18:52 ... which unfortunately is what a lot, a lot of people

Dr. James Kustow 18:54 do.

Alex Partridge 18:55 And the people pleasing piece, um, you mentioned people pleasing before. Again, I know it's a, um, a big topic within the community. I think many people would probably want to get better at saying no and, and putting boundaries in place to, to build some kind of fence of, of, of self-love around themselves.

Dr. James Kustow 19:15 Mm.

Alex Partridge 19:15 Do you have any advice for someone who wants to get better at, at, at saying no, putting boundaries in place, being less of a people pleaser?

Dr. James Kustow 19:22 Sure. Well, I think it develops because people fall into the trap of thinking that if I say yes, if I take on this project, you know, I'll somehow make up for all of my previous inadequacies, and they won't see me in a bad light, and I'll prove it. But what actually happens is a very clear message gets sent to the other person that you're, you're allowing yourself to get sort of walked over. You're not standing your ground. You're not putting up boundaries. And not everyone, but some people will take advantage of that. And I think right from the very beginning, and this, this is also a mindset thing, you've got to, you've got to respect yourself and respect your views and respect your ability to say no maybe, but, or to take time out, sleep on it. That's my little line. Take ti- take a moment to sleep on it, to reflect on it. Try not to get into that impulsive, "Yeah, I'll do that." I always pause, and I say, "Okay, let me have a think about it, make sure I've got all the right information, come home, discuss it with my wife." And very often it will be, "No, it's not a good idea. [laughs] It's not a good idea."

Alex Partridge 20:34 [laughs]

Dr. James Kustow 20:34 "Definitely not a good idea at the moment." [laughs] So yeah, and it's a, a mixture between getting the mindset right, loving yourself, but also not f- falling to the belief that you're in some way repairing your, your previous mistakes.

Alex Partridge 20:50 Mm.

Dr. James Kustow 20:50 It just doesn't work.

Alex Partridge 20:52 I- in your practice, um, do you notice a theme in terms of the time of life someone comes to you, um, suspecting they might have ADHD?

Dr. James Kustow 21:03 Mm.

Alex Partridge 21:03 Do you notice a theme in, in what sort of age range do you see a s- a s- concentration of people coming to you in?

Dr. James Kustow 21:08 I do actually. End of the first year of university, and I know not everyone goes to university, but just the concept's important. And it's very much because someone who has just lived at home and gone to school and then perhaps, you know, finished their s- their A levels and then is, is perhaps going off to university, is leaving a very scaffolded environment. Schools often, you know, y- a lot of structure, and you're told what to do and when to eat, and meals are provided. And at home the same thing happens. Mom or dad washes your clothes and-

Alex Partridge 21:45 [laughs]

Dr. James Kustow 21:45 ... makes your meals, and then suddenly you're off to a random room with a shared kitchen and, and, uh, gradually over the first year, things just deteriorate. Uh, sleep goes off, use of substances and alcohol goes up, work doesn't get done. Um, and then when it comes to those final exams, there's a massive decompensation. And often the individual will say, "I'm just not gonna do the exams." And then it becomes, "So what are we gonna do now? Are you gonna repeat the year? Are you gonna try and catch up?" So often people will present at that time, and it really, really reinforces how important the environment is, how important the structures around you. You know, if you have ADHD and your internal world is quite chaotic, your job is to create the structure and, and the stability around you because internally it's lacking. The regulation's off. So you gotta prov- you gotta have external regulation in some way, systems, structures. You gotta have, you gotta have a, you gotta have a day that's, that's balanced and that's got order and that's got routine in it as well. Habits are very important in ADHD. Now, when you, when you try and ma- change behavior and bring in a new habit, a new, something to change, it, it very often fails. You know, you do it for the week or, especially in ADHD, do it for a week or two and motivation goes. Um, but when you do manage to bring in that habit, and I think the concept of habit stacking's really, really useful, the idea of taking an existing habit that's in place and latching onto it a new habit, which is really, really effective, by the way. Um, when you start building more and more routine in, like your morning routine and your evening routine, and one thing's linked to the other thing, linked to the other thing, suddenly you've actually only got... Well, you've set up your morning and your evening, you've only got a limited period in between to order and manage in, in a different way. And that's like blocking time and how do you deal with tasks? So I think, um, bringing in more structure, but it's gotta be structure with variation. If it's just too structured and routine and boring, you'd get bored of it as well. So I used to change the way I went, went to work when I got a bit bored. I work one day i- in an office, in a, like a clinic, and one day at home. I just, you need to have variation. But you also need to have structure. And I think the more rooted in you can have certain healthy habits, including mealtimes and downtime and exercise time, the more routine it is, the more likely it is to hold. And, um, so yeah, that's a big piece.

Alex Partridge 24:45 Mm.

Dr. James Kustow 24:45 That's a really important piece.

Alex Partridge 24:46 The, the whole university piece I find fascinating because I went to university. When I moved to university, it was almost like the scaffolding, my support structure around me had fallen apart. I no longer lived with my parents. I no longer went to school where I was told where to be. I had to go to class. When, when I went to university, I, I fell into social media, and I became obsessed with that, but I could not focus on my university work, and I got kicked out within the first year. But I've spoken to a lot of people with ADHD, and including yourself, who have a degree, have qualifications that many people would look at and think they're super impressive. So what, what is, does, has someone like you done differently in that environment of university that someone like myself didn't do well in?

Dr. James Kustow 25:33 Um, I worked bloody hard. I, I, I worked so hard, and I worked so much more than other people. I didn't know, I didn't know I had ADHD then, so I just couldn't really under- I actually didn't think I was bright enough, and I just had, had to work much harder. What I didn't realize that my mind was just drifting off, and it was taking me longer. A- any reading was just really hard work. Needed to have multiple highlighters and annotating as I went along with arrows coming out everywhere. I recorded it, sang it. I made mnemonics. I, I found every possible-

Alex Partridge 26:06 Mm

Dr. James Kustow 26:06 ... strategy for trying to reduce or minimize my symptoms. I also took a significant amount of Pro Plus.

Alex Partridge 26:13 [laughs]

Dr. James Kustow 26:14 I don't think Red Bull was here at that stage.

Alex Partridge 26:16 [laughs]

Dr. James Kustow 26:17 I could only get it in Thailand at that time, I think. But I took a lot of Pro Plus. Um, [laughs] I had no idea why I needed so much Pro Plus, and that I needed to work through the night before all of my medical school exams. And it really, really hit you when I had two exams a day for the whole week 'cause you just couldn't do that all-nighter thing. So I think it's a combination of working really hard, really struggling at times, um, balancing, um, really putting a lot of emphasis on sports. So I played a lot of rugby. And for me, I didn't even know at the time, but that was my way of just releasing energy.

Alex Partridge 26:53 Mm.

Dr. James Kustow 26:54 Um, but it wasn't straightforward. It wasn't straightforward. I knew what I was good at and what I wasn't good at, and I did a bit of masking. I tried to excel in the things that I was good at, and I really just scraped the barrel in the other areas. And, uh, yeah, I think a lot of, uh, I did that throughout school as well. You know, impairment shows in all sorts of different ways. For, for me, I mean, uh, I don't want, don't need to go into all the finer details of, of, you know, h- where the struggle's been, but it was, you know, there was social, social challenges at various stages. Um, I, uh, you know, I'd, I'd get, I'd get completely absorbed in things and then move on to the next thing. But over time I started, even though I had- didn't have a name for it, I was just permanently working on it and just not being able to, yeah, hiding it, really working on it really, really hard. And I don't think it, it became that much easier. The struggle was there, and that energy use, as I said, was fine then. I could deal with that. But later on, I started feeling it was taking its toll, and that, that was the main reason why I thought, well, when I worked out what it was, I thought it's absolutely appropriate for me to treat this.

Alex Partridge 28:23 Mm. I think, you know, it's one of the biggest myths I think that's great to debunk is that people with ADHD, uh, just need to work harder. And I think like you've just perfectly explained with your experience of university, we work bloody hard, [laughs] often harder than a lot of people to achieve the same results, even if that's just masking. The amount of energy and-

Dr. James Kustow 28:42 It is

Alex Partridge 28:42 ... and hard work that requires just to, just to stay at base level, um-

Dr. James Kustow 28:49 But that hyperfocus, I just, I mean, I never understood. I could literally just zone in for hours. It's just not good for you to do it-

Alex Partridge 28:57 [laughs]

Dr. James Kustow 28:57 ... this intensively that long. I wouldn't recommend medical school exams-

Alex Partridge 29:00 Another Pro Plus

Dr. James Kustow 29:01 ... to many people with, with ADHD.

Alex Partridge 29:03 Why is ADHD, do you think, so objectively hard to prove to a cynic who might not think it's a legitimate diagnosis?

Dr. James Kustow 29:12 Well, I think everyone knows what the experience is to be a bit inattentive. Everyone has been, at times, impulsive or distracted, and it's not like psychosis. Um, you know, delusions and hallucinations are clearly abnormal features. When you see something like that, you see that there's an issue. It's about degree. It's about how problematic, um, these, these features of inattention that, you know. I think, I think people think just because it's not an abnormal type symptom in itself that it must not be true, but it's about the degree, the severity, the persistence, the recurrence, how intense, how disabling it is. And it's very interesting to see how this cluster of features comes together. When you look at the criteria and you think, "How do these things all link together?" And I, I didn't really understand how they link together for a long time. It's all about regulation. It's all about that every symptom in ADHD or every feature of ADHD can be explained through a dysreg- a model of dysregulation. Whether it's sleep, you know, the circadian rhythm is dysregulated in ADHD, biologically dysregulated. The immune system in ADHD, there's increasing evidence that there's immune dysregulation, um, higher levels of allergies and autoimmunity and sensitivities and food intolerances. The sen- the sen- sensory processing system's dysregulated. The reward system's dysregulated. Every single symptom in ADHD can be understood in those terms. Um, and it makes it much easier to communicate about what this thing is because rather than saying s- attention deficit, well, what about the people who can hyperfocus for six hours? It's not just attention deficit, and so it shouldn't be in the name. But if you s- see it as a dysregulation of attention, you can explain both the attention deficit and the hyperfocus. It's just too much regulation or too little. Brakes on too much or brakes off.

Alex Partridge 31:34 Mm.

Dr. James Kustow 31:35 You know, the problem with hyperfocus is not that you can't latch on, it's that you can't detach.

Alex Partridge 31:40 Yes. [laughs]

Dr. James Kustow 31:41 And it's a really, I mean, as well as being an amazing tool if you know how to use it, it's a highly impairing symptom.

Alex Partridge 31:48 And if someone distracts you when you're in the middle of a hyperfocus-

Dr. James Kustow 31:50 Very angry. [laughs] Very angry, yeah.

Alex Partridge 31:52 The rage.

Dr. James Kustow 31:53 Yes. [laughs]

Alex Partridge 31:54 [laughs]

Dr. James Kustow 31:55 So might not be able to get back in.

Alex Partridge 31:57 No, exactly. It pulls you away from it. So i- i-

Alex Partridge 32:00 you must get frustrated then if, if, if you hear someone say ADHD doesn't exist. What would you say to someone who says that?

Dr. James Kustow 32:07 Well, as a discrete entity, I don't think it does exist. I think it's a constellation. It's on a spectrum. It's a bit like blood pressure. This is a great answer to your previous question as well. You know, we all have a pressure in our blood system. Um, at some point, when it reaches a certain point, it becomes problematic. Um, and then you have hypertension or high blood pressure. The cluster of features that presents, uh, as ADHD, you know, features of dysregulation, a- at some point, it becomes problematic. And, uh, the fact that this very characteristic cluster forms, that you see it, you see the same sorts of difficulties in a particular group, tells me that it's a thing. But is it a discrete entity which has one cause and one, uh, you know, one model to explain it? No, I think it's the final common pathway of potentially lots of different things. Um, things that involve the physical body much more than we think that it does. I mean, we understand it's very centered on the brain. There's a lot of evidence to show it's a, it's a, it's a brain disorder, but it's also a very systemic problem. And I, and I know that because I've spent the last 15 years looking at the physical health comorbidity, the physical health problems that cluster together with ADHD, and I've discovered some crazy stuff.

Alex Partridge 33:40 S- so out of everything you've learned about ADHD and all of the new research you've done,

Alex Partridge 33:44 uh, what are the three biggest myths around ADHD that you would like to debunk today?

Dr. James Kustow 33:51 Well, there's the obvious ones aren't there, that it's, like, an invented condition for pharmaceutical companies, um, that it is a childhood disorder, a childhood, it's childhood bad behavior, it's poor parenting. I mean, these things are just ridiculous. You know, ADHD is actually the second most genetic m- m- mental health condition. It's far more genetic than depression. It's literally, it's, I mean, the how genetic something is, you know, is measured, is measured with a sort of statistic. It's a s- it's a heritability. It's a, it's a percentage or it's a... And ADHD's, like, way up there in the 70s. Um, so it, it's very genetic, which means that, uh, but that those genes might be coding for all sorts of different things and not just the neuropsychiatric expression. But same genes might be causing 50% of people with ADHD to be hypermobile, to have lax joints, to have abnormal connective tissue. That might explain the whole lot.

Alex Partridge 34:57 Mm.

Alex Partridge 34:58 With, with your patients, do you, do you notice a, or do you diagnose a change in their mental health after you've given them a reason for certain behaviors in their life?

Dr. James Kustow 35:10 Enormous. Like, that, that... Well, the, normally what happens is they have a light bulb moment way before they come to see you in the clinic. They either watched something or read something or put the pieces together. I had that moment in my own story. It was quite a profound moment, and then it was months before I actually got into f- uh, by that point, people have done their research and they've learnt about it and they've understood it and they're, um... So there's different stages. Actually getting the diag- realizing that it's probably what it is, is one stage. It's an amazing thing. Wow, it all makes sense. Getting the diagnosis, you know, it's often been quite a battle to get there. You might have been on a waiting list for three years and, um, and it's, it's, it's a validation that you, it's not your fault. [laughs] It's not your fault, and that this is to do with genetics and body and brain. Um, and then often if people decide to go down the medication route, that moment where their brain is regulated for the first time, because that's what the meds do, they boost up dopamine and noradrenaline across the brain or, or in the frontal part of the brain, which is basically pumping energy into the regulatory centers of the brain, and they go It's like putting glasses on for the first time. That's a profound moment. And then often people are in this honeymoon phase where they think, "Oh, I'm gonna be fine now. It's gonna be perfect. I- I've got, you know, I've got my diagnosis, I've got my meds, and, uh, you know, it's all gonna be fine. I've sorted it." But it's not fine because it's... You know, meds are effective, but there's a whole load of extra work to do. And actually, that discrepancy between where the meds can take you if you take meds and actually what it takes to live really well and to thrive with this thing is a big jump. And within a health service, a health system where there's limited resource, it's absolutely appropriate that the focus should be fir- at first on diagnosis and at least offering medication, 'cause we've got good evidence to show that it works very well. But to think that's the job done is like madness. That's why I started the group program, because it's resource, um, light, but very impactful, and you have an opportunity to look at all these different areas that are really important to work on in a social setting. So, um, and I, and I recognize that some people don't want to and don't, uh, can't tolerate meds and don't want to take them. And so there has to be an approach that, um, is, is very nuanced and comprehensive and very targeted towards you as an individual and your needs, your sensory needs, and your sleep issues and your nutritional issues, and it's very tailored, but, uh, it takes a lot of work to get there.

Alex Partridge 38:20 I wanna talk about executive dysfunction, um, what it is, how people can understand it, and how people can thrive-

Dr. James Kustow 38:27 Mm

Alex Partridge 38:27 ... with it. Um, but first I wanna draw attention back on the owl and-

Dr. James Kustow 38:33 The night owl

Alex Partridge 38:33 ... ask you... The night owl. [laughs]

Dr. James Kustow 38:34 [laughs]

Alex Partridge 38:34 Yes. Sorry. It's that, that memory.

Alex Partridge 38:37 Um, night owl. Why is a night owl your ADHD item?

Dr. James Kustow 38:42 Because so many people with ADHD go to bed late, one. There's a few things. They go to bed late, right? And they might do that because they're distracted and can't turn the series off or they're, you know, appreciate the quiet of the late of night. But one of the main reasons they do it is because their circadian rhythm, their sleep-wake cycle, is literally shifted. Imagine you could take the sleep point and the wake point, and you just pick it up and move it across an hour or two. An hou- an hour. About an hour. That's literally the case. So, um, people with, with ADHD will naturally usually want to go to bed later. And though it's interesting, those late night hours, um, people can sort of get lost in all sorts of different places there. Um, and it has a real knock-on effect because the rest of the world lives on Neurotypical time, and work starts at 9:00. Now, if you're going to bed at 2:00 and you're having to get to work at 9:00, you will be accruing a big sleep deficit, and that has a huge impact. Some people even believe that that might be primary in some people, as the primary cause. You know these pathways leading to ADHD? The sleep, the sleep disturbance might be the main central issue, and everything builds off it. The other reason that I think the night owl's a good analogy is because of this wide-eyed, you know, alert, scanning the environment, you know, the, the, the owl that's look- And this wide-eyed thing, we don't really, uh, discuss it enough, but individuals with ADHD often have autonomic nervous systems that are imbalanced. People who don't know what the autonomic nervous system is, it's the n- one of the main, one of the top, I think one of the top three stress systems in the, in the body. But it's this balancing act between, on one side, the stress system, the sympathetic nervous system, and the parasympathetic nervous system, and they're literally i- in a, an opposing force. One is adrenaline, stress, fight or flight, and the other one is the relaxation, regeneration, recovery, relaxation. And individuals with ADHD have higher rates of dysautonomia, which is dysfunction of the autonomic nervous system. In its most profound form, dysautonomia is linked to something called POTS, postural orthostatic tachycardia syndrome. But for many people, dysautonomia presents with, uh, dizziness and lightheadedness on standing, particularly when it's hot or coming out of a bath, fainting more often. It's a sign the autonomic nervous system's not functioning optimally. Now, when you are, when your autonomic nervous system is imbalanced towards the stress side, you're gonna be hypervigilant, you're gonna be wide-eyed, you're gonna be scanning your environment for threats. And I think that sort of image of the owl scanning can actually go quite a long way to explain, again, in a different way, the, um... It's not sensory now. It's, it's stress, it's threat, it's protection, scanning the environment. And this is where trauma and ADHD overlap, because when you're traumatized, you're also left in this perpetual height- hypervigilant, threat-focused state. And I think there's more overlap between these two things than we give credit to. We know that trauma is integrally linked to ADHD in many people. There's evidence to show that early deprivation and- And, um, uh, uh, like, well, various forms of adversity in childhood, uh, can, can drive an ADHD picture. And the third reason I think the owl, like, I like the idea of it sort of flighty. You know, jumping off and-

Alex Partridge 42:54 Mm

Dr. James Kustow 42:54 ... moving on to the next tree.

Alex Partridge 42:56 Yeah. [laughs]

Dr. James Kustow 42:56 So I just thought it captured it really nice. And you've bought a beautiful, shiny blue and red, gold owl. Very happy.

Alex Partridge 43:02 Well, I wanted to, to, to put the, the effort into encapsulating the, the item for you. And that's a brilliant description. I'm just trying to work out where it will g- go in the, in the-

Dr. James Kustow 43:10 [laughs]

Alex Partridge 43:10 ... on the shelves overlooking the studio.

Dr. James Kustow 43:11 Does it have a light inside it or...?

Alex Partridge 43:13 Uh, it does, actually. I've taken it out, but I'll, I can put it back.

Dr. James Kustow 43:15 Yeah. [laughs]

Alex Partridge 43:15 But I'll put it there for now.

Dr. James Kustow 43:17 Oh, nice.

Alex Partridge 43:17 Next to the bath and the beer.

Dr. James Kustow 43:19 [laughs] Lovely. Excellent.

Alex Partridge 43:21 I wanna do the ADHD-

Dr. James Kustow 43:22 It'll be a drunken owl then

Alex Partridge 43:23 ... drunken owl, yeah, and have a bath afterwards.

Dr. James Kustow 43:24 Sitting in the bath. [laughs]

Alex Partridge 43:26 [laughs] That's a weird visual, isn't it?

Dr. James Kustow 43:28 Yeah.

Alex Partridge 43:29 I wanna do the ADHD agony aunt section.

Dr. James Kustow 43:31 Okay.

Alex Partridge 43:31 Um, which is called The Washing Machine of Woes, because my item is the washing machine because I always forget my laundry in the machine. Do you forget your laundry?

Dr. James Kustow 43:41 Um, I, uh, I u- I used to when I did the laundry. My wife has realized that, uh, we don't like smelly clothes 'cause I used to leave it always in, on, in the washing machine, and I just can't bear it. But-

Alex Partridge 43:53 Well, I should say, I also used to, before I started using the Tiimo app, which is our sponsor, every week I ask my Instagram community to send in, send in their biggest woes, their biggest ADHD woes. It goes in the Washing Machine of Woes. Um, and I read it out.

Dr. James Kustow 44:07 That's quite a good description of, like, the ceaseless mental activity of, uh, of ADHD.

Alex Partridge 44:12 Yeah, we thought so.

Dr. James Kustow 44:13 The washing machine.

Alex Partridge 44:13 Yeah, yeah.

Dr. James Kustow 44:13 Nice.

Alex Partridge 44:13 Good visual, I thought. Um, so this week, someone's asked, "My partner has ADHD, and it's apparent in the way he is so emotional, which can come out in arguments as aggression. He, however, is a creative and would refer to this as passion, but it's really in, in ... But it's really interfering because I find it intimidating. How can I explain this to him in a way that isn't demeaning?"

Dr. James Kustow 44:38 I think this c- touches back to where we went earlier when we talked about the emotional dysregulation and rejection sensitivity 'cause the chances are... First of all, I think it's, uh ... I th- I think the, the last q- bit of the question's interesting. How can I explain this to him in a way that isn't demeaning? I think he's got to be doing a lot of work-

Alex Partridge 45:02 Mm

Dr. James Kustow 45:03 ... to try and make sense of it as well. But it's very likely that he is getting passionate, as it's described, um, when he's getting triggered. And, um, it's very likely that it's a perception of being sidelined, teased, rejected, told off, told you're not doing something right, and he's reacting. Now, some people shut down and zone out and numb out and can't talk. And other people get really, really anxious visibly. And some people get angry, and I think that anger, um, is very often linked to this rejection sensitivity. I think also the regulation, um, disturbance, uh, I think often l- leads people, including myself actually, if I'm being honest, not realizing how loud I'm speaking or how excited I'm getting.

Alex Partridge 46:04 Mm.

Dr. James Kustow 46:05 Um, and I think to have that sort of quiet discussion, like, before it gets into the argument phase, there's a little, little sign that the non-ADHD partner can give to say, you know, like, "Maybe we're getting a little bit overexcited here." And they've had the discussion that this is the pattern that happens, and this is what it makes me feel like, and I know you don't mean it, but this is how it, how it manifests. And to try and stop it happening in the first place or nip it in the bud or detach. But I think the ind- the person with ADHD needs to shift, um, to, to try and work it out themselves. Uh, it sh- if, if they're not doing the work, then I think the partner has a right to be a bit upset. It's, you know, it's ... You gotta be able to take feedback and work with it. You know, when you get told something, you know, you get told something that's difficult to hear, it's very easy to get defensive, to take on the victim role, and to start, you know, before the person's even finished, telling them why they're wrong and you're right, you know? And it's like, okay. I've learnt more and more to listen. This is like, I've got a section in my book about communication and some really top tips about to really listen, uh, to not try and win 'cause compromise is, is the only way. Um, not wait to speak, but really listen. And when you hear that you've overstepped the mark, and you, you ... One knows when they've made a mistake or gone too far. And I think when you, um, you know, when you screw up, you've ... I think it's really important to own it. Say, "You're right. I'm really sorry. [laughs] I didn't mean to." And it just immediately diffuses. It immediately diffuses. So I, I think owning, apologizing. Now, what happens if the other person doesn't accept the apology or carries on the argument? At that point, you can say, "Okay, I've done my bit. I've really, I've made my effort. I'm not going to hold any of that, I'm not gonna hold, take any of that now because I've, I've really, I've reflected." And not, and not just, not just sort of doing it for word's sake. I've ... You know, you've gotta really mean it.

Alex Partridge 48:29 Mm.

Dr. James Kustow 48:29 And you've gotta reflect and think, "Okay, I'm gonna try to do it differently." Strategies. It's all about strategies and planning and preempting, um, but also owning and not, not hiding and not walking away from those situations with any resentment You clear it, you discharge it as much as po- of course, you're gonna have situations where you take resentment forward and you can't help it. But as much as possible, deal with it, own it, apologize, and discharge. Because you c- you go through life holding onto these charges, these mini traumatic things that aren't cleared. They produce illness. They will coalesce and cause mental and physical illness and addiction, and they'll wear you down. And it, and it's l- it's like you can think of tr- big traumas, but you can also think of these mini micro traumas. So I think as... I don't like to carry anything forward that's got a negative charge attached to it, ever.

Alex Partridge 49:31 Truly fascinating.

Dr. James Kustow 49:32 Mm.

Alex Partridge 49:33 Thank you so much for answering that so well. [laughs]

Dr. James Kustow 49:34 Okay. [laughs] Good.

Alex Partridge 49:37 As if by Hollywood magic, your book has appeared on the table. [laughs] Um, a, a, a big theme in the book is, is executive dysfunction. Um,

Alex Partridge 49:46 very briefly, what is executive dysfunction, and how do I know if I've got executive dysfunction or if I'm just lazy? And how can I explain this to my partner, who might just think I'm making excuses?

Dr. James Kustow 49:58 Hmm. It's a good question. So it confuses a lot of people, executive function and executive dysfunction. So, um, I like to describe executive function as all the different cognitive or brain capacities that are needed to achieve a goal, to make something happen that's not immediate. The, it needs various facets of, um, of, uh, brain function to do that. You need to be able to hold information in mind, you need to be able to stay connected, and you need to have this sort of future perspective and pace something, put, you know, organize it and manage it, and put these pieces together with this endpoint that's down the line. Problem is that the main issue in, the main executive dysfunction in ADHD is affecting the ability to achieve goals down the line. It's to do with the future. So that's why people with ADHD are often very in the moment.

Alex Partridge 51:04 Mm.

Dr. James Kustow 51:04 Um, and that can be great in some ways. I think it's quite interesting, the in-the-moment thing, because you also sort of forget [laughs] stuff from the past, and, uh, I, I think that, um, can be quite interesting. I think that's one of the reasons why addiction's quite problematic in ADHD, 'cause you forget the reason why you've stopped something. You just sort of forget. You're too in the moment. So, um, what I'm saying is that this idea of delaying gratification and seeing something that needs these various steps is interrupted, and really, the overarching problem that describes all the executive function issues is called inhibition or disinhibition. That is the brakes. If you don't have brakes, you can't stay with things. You get distracted. You can't hold off something that's rewarding now to have a later benefit.

Alex Partridge 52:02 Mm.

Dr. James Kustow 52:03 You can't-- You're impulsive. So, you know, you're working on this thing that you... for next week, but something shiny comes up over there, and you're off. Uh, you-

Alex Partridge 52:12 [laughs]

Dr. James Kustow 52:13 So all of the symptoms of ADHD, the, the hyperactivity is usually, the brakes are on, is usually inhibited. But when the brakes are off, when there's disinhibition, it explains all of the symptoms of ADHD. So a very simplistic way of understanding executive function is it, that it's characterized by disinhibition, a problem with inhibition, that results in difficulties in achieving goals over time. And it pretty much explains all ADHD in one go.

Alex Partridge 52:48 Very relatable. [laughs]

Alex Partridge 52:50 If, if someone's listening and they relate, like I heavily do, to what you just said, and they come to your practice and they say, "I don't just want to manage and survive with my ADHD, I want to thrive-"

Dr. James Kustow 53:01 Thrive

Alex Partridge 53:01 ... "with it," um-

Dr. James Kustow 53:02 [laughs] Read my book.

Alex Partridge 53:03 Exactly, yeah. [laughs] What tools could you give that person, um, that's, that asks you that question? How can you thrive with ADHD?

Dr. James Kustow 53:13 Well, I think it goes back to what I said before. It's about mindset. It's about lifelong. It's about a commitment to, a commitment to growth, personal growth. Um, I think it's about clearing trauma, because it's really hard to thrive when you're carrying baggage. So clearing trauma, and there's very powerful and effective ways to clear trauma, and interestingly, they, in my experience, the best ways of processing trauma involve the body and some sort of body stimulation, whether it's tapping or eye movements or shaking. Even walking's very good, actually. Um, so, um, I, I think that, uh, having the right mindset, commitment to lifelong change, and looking after, like treating yourself with respect is the foundation. And then there's, there's an incremental build from there, and that's exactly what the seven pillars are. The first pillar is nurture a growth-oriented mindset. The second pillar-- Go on, you guess. What do you think is the next most important thing to get right in ADHD? Once you've got your mindset sorted, what would you go to first?

Alex Partridge 54:25 Gosh. Self-awareness?

Dr. James Kustow 54:27 All the self stuff is inside the mindset there.

Alex Partridge 54:30 Mm.

Dr. James Kustow 54:30 So it's, uh, it's, it's sleep. Anchor your sleep, because if you're not sleeping enough, or if you have disrupted sleep, or if you have sleep apnea where you stop breathing at night or you have restless leg syndrome or you have bruxism or you have nightmares, which are higher in ADHD, then you are potentially going to just be, like, fighting a tide. So getting good sleep practices that work well for people with ADHD and deal with that particular stuff is really important. And so in the book, the second pillar, I collaborated with the top sleep specialist in the country, an amazing psychiatrist called Dr. Hugh Selsick, and, um, we've collaborated for years now, but we, um, you know, I wrote the chapter with his guidance. And, and then it moves on to o- other steps and stages. I, I move to time and task management. You know, get control of your time after that. And then later stages, and this is not necessarily in order, but there's a nourish and move your body, so nutrition. And again, although I am actually a nutriti- I trained as a nutritionist many years ago, not to be a, work as a nutritionist, but to really understand this a bit better. But I collaborated with an amazing nutritionist on that chapter. So where, where expertise is really required, I've pulled it in, and where I feel like I've got enough expertise myself, I've just done it. And, and it builds. It builds like that, and I think it's about bringing in good practices, so organizational practice. So after your time and task management, the, the focus needs to move to your environment. You know, from clutter and decluttering to how do you set up your, your, your zone to work best for you? Things need to be visible. You know, things need to be there-

Alex Partridge 56:23 Mm

Dr. James Kustow 56:23 ... in front of you in ADHD.

Alex Partridge 56:25 Yeah. The, the moment I adopted a massive whiteboard in my office was a game changer-

Dr. James Kustow 56:32 Mm

Alex Partridge 56:32 ... for my organization. Another big topic in the book is emotional dysregulation.

Dr. James Kustow 56:36 Yep.

Alex Partridge 56:37 Could you explain exactly what emotional dys- dysregulation is and how it might differ from sex to sex?

Dr. James Kustow 56:42 [laughs] Okay. Um, so emotional dysregulation, so it's where the emotions are hotter and they move more. So, um, someone with ADHD will shift their emotional state multiple times in an hour. Like, and often excited and anxious and angry and scared and sad and, you know, it just changes much more. The emotions are the same, they just cycle a lot more. There is a tendency to have a short fuse, to have a low tolerance to frustration, to, you know, erupt into anger more easily. Um, and so emotional regulation can actually come in so many different forms. I actually, um, have been so interested in this for a long time, and not just within ADHD, but thinking about the multitude of ways you can regulate emotions through cognitive strategies, like thinking strategies, to body-based approaches, even through nutrition. How can you eat and, and cr- create a more regulated blood sugar and, and more energy expenditure? So regulation from many different angles. But being able to regulate emotions well, I think is the absolute crux of living well with ADHD because you have to be, you have to be able to s- to, to limit these fluctuations a bit, and there's two strategies. One is how do you bring yourself down when you've been activated? That's one important thing to do. What do you do in the moment where, you know, you're, you're fuming? And then there is what can you do, like on a day-to-day basis, to keep the system tuned up, to keep, to, to, to not trigger so easily, to increase the threshold at which you, you get stressed? And so the book's, the largest pillar of the book, it's the seventh pillar, is regulate your emotions, and I introduce a sort of six, I think six different approaches, and one of them... Yeah, there, there's, there's all sorts of different things. Tapping is, is one of them, and I really teach people at a granular level how to do this amazing technique. Um, working with the sensory system is another. How do you modify your environment that works well for your sensory system, um, and that regulates you through that? And my, the most exciting one, the one that I think I've brought to the table, that I think is, possibly will be one of the best things I've ever created [laughs] is something called Solo Soma. And, um, it actually started as something for myself, and I only, uh, in the last few years have been sharing it wide, more broadly. But basically, I could never do mindfulness practice in the, in the traditional way of staying really still and listening or focusing in on one thing. I just got restless. I couldn't do it, and I know for a fact that many people with ADHD have the same challenge. And I also w- love effi- being efficient, not wasting time. One of the massive things in ADHD is not wasting time to... Half the reason I'm late is 'cause I just wanna, you know, get as much done as possible-

Alex Partridge 1:00:06 [laughs] Yes

Dr. James Kustow 1:00:06 ... in a short space of time. So, um, and I also had had exposure to some of the most amazing trauma processing and emotional regulation techniques. I've trained in EMDR, the eye movement one, to an advanced level, and EFT, the tapping approach, E- emotional freedom techniques, to an advanced level, and various other... I'm getting into the very interesting area of energy psychology, which is a whole different discussion, not for today. But I have all these different tools, and I thought, "Wouldn't it be nice to extract out what I judge to be the most potent elements of each of maybe..." I think there's 12 or 13 different established approaches. Kundalini yoga and acupressure or Tuina, um, EMDR, the eye movement, tapping, uh, even things like intention and gratitude and awe, like- Um, repetitive movement, hypnotic stuff, inversion, like physiological stuff, the Valsalva maneuver. I've pulled like, uh, the most powerful bits of all these approaches and weaved it into like a flowing movement, touch-based, um, movement meditation, which I do every day in the morning when I'm on good form. I know when I'm not on good form because I just say, "Oh, I can't be bothered to do it." That's when I definitely need to do it. And, um, it's, uh, I've, uh, it's too much to put the whole thing in the book, but I've done a, like six taster exercises of it. And actually, if people do like it, they can go to, uh, a, a website called thegrovepractice.com, which is, I'm, uh, I'm, I'm the sort of co-director of this really amazing educational, mental health educational hub that's been going for many years now and does, it's cutting-edge work, and that's where my Regulate program is. Um, for professionals, that six-day course for professionals. But on there, in the next few days, because it's literally been videoed, I think I'm quite used to these microphones and cameras and lights and everything because I've been with a production team videoing it and doing the voiceover of it because, um, uh, so many people wanted it, and it takes a lot of time just to show. So I'm, created a video of it, and it's gonna be available for people who love it. But that sorts me out. It's like if anything is built up, if I've had a bad dream, if I'm carrying stress over from the, like ye- yesterday, if I've got something important today and I'm a bit anxious about it, this 20-minute really efficient thing just sorts me right out, and I just sort of hop into my day very happy and realize that this is the preventative, this is the proactive, the preemptive bit. It's not the reactive bit. The reactive bit's important, but I'd rather not react in the first place. I'd rather be able to keep my cool. And without a doubt, this has allowed me to do that. And I had no vision of ever sharing it beyond myself, but I just realized how good it was, so I did, to my colleagues first, and then now to my patients and to groups and here in the book. So that's, that's just one example of, um, how I, I approach emotional regulation.

Alex Partridge 1:03:13 Mm-hmm.

Dr. James Kustow 1:03:13 But there's many more in there as well.

Alex Partridge 1:03:15 Can a person hack their ADHD to become more productive?

Dr. James Kustow 1:03:20 Hmm. Well, everything we've talked about today is essentially doing that. So for example, putting items that you need or reminders at the point of action or the point, you know, when, where they're gonna be used, that's the Post-It Note thing, or that's the, the sports bag by the door so you don't forget it on your way out. Putting in, you know, y- y- you need things at the point of action in your direct vision. Can't miss it. That's a hack. Um, setting your alarm, if you're on medication, setting your alarm half an hour early, taking your meds, going back to sleep for half an hour, waking up with a sort of little bit more energy in you and focus and ability to get moving. But, uh, that's a hack. There's so many different hacks. The book is just big book of hacks, basically. Uh, all practical things. There's, it's not, this is not really a theoretical book. This is how to actually do it. And, but I start from creating a platform. So we've literally got these sev- seven pillars on this big platform, and the platform really is understanding ADHD and different aspects of it, but in a much more sophisticated way than I think that we've currently got understanding of it, and that's the 10 domains of dysregulation stuff and, and building, building up from the bottom. And then it moves into the pillars. And importantly, um, after, in part three, is only when I move to the more traditional, the medication, and the more traditional approaches. 'Cause my view is that even before you get a diagnosis, you should work on this stuff because there's a number of people who are a bit borderline in terms of whether or not they meet criteria, and when they start and clean up their life and, and make some changes and clear some stuff, they judge that they don't need to go and get a diagnosis. And so why jump in with medication immediately when actually you're getting drunk five nights a week and you're smoking cannabis in the morning and you're, you know, you're sleeping five hours a night and you've got loads of traumas that you haven't processed and you are eating rubbish food? And you know what happens when you rein in some of that stuff? Now, I understand fully that good-going ADHD, you just can't do it. [laughs] You just can't do it.

Alex Partridge 1:05:39 [laughs]

Dr. James Kustow 1:05:39 But, you know, it's, y- you can make a bit of a, an effort, and sometimes-

Alex Partridge 1:05:45 Mm.

Dr. James Kustow 1:05:45 Sometimes you avert the need for medication if your ADHD's not particularly impairing or particularly severe. But what I do find is if you are going to go down the medication route, you reduce your dose needs because you've dealt with 30% of it through, through lifestyle management.

Alex Partridge 1:06:06 Mm.

Dr. James Kustow 1:06:06 But really good lifestyle management.

Alex Partridge 1:06:08 It's all great advice. Um, a hack I've recently started adopting, which I, I found really been beneficial, is I, I really take advantage of my nighttime brain. My, my brain is super active, efficient, productive in the evening.

Dr. James Kustow 1:06:23 Mm.

Alex Partridge 1:06:23 In the morning, it's the opposite. Very slow. Takes me a while to get out of morning mode. So I really take advantage of the nighttime brain.

Dr. James Kustow 1:06:31 Mm-hmm.

Alex Partridge 1:06:31 And I plan my day the night before, and I decide upon five tasks that need to be done that day, and I create bracelets for each task.

Dr. James Kustow 1:06:41 Mm.

Alex Partridge 1:06:41 So I wake up, put five bracelets on of, uh, they could be small things like take the dog to the vet, buy a shirt-

Dr. James Kustow 1:06:47 I love it

Alex Partridge 1:06:48 ... clean the, Hoover the flat, whatever they are. And as I accomplish each task, I take off the bracelet, put it in a bowl, and if I fill up the bowl by the end of the day, I reward myself with something, like, uh, I buy something on my Amazon wishlist, whatever. So I gamify it as well. Um-

Dr. James Kustow 1:07:03 That's brilliant

Alex Partridge 1:07:04 ... you know, perfect, but it, it-

Dr. James Kustow 1:07:05 Oh, it's brilliant

Alex Partridge 1:07:06 ... makes a fun, a fun little thing.

Dr. James Kustow 1:07:07 I think making, uh, like creating a game out of things, making it fun, like [laughs] with my kids, one of whom has ADHD, um, you know, the, "Okay, let's see if you can tidy your room in four minutes."

Alex Partridge 1:07:21 [laughs]

Dr. James Kustow 1:07:22 Yeah. What amazing stuff. Anything that has a game attached to it.

Alex Partridge 1:07:24 Yeah, see if you can clean the kitchen before, uh, your favorite song finishes. Li- little things like that which, you know, add, add dopamine to a mundane task.

Dr. James Kustow 1:07:32 So, and funny enough, I, you know, your strategy, I, it, before I had any clue about even what ADHD was, let alone knowing I had it, in my, like, teenage years and 20s, I used to wrap a little piece of string around my finger when I needed to remember something because, you know, uh, my mum didn't like me writing, uh-

Alex Partridge 1:07:49 [laughs]

Dr. James Kustow 1:07:49 ... all up my hand and... But, um, yeah, I, I think that's exactly, it's just, it's the, at the point of action.

Alex Partridge 1:07:55 Mm.

Dr. James Kustow 1:07:55 Like, you can't miss it. And if you take that hack, and you can then apply it in so many different ways.

Alex Partridge 1:08:00 Mm. So much, so much, so much value. And yeah, I'm excited to dive into your book. I'm sure there's a ton more in there. We've got-

Dr. James Kustow 1:08:08 I've got an aud- a audio version of it bec- and I actually read it, 'cause I know that I can't, I mean, I find it really hard to read books. So it was really important to me that the audio version worked as well. So if some of your viewers are really, like, anxious about the reading side of things, um, they can listen to my voice for a few hours as well.

Alex Partridge 1:08:26 Yeah, [laughs] that's a good idea.

Dr. James Kustow 1:08:27 [laughs]

Alex Partridge 1:08:27 I should've said I, I, I will dive into the audio version. I've got a bookshelf at home full of books I've never read.

Dr. James Kustow 1:08:31 I know, so that's-

Alex Partridge 1:08:32 It's fun to buy them

Dr. James Kustow 1:08:32 ... used to be shame-inducing.

Alex Partridge 1:08:34 Yeah.

Dr. James Kustow 1:08:34 But now I don't do that anymore-

Alex Partridge 1:08:36 Mm

Dr. James Kustow 1:08:36 ... because it's not allowed.

Alex Partridge 1:08:38 Absolutely. James, we've got a closing tradition on the podcast now where I deliver a letter to you that was written by the previous guest.

Dr. James Kustow 1:08:48 Mm.

Alex Partridge 1:08:48 And the letter is three life rules to live by. So I'll deliver the letter to you, James.

Dr. James Kustow 1:08:54 Okay.

Alex Partridge 1:08:55 Um, and if you could kindly open up the letter and read the previous guest's three life rules.

Dr. James Kustow 1:09:00 Three life rules, eh? Three rules to live by. Most important love affair you ever have will be the one you have with yourself.

Alex Partridge 1:09:11 Nice. Profound.

Dr. James Kustow 1:09:12 Lovely. Two, when someone questions why you, remember why not. Why you...

Alex Partridge 1:09:24 Kind of makes sense, doesn't it? [laughs]

Dr. James Kustow 1:09:25 Why you-

Alex Partridge 1:09:26 Sounds nice.

Dr. James Kustow 1:09:28 Why do you have ADHD? Or not sure. It's nice, nice.

Alex Partridge 1:09:31 Yeah. It's, it's meaning-

Dr. James Kustow 1:09:32 Could be lots of things

Alex Partridge 1:09:33 ... nice on a poster.

Dr. James Kustow 1:09:33 Yeah. Uh, three, be your brilliant, complex, vulnerable, beautiful, unique self. No apologies. Everyone else is taken.

Alex Partridge 1:09:45 Beautiful. Three little hopeful-

Dr. James Kustow 1:09:46 Beautiful. Love it

Alex Partridge 1:09:46 ... nuggets of, uh, of, um, advice to end the episode on.

Dr. James Kustow 1:09:50 And so much, so much that, you know, we've touched on today as well. It's really interesting.

Alex Partridge 1:09:54 Yeah.

Dr. James Kustow 1:09:54 These are sort of important lessons.

Alex Partridge 1:09:56 James, this has been fascinating. Thank you so much.

Dr. James Kustow 1:09:58 Pleasure. Great to be here. Thank you for inviting me. [upbeat music]

Alex Partridge 1:10:03 We had an idea to ask you what famous TV character, cartoon character, could be anyone, you think has ADHD.

Dr. James Kustow 1:10:13 Oh, I got a couple of good ones. I mean, Robin Williams, not only in real life, but in his, in, in all of his performances, he's just the hallmark of ADHD. And my favorite one that most people don't know is Maria from The Sound of Music.

Alex Partridge 1:10:30 The character?

Dr. James Kustow 1:10:31 Yeah.

Alex Partridge 1:10:32 Wha- [stutters] I-

Dr. James Kustow 1:10:34 Singing and dancing and creative, making clothes out of, out of, uh, curtains and breaking rules and being quite dysregulated and singing when she shouldn't and getting in trouble with the nuns and-

Alex Partridge 1:10:48 Is that the hills are alive?

Dr. James Kustow 1:10:49 Yeah.

Alex Partridge 1:10:49 Just singing through the countryside.

Dr. James Kustow 1:10:50 Exactly.

Alex Partridge 1:10:50 Yeah, I know it well. Yeah.

Dr. James Kustow 1:10:51 They can't settle her.

Alex Partridge 1:10:52 Yeah.

Dr. James Kustow 1:10:53 And she goes into this really strict, strict family, and then it's like, it's a perfect example of ADHD and structure. [laughs]

Alex Partridge 1:11:01 Yeah. [laughs]

Dr. James Kustow 1:11:02 It's mad. She's brilliant. We should rewatch it for that.

Alex Partridge 1:11:04 I will do.

Dr. James Kustow 1:11:05 In fact, most of the, some of the most brilliant films, the main character has ADHD. It's definitely more interesting. So many per- so many-

Alex Partridge 1:11:14 What about The Hulk? [laughs] What about, sort of-

Dr. James Kustow 1:11:16 [laughs]

Alex Partridge 1:11:17 Bruce, what's his name? The, the, uh, The Hulk could be his representation of RSD.

Dr. James Kustow 1:11:21 [laughs] Maybe, I don't know.

Alex Partridge 1:11:23 So as he, as he turns into.

Dr. James Kustow 1:11:25 I'm, I'm shocked by the number of characters in, like, in films, but also probably in, in cartoons. It's just so often the case that they're presenting someone who's a little bit dysreg- 'cause it's more fun, isn't it? More interesting.

Alex Partridge 1:11:38 How many domains do you own?

Dr. James Kustow 1:11:41 So I actually don't do any social media. I just don't like it. It makes me stressed, and I actually can't handle it. I can't handle the, the inputs, so I, I made a decision early on, and it's amazing. I'm seeing all my addicted friends now saying, "Oh, I wish we'd done what you did," and trying to get off it, lasting, like, a few days and then going back. It's so addictive. It's so unbelievably addictive. I think I'm really very annoyed that, uh, that we have allowed our children to get properly addicted to these things, and particularly ADHD children, and you can't do anything about it because everyone's doing it.

Alex Partridge 1:12:16 Well, I think I've mentioned before, there's never been a point in history when humans have had such accessible free dopamine. You can just reach into your pocket, and within a second, I can be hysterically laughing off an Instagram Reel. That can't be natural, right? That sort of, like, accessibility to that, that feeling.

Dr. James Kustow 1:12:33 So I've, I've, um, always been a bit wary of Shorts, like, you know, short film, short YouTubey things, 'cause I do watch some YouTube, but I don't really consider that in, in social media. In fact, I learn loads from watching videos and interviews and podcasts and stuff. Um, while I was away on holiday this summer, for the first time ever, I decided to see what this Short thing was all about, and honestly, I lost eight hours over two days just looking at Shorts, and having not ever done it before, I was like going, "Natalie, look at this. Look how funny this little animal is." Like, she was just loving it. She was hysterical, but I properly got absorbed into it. I was, like, hooked in.

Alex Partridge 1:13:10 Yeah, you lose all perception of time. You just-

Dr. James Kustow 1:13:12 Absolutely

Alex Partridge 1:13:12 ... hours can go past.

Dr. James Kustow 1:13:13 I mean- A phone. Um, I, yeah, the phone is really problematic

Alex Partridge 1:13:18 Do you remember your reusable shopping bags when you go to the supermarket?

Dr. James Kustow 1:13:22 Do I remember them?

Alex Partridge 1:13:23 Yeah

Dr. James Kustow 1:13:23 No, not a chance. And I really resent having to buy them as well.

Alex Partridge 1:13:26 [laughs]

Dr. James Kustow 1:13:26 I'm normally carrying, like, 20 items and dropping them everywhere.

Alex Partridge 1:13:30 Yeah [laughs]

Dr. James Kustow 1:13:30 Pockets full.

Alex Partridge 1:13:31 It's that ADHD-

Dr. James Kustow 1:13:31 Food full

Alex Partridge 1:13:32 ... ADHD tax. You have to buy another one for 30p

Dr. James Kustow 1:13:35 Forgetting it [laughs]

Alex Partridge 1:13:36 How many unread emails do you have, or are you quite good at emails?

Dr. James Kustow 1:13:39 Oh, I'd love to show you on my phone 'cause I, if you grab my phone-

Alex Partridge 1:13:43 Yeah. If, yeah

Dr. James Kustow 1:13:43 ... I'll, I'll tell you because I literally, I think I might have the record. It just says 99 plus. I think it's got-

Alex Partridge 1:13:49 [laughs]

Dr. James Kustow 1:13:49 ... too many. Yeah, so I, uh, no, I last, when I see on the computer, I think it was something around 10,500, something like that.

Alex Partridge 1:13:56 Yeah. What about WhatsApp messages? How many unread WhatsApp messages?

Dr. James Kustow 1:14:01 Oh, unread WhatsApp messages.

Alex Partridge 1:14:02 You don't have to read them obviously, just us-

Dr. James Kustow 1:14:03 No, no, no

Alex Partridge 1:14:04 ... the number.

Dr. James Kustow 1:14:05 Uh, actually I'm pretty good on WhatsApp. You know, I, I look at most things. Um, only probably about 20. [laughs]

Alex Partridge 1:14:15 Do you have, like, in your house or flat, do you have... Y- Is it clean?

Dr. James Kustow 1:14:18 Oh, 31, 31.

Alex Partridge 1:14:19 31. That's okay. Do, do, is your flat clean generally?

Dr. James Kustow 1:14:23 Uh, is my... What's the word?

Alex Partridge 1:14:24 Do you have shame rooms, shame piles?

Dr. James Kustow 1:14:27 Um, I, I sort of go f- I, I sort like a pendulum. I let it get to a certain point.

Alex Partridge 1:14:33 Mm.

Dr. James Kustow 1:14:33 So I have a funny story about my clothes. So I don't, uh, I don't know if your listeners will relate to this, but, uh, I have what has been called the clothes mountain, which builds up on the chair.

Alex Partridge 1:14:43 [laughs] Yeah.

Dr. James Kustow 1:14:43 I mean, it gets really, really big. And at some point, I feel like I build up the energy and, uh, and I, I'll attack the clothes mountain. A- and there's two steps to this. There's the laying out all the same items on top of each other, emptying the pockets and straightening out, and putting the dirty washing away. That's stage one. And normally, I get as far as stage one, and then something distracts me and takes me off. So I've got these, like, rather than a big mountain on the chair, I've got these mole hills all over the bed.

Alex Partridge 1:15:10 [laughs]

Dr. James Kustow 1:15:11 And, um, and then, then I will go and end up doing something else 'cause it's really boring to do stage two. And then what typically, uh, stage two's putting it in the cupboard and putting it away, and it's, like, hangers and stuff. So stage two often doesn't get done. And then my wife comes to bed earlier than me 'cause I'm a bit of a night owl sometimes, and, uh, will take all of the clothes, mole hills, and put them back onto the mountain.

Alex Partridge 1:15:34 [laughs]

Dr. James Kustow 1:15:34 And we start the charade the next day. It's great. I've done that, like, three days in a row. It's amazing.

Alex Partridge 1:15:39 [laughs] Gosh, yeah. Very mountain-ful.

Dr. James Kustow 1:15:40 Mountains and mole hills.

Alex Partridge 1:15:42 What's the most impulsive thing you've ever done?

Dr. James Kustow 1:15:44 I can tell you a really big, like, careless error I made that had the biggest impact. So I missed the deadline for, like, an important, like, medical psychiatry exams, which meant that just one mistake meant six months extra on, on a jo- on the job just because I'd, like, yet again, managed to get the date wrong. Things like that, that people don't realize, it has a real impact. So I did six months extra training from a little, little mistake. That taught me a lesson. I used to, I used to be very quick to go, "I'll do that," like, put my hand up. And it was often out of excitement 'cause I get, just get excited about new projects and stuff. So I have, like, agreed and started writing my own book. So I wrote a book once 'cause I thought I had this great idea before this book to write another book, and I- I... It was a very impulsive decision. I got hyper-focused for six months. I literally didn't work. I did nothing else but procrastinated and wrote a bit, and then realized that I just lost interest when I'd written half a book and had to shelve it. And I'd not only written it, I had paired up with my amazing cousin who's a designer and designed it. Like, who writes and designs a book without, without some commission to do it? I just literally dived in, and, um, I could never finish it because I just, you know, sometimes something just, something finishes, you just-

Alex Partridge 1:17:14 It's that boom and bust you mentioned earlier

Dr. James Kustow 1:17:16 ... I mean, six months of daily work is just never been used, and I have a few things like that, and that was an impulsive decision. And now I know I should connect with a publisher before I start writing.

Alex Partridge 1:17:29 Yeah. [laughs]