I'm gonna invite Professor Weiss in and celebrate. I'm going to do a quick introduction. I need to tell you, like, so look, she has created the I'll just do this. So she specializes in ADHD and autism sleep throughout her lifetime. Doctor Weiss has been working in health equity research lab at Cambridge Health Alliance in IMH study screening youth and community to identify risk of mental illness and functional impairment. She received her MD and fellowship in psychiatry from McGill University and her PhD in history science from Harvard University. She has published over 150 articles. She's absolutely preeminent.

Relating to these topics and is known for her research demonstrating that melatonin is safe and effective for initial insomnia in ADHD. She's author of the Weiss Functional Impairment Rating Sale, and that is how I got to know her. I wrote her an email saying we would love to be able to use this, and she absolutely gave her blessing and directed her to where that's managed now. It's a widely used scale. It's using 23 languages, and she was so kind. And at the same time, I said, we're doing a global conference. Would you consider coming? And I mean, the reply was almost instant. It was yes. And I think it's a testament to her work in the community, her passion for ADHD, that there wasn't even a blink in getting involved to look to.

Share her knowledge and support. And absolutely wonderful. She is going to be taking questions after the session. Depending on technology, they might work if you put them in the social media. But really, the place it's going to work is if you go to globaladhd.com, go to the Q and A part, and you'll see you can put the questions in there, and I will be asking questions. She's Okay. Been hanging in the wings for long enough, so I'm going to invite her in to say hello. Hello. Professor Weiss has rejoined, so let's see how we're doing on Can you hear me now? Yes. Yeah. We can. Well done. Alright.

Just going out and coming back in for some reason. Worked. But all my mics are enabled. Thank you. It was a very worrying moment.

I'm telling you, like, you are our first live guest, so we did a prerecord before. And so the absolute fear that this is the rest of the twenty four hours was going through my world.

All's the world that ends well.

Wonderful. Now, I'm sharing your slides. Obviously, we've done the introduction. And genuinely, you are preeminent in the field. You are one of the most published and most extraordinary people within ADHD. And we're absolutely thrilled. You'll hear your CTR anchor presenters are absolutely thrilled. Now I've got the now for people British people, you are about to have a very terrible flashback because for the slides, the way we're doing it is I'm sharing the slides. And Margaret is going to have to press and say next slide, please, for each one. For you, Professor Weiss, during COVID, we would have daily updates from the head of medical science.

I forget his full title. And as they went through it, was all next slide, please. So like it's terrible. Okay, shall I hand it straight over to you? Are you ready to roll? I am. Thank you. Okay, this will take me just a moment whilst I set this up.

Okay.

Over to you.

Okay. It's a pleasure to be here. So the subject that I chose to talk about today is something which I think affects the lives of many people with ADHD. In addition to the symptoms of ADHD, it is often true that people with who have difficulty with attention, hyperactivity, or impulsivity also have difficulty with things that are very important in terms of functioning in life, things like sleep, good diet, and management of screen time. And what I'm gonna focus on today is what we know about sleep and diet with some of the tricks which I have found helpful in management of these two areas of challenge. Next slide. These are my disclosures. Next slide is sleep, and then we can go right to the next slide after that. So what you see here is.

That we have many, many studies of sleep, and all of them are consistent, including meta analysis, which means grouping all the studies together to find out how consistent they are with each other. And all the studies demonstrate that ADHD by day, but difficulty with sleep by night is the, most common presentation. Majority of children and adults, about eighty percent, will have difficulty with falling asleep. We call that sleep onset latency. Does it take you more than thirty minutes to fall asleep? Difficulty with feeling tired during the day, and the way we measure that is very interesting. We use something called the multiple sleep latency test.

Which just means allowing someone to go to bed and measuring how fast they fall asleep, which is a measure of how tired they are. And there are also difficulties with sleep disordered breathing. Next slide, please. So ADHD is a cause of difficulty with sleep, but the converse is also true. If you can't sleep, that has a major effect on your capacity to pay attention the next day. So sleep causes difficulty, with, management of boredom. ADHD people, when they go to bed, often complain that their thoughts are relinked. They can't turn their thoughts off. Difficulty with sleep, just like ADHD, is a familial condition.

So parents who have a dysregulated sleep schedule are also gonna have difficulty knowing how to put their child to sleep. Next slide. This is a paper that we wrote, and what it says, which is what I've been trying to get across, is if you measure functional impairment, that means difficulty with the doing of things in life, difficulty with family, socializing, risky activities, learning, appropriate behavior, managing at work. The difficulty with ADHD during the day and the difficulty with not sleeping at night both contribute very significantly to that functional impairment. Next slide. So you can see here that adolescents, in particular, have difficulty with sleep. Sixfold that of, if they have ADHD than if they don't have ADHD.

And the types of sleep disorders that we see in ADHD are many different things. They can be insomnia, general difficulty with sleep. In adolescents, the most common presentation is, eveningness. That means that instead of being wide awake in the morning and tired at night, what we hear is that the adolescents kinda wake up when they should be getting sleep, which means that they're gonna go to bed really late sometimes at one or two in the morning. Then if they have to be woken up for school the next day, they're really completely exhausted. There are other problems associated with sleep and ADHD, like moving your legs in the middle of the night, difficulty with breathing, grinding your teeth. Next slide.

So one of the things that I think really changed in our understanding of the relationship between sleep and ADHD, which is very important and very interesting, is that we always considered that stimulants were bad for sleep. And that's because about twenty percent of the people who have sleep difficulty on stimulants have it as a side effect. But if instead of asking about sleep as a side effect, you ask everybody who takes a, stimulant medication, you will find out that sleep is also an outcome. And in fact, more people go from being bad sleepers to good sleepers on stimulants than the other way around. So some people will have insomnia as a side effect, but many people will actually sleep better when their ADHD is well regulated.

With stimulants, partly, probably, because they can organize to go to bed. And that improvement in sleep covers all aspects of sleep. Next slide. So this is a study we did demonstrating exactly what I just described. What the study shows is that in a large group of people who took a very long acting stimulant, a variant of methylphenidate that lasts about fourteen hours. Actually, there was no difference from placebo and sleep overall during the double blind phase of the study. And when we followed these people over six months, if you looked at the group as a whole, not only did their sleep get better, it normalized. So this is the Pittsburgh sleep index, and the cutoff for normal is five. And the individuals with ADHD, their group score.

Went from abnormal to normal. Next slide. This is a very important study which came out in 2022, and what it showed is this study demonstrated not only the cross sectional that's at any given point in time associated between sleep and ADHD. It also demonstrated a longitudinal association. That means if you identify a child with sleep problems, there's a very high likelihood they're gonna show up with ADHD later on. And if you identify a child with ADHD, they're likely to have difficulties with sleep later on, and the same is true retrospectively looking at adults. So this association is predictive and goes through the life cycle. There's very little in child psychiatry.

That shows that kind of a strength of association that it's predictive over decades. Next slide. So if you're going to think about sleep, one of the things that's important then is when you go to the doctor or if you are the doctor or psychologist who is doing an assessment for ADHD, don't forget about sleep. Because if you don't ask about sleep before you start treatment, then you're going to think that the difficulties that you identify later are caused by the treatment, whereas they may have been present all along. There are many great, short, easily available free measures for sleep that are available on the web, such as the child sleep habits questionnaire, that's terrific, the Pittsburgh sleep quality index.

These measures are a very quick way of getting a full spectrum of all the different types of difficulties with sleep, which you may have, difficulty remembering in an interview. If you don't wanna use a questionnaire, then the easiest way to evaluate sleep is the BEARS acronym. B stands for bedtime. Do you go to bed? E for are you tired during the day? Excessive daytime sleepiness. A for awakenings. Do you wake up after you fall asleep? Regularity stands for your consistency in falling asleep at the same time and waking up at the same time every day. And lastly, the issue of sleep disordered breathing. Next slide. What I show here is one of the most useful ways. You can get this on the Internet any anywhere.

What this is is called a sonologue or sleep diary. And what someone does is they put an arrow for when they go to bed, and they color in all the blocks for when they were asleep, and then they put an arrow going up for when they get out of bed. And just looking at this tells you a great deal about the duration of sleep, the sleep latency. You can see here that, for those dates in December, the person was going to bed very early, like at 09:00, but it was taking them several hours to fall asleep. That's a very long sleep latency, and I would imagine that person would be quite frustrated. So it tells you the pattern of sleep in a picture that, is worth a thousand words. Next slide.

Tools for behavior management. This is probably the most important slide that I'm gonna show. What are the things that you can do to make sure that your sleep is as good as possible? The first thing is a regular schedule. Deciding when to go to sleep and when to get up and doing your best to maintain that schedule on an ongoing basis. If you do have trouble falling asleep, the way you set the clock, the way you fall asleep earlier is not by going to bed before you're tired, but in fact, by waking up earlier so that you're tired during the day and you have a sleep debt, which causes you then to sleep earlier. Don't use screens before bed. That's a very difficult thing for people with ADHD. But if you're a parent, for example, you can reward.

The going to bed by increased screen time in the morning. Physical activity, a good diet, things that you associate with going to sleep. So for children, talk about sight giver. It's an important term which means time giver. Children fall asleep by association. It can be with their blanket. It could be with story hour. It could be with a snack, and the same thing is true for adults. You need to evaluate and modify parents providing the child with attention when they are not sleeping. So sometimes what happens is parents give children a lot of attention when they wake up at night, and they let the kids crawl into their bed, and they play with them. That's very positively reinforcing of difficulty with sleep. Next slide.

These are, again, ways in which parents can help children to sleep. You need to establish a firm time. You need to restrict sleep so that the child is falling asleep within thirty minutes of going to bed. If you put your child to bed at 7PM because you want a lot of time for yourself in the evening, but the child isn't actually tired till 9PM because they don't need more than nine or ten hours sleep. And in fact, they're gonna sleep worse rather than sleep better. Not taking naps during the day is another important criteria for having good sleep. All of these things build up the sleep debt to maximize your fatigue, at night.

And the way, again, that you're going to establish this schedule is by always waking the child up at the same time. Next slide. Well, all of these tricks that I've just described to you have actually been, formalized in sleep therapies. We call that sleep hygiene. And it's remarkable how easy it is to help someone have better sleep without using sleeping pills. So the behavioral treatment, setting up that regular schedule, a time to wake up in the morning, all the things that I just described, all those behavioral interventions, they can be taught to children, parents, adults in approximately two sessions with remarkable excellent results, results that are, safer and just as effective without the side effects of using sleeping pills.

Next slide. This is a study that demonstrates what I just described. There are two researchers in Australia, Emma Siberis and Harriet Hiscock, who have developed this sleep therapy, and they have tested it on hundreds of children who are randomized to treatment as usual or to these two sessions, delivered by a pediatrician or psychologist who has been trained in these techniques, and they showed excellent improvement and improvement that lasts three and six months later. It doesn't necessarily mean, and the results literature are inconsistent on this, some studies show that if you sleep better, some of your ADHD is also gonna get better, whereas other studies say that if you sleep better, you may still have difficulty with ADHD. Next slide.

Sometimes one of the difficulties, that we encounter in working with families are some of the beliefs that families have. So one of the difficulties parents have when you have ADHD children is it's exhausting, especially if you're a working parent. And if you have a child that needs less sleep than you, because some children with ADHD don't need that much sleep, that means you're always on. You don't have any time for yourself. Sometimes what parents do is they use sleep as a babysitter, or they use screens as a babysitter just so that they can have some time to themselves. But the trouble with that is the side effects are that, you're gonna get further impairment in the child's sleep difficulty.

Another thing that's difficult for parents to understand is that their child can't be tired because they're so hyper. An overtired child doesn't always look tired. As experienced parents know, an overtired child, can, in fact, be very hyperactive. Next slide. ADHD is associated with actual physiological changes. Melatonin is a sleep hormone. It's the hormone that is released by the absence of light going through your eyes. So when your eyes sense darkness, they release this hormone, which is responsible for you then experiencing sleepiness, which is one of the reasons why a bright screen will suppress melatonin and also why taking melatonin exogenously is so helpful. Next slide. So here you see a slide demonstrating the difference between.

Short acting melatonin and long acting melatonin. One of the side effects of short acting melatonin is that it's incredibly effective at putting people to sleep. It really does work to help you fall asleep. The difficulty, however, is that the short acting melatonin doesn't work through the night, which means that when it wears off, if you wake up, if you have middle of the night awakening, you may again have difficulty falling asleep, in which case you might have to take another melatonin, or, alternatively, you can take a long acting melatonin, which is slowly released right through the night. Next slide. There are other medications that are used to help people with sleep.

One of the most common is a medication called clonidine. We use that mainly in children, and, the clonidine is an alpha agonist. It's also sometimes used for ADHD, and it's quite effective in terms of helping children fall asleep when everything else has failed. When sleep hygiene has failed, and sleep hygiene is established, when melatonin has failed, there will still be some people who need help with sleep. And in that circumstance, there are some medications that physicians use. Clonidine is one of them, trazodone is another, mirtazapine, which is an antidepressant, is a third. One way or another, then I think the take home message is working with a physician, you will find ways to assure a good night's sleep. Next slide.

So this is a study I did a long time ago, and it's always been very interesting to me that this study has never been replicated. We have hundreds of studies of how effective melatonin is, but what we don't have are studies that look at the relationship between using melatonin with sleep hygiene as opposed to using melatonin alone or sleep hygiene alone. And it's my belief and demonstrated here that these two, interventions work best in concert with each other. It's not gonna work very well to take melatonin if you don't have a regular sleep schedule and you're going to bed at 7PM one night and midnight the next. But if you have a regular schedule and you're always going to bed at 9PM, That it will what we call entrain your circadian rhythm.

Teach your brain when it's going to need to fall asleep and when it's going to wake up. The combination of that kind of irregular schedule with melatonin works really well. So you can see here in this graph that what we found is at baseline, group of individuals took an hour and a half to fall asleep. With just a regular schedule, that went down to about an hour. When you added placebo to the regular schedule, there was very little change. But when you added melatonin, the, sleep onset was about thirty, forty minutes, which is almost normal. And when you kept melatonin with a regular sleep schedule over time, sleep normalized completely to thirty minutes. Next slide.

So here are some of the studies. There's more than nine studies demonstrating effectiveness in all the neurodevelopmental disorders. So that's not just ADHD. It's also things like, autism. And we have demonstrated that melatonin decreases delayed dim light melatonin onset. In other words, it, allows melatonin to be, to reach higher levels earlier. And most interesting of all, unlike almost every other medication I've ever used, there's no tolerance. Melatonin actually works just as well after the first week, after six months, and for some individuals, they stay on it for years with excellent effect. And then when they stop it, they go back to being how they always work. As a result of that, I think patients.

Vote with their feet, and a very significant number of patients that respond to melatonin will end up taking it for a long period of time. The clinical success of melatonin has led to very widespread use, not just for people with neurodevelopmental disorders, but also in the public in general since in many countries, for example, The United States and Canada, you don't need prescription for melatonin, so it's become a very popular over the counter drug. Next slide. This is just going back over again demonstrating that the long acting melatonin, is going to be released at the same time as the short acting melatonin, but the curve of the release is going to continue.

For at least six hours, which is gonna bring you right through the whole night, assuring not just that you fall asleep, but also very importantly that you stay asleep. Next slide. There are studies for what is the most intractable sleep difficulty, which is deep delayed sleep wake phase syndrome, which means people who are night owls, they fall asleep late, and they wake late. These individuals, when they take melatonin, we can sometimes get them to phase advance, meaning to fall asleep earlier and wake up earlier. This can be really important intervention for someone who, has to get up for school at 08:00 in the morning or has to be at work at 09:00 in the morning. If they aren't able to fall asleep.

Then they're not going to be able to sleep late because that puts them in a schedule that's out of sync with the schedule of rest of society and leads to chronic sleep deprivation. Next slide, please. I've talked about clonidine, trazodone, and mirtazapine. I think there are over the counter drugs like diphenhydramine or Benadryl that sometimes people use for sleep. Difficulty with the yeast drugs is that that sometimes you get used to them and then they stop being effective. What's really important to realize is what not to do with medication, especially in children. We do not want to use the sleeping pills like zolpidem or zopiclone or eszopiclone, what we call the z drugs, which are quite commonly used in adults.

They don't work in children. They actually make things worse. We also do not want to use antipsychotic medications. These are medications like olanzapine, quetiapine, and although they do work in terms of making someone sleepy, they have very serious side effects such as obesity or difficulty with regulation of cholesterol and sugar. So these side effects are serious enough that they really make it contraindicated to ever use those drugs just for the purpose of sleep as opposed for psychosis or other indications. Next slide. So clinical pearls. The first thing is everybody is different, and if you're going to really be effective in management of sleep, you have to personalize it.

Everybody's sleep problem is a little bit different, and it's in talking to the individual that you find out what their specific difficulty is. It might be that they're watching Netflix until one in the morning. It might be that screens aren't an issue at all, but they go to bed very early because they're drinking too much alcohol, then they're waking up in the middle of the night. For children, the difficulty might be that they're having nightmares or trauma, and that has to be treated as an issue in its own right. The next clinical pearl is to measure sleep. The third clinical pearl is what I said that the sleep clock is set in the morning. If you wanna go to sleep earlier, wake up earlier.

Be tired for a few days, and that will make you fall asleep earlier. The fourth clinical pearl is if you're having difficulty with waking up after you fall asleep and you're taking melatonin, think about switching to a long acting melatonin. And, lastly, the relationship between use of stimulants and sleep is quite complicated. For some people, stimulants lead to insomnia. For other people, stimulants lead to improvement in sleep, and sometimes even taking stimulant later in the day can be helpful for sleep. There are even some people who say they fall asleep best if they have a cup of coffee at night, is which unusual, but definitely something that, I have heard reported. And finally.

If you really want your patient to be well or you really want to feel well yourself, think both about the ADHD by day and the sleep by night. Next slide. So I'm gonna move to diet now and talk a little bit about this other aspect of a life skill that's difficult in ADHD. The story here is very intriguing. What you can see in these graphs by Larry Greenhill is the pattern of weight that we see in children with age and you can or with time. And what you can see is that after starting stimulants in children, they have appetite suppression, and they may actually lose weight. But the interesting thing is that if you look at it over time, individuals will actually gain weight, and there's very high rates of obesity in ADHD.

Even though they were scrawny little kids when they were on stimulants. So there are three colors in this graph, and you can see that the blue line looks at those people that never took stimulus, and their weight stayed pretty much regular. The next line is the red line, and those are people who took sleep took stimulants sometimes but inconsistently. So sometimes they were on it, and sometimes they were off it. And what you can see here is that their BMI went down, and it went up, but not to the extent of people who took stimulants all the time. And then the, last slide is the the last line is the green line, and you can see from the green line that actually people who take stimulants.

All the time, those were the people who ended up at greatest risk for obesity. And one pattern that I watch for very carefully is people who have appetite suppression during the day, they're just not hungry. They don't eat all day, so they have a starvation syndrome during the day. And they only get hungry at night, and then they binge eat at night. That is made even more serious if you take a medication that causes weight gain in the evening. So if you have appetite suppression from stimulants in the morning, but then you take a drug like an antipsychotic or mirtazapine that causes weight gain, that's gonna put you at tremendous risk for obesity. Next slide. So you can see here that for children with ADHD, the increased risk for obesity.

Was occurring by adolescents, and that's adjusting for income and other mental health disorders. ADHD increases by seventy percent in adults, and they difficulty with sleep and forty percent in childhood. So difficulty with sleep outcome is a common, attribute of ADHD as a traversal life cycle. Next slide, please. Interesting study. This is, one of the very few people who have actually worked to look at, in a research manner, how to manage gross suppression, in children treated for ADHD with stimulants. And they had three groups. Next slide, please. So one group, they just watched them. The next group, they, treated them with a caloric supplement. In other words, these were people who were, losing weight. And, what they found is that the.

People who were treated with stimulants ran a risk of weight loss, especially if they didn't eat, if they were thin to start with, if there was a greater change in appetite or greater medication exposure. Next slide. So of those three interventions, drug holidays, not taking the medication on the weekend, just monitoring for weight or giving a fluoro all three strategies worked in terms of minimizing the weight loss associated with steroids in children. But interestingly, even though these children didn't lose weight, this did not lead to their having an improvement in terms of the ultimate effect on height. Due to a very slight loss of height with age and time, and we thought that maybe if we could give them I can't hear you.

Actually, I had mute I I had muted myself just for fear. I'm just jumping in. We'd had we've got had quite a few problems with sound. And people, up till now, it's been okay. There's a lot of rustling. I I think you may have a separate mic some Yeah. I put on a separate mic when there was a mic. Well, one of the reasons I feared interrupting was that, yeah, you'd solved it, but it's.

Getting it's getting hit Can you hear can you hear me now?

Yes. I can.

Is that better?

That is much better. There's gonna be a whole lot of people who gonna be like, why didn't I jump in earlier?

Yeah. Because what happened is you told me to switch mics. So when I switched mics, it was my I switched to an external mic, which led to the rustling.

Okay. Well, it's well, but then we couldn't hear you at all. So that I think it looks sounds like we might be much better. So let's go back to the slides. But it was the big it was the risk on that because obviously we couldn't hear you at all before. So I was terrified if we intervened that we'd lose all sound and struggling on. But then there was some a whole load of movements and actually we really couldn't hear. So I think that's much better. I will bring us back to the slides. And there you go.

Back to you. Okay. So I was talking about I had given a talk saying that 88 I'm really sorry about the mic problem, and I'm glad that it's fixed. I what I had said was that ADHD is associated with sleep problems and that sleep hygiene, having a regular schedule, waking up at the same time every day, and sometimes also supplementation with melatonin can help with sleep and when it helps with sleep, that also helps overall. And then I went to diet and I explained that interestingly ADHD is also associated with obesity And although, many children who start medication with stimulants lose weight, they in fact later on in adolescence become at risk for obesity, especially if they're starving during the day and.

Then take medications that increase their appetite so they binge eat at night. So, in managing the children who lose weight when they're on stimulus, this is a study I was describing with three interventions. Some of the children, they just monitored them, some of them didn't take medication on the weekend, and some of them took a caloric supplement. All the strategies led to improvement in terms of mitigating weight loss, but the mitigation of weight loss, even though the children didn't lose weight, they still had the same impact on height. Next slide please. So, in conclusion, calories and drug holidays did not increase height. Height loss over a long period of time is usually a half to one inch over thirty months. So, know, the actual.

Extent to which taking stimulant medication will make you shorter is very small. And weight loss correlates with height suppression, but weight gain doesn't necessarily mean you're not going to have that difficulty with losing about a half to one inch of height. In looking at the impact of stimulants, it's not just how much stimulants, but how frequently you use them. And summer drug holidays didn't do a whole lot in terms of increasing height velocity over two years. Height rebounds and weight rebounds in adolescents. So in fact, although you have very scrawny small children with ADHD, when they start stimulants often as adolescents, they will grow quite large and also.

Can be at risk about a seventy, forty percent chance in children, eighty percent chance in adults of having difficulty with obesity. Next slide. I think that's it. Okay. It's bouncing around. So ADHD are powerful.

That's on me. I I I flipped the thing, it moved too quickly. I'm sorry. Just going to Alright. Okay. There we go. We're back. We're in the right place.

Stimulants are really powerful appetite stimulants. And one of the things that I see in trying to work with mothers who are dealing with children not eating on stimulants, Force feeding a child to eat when they're not hungry doesn't work. And in fact, the more you nag, the greater the resistance to eating is going to be. There are other things you can do. You can get breakfast before you start the stimulant. You can give something to drink at lunchtime. It's much easier for an ADHD child to drink something quickly than to sit down and eat a giant meal. And you can get a lot of calories from drinks, especially nutritious drinks like, protein shakes or milk. And lastly, the other window of opportunity is late at night when children are quiet.

Their appetite rebounds, they're off stimulants. So allowing snacking late in the evening really helps. So does grazing, allowing children to have small quantities of food throughout the day. Some of our usual rules for eating in children really can further compound the difficulties with appetite. If you say to an ADHD child, you can only eat at the table. The difficulty with that is sitting at the table eating is attention demanding. It's boring for these children and as a result they're going to run away and they won't have finished their meal. Another thing is telling them to finish everything on their plate. They may need smaller quantities of food more often. ADHD children and certainly autistic.

Children are often picky eaters and you have to work their diet around what they're willing to eat and be flexible. And do something that makes eating less attention demanding by offering some form of entertainment. Either talking with them or sitting with them or letting them do something else while they're eating. Next slide. Another thing to know about ADHD and diet is actually some of the things in our diet, zinc, copper and iron, are co regulators of the production of dopamine, which is the neurotransmitter most responsible in ADHD. So, what I recommend in these circumstances to make sure, because it's going to be hard to get ADHD children to eat enough green leafy vegetables. What I recommend in this circumstance is a multivitamin.

With minerals. I think that's all that it takes to assure that the child is getting sufficient zinc, copper and iron. And leaves you with the knowledge that they're well nourished even if they're somewhat picky eaters. Next slide. There is evidence from well conducted studies for a very small effect of supplementation with free fatty acids. Restricted elimination diets may be beneficial for a small number of children, but we don't know who they are. And I am very careful with restricted elimination diets that I make sure that the child is getting exposed to both what they'll eat so they get sufficient calories. Don't forget ADHD children are burning a lot of energy and that they're getting all the different food groups.

So, we need more studies in this area and right now I think the best approach is to focus on management of the ADHD and a normal healthy diet. Next slide. Sometimes it's worthwhile doing an evaluation to make sure that if you have a child where the diet is poor, that there aren't nutritional deficiencies. So, there are a significant number of children that will have deficiencies, for example, of iron as measured by ferritin or deficiencies of vitamin D, is really common. And in those circumstances, correction of those deficiencies may be supportive in improving the overall health of the child and to some extent remediate the ADHD. Next slide.

One trick which I find has been quite helpful is I mentioned that on stimulants children are not going to eat their lunch. If you give a child a big sandwich and they have intense appetite suppression, the sandwiches are either going to be traded for something else with another child or it's going to come home in the lunchbox. So, what can you do to make sure that the child is not actually really hungry at lunch even though they don't experience the hunger. One thing I find is that it's much easier to drink than to eat. Especially if you give something nutritious like salty nuts and milk or a protein shake and provide an immediate reward for the child. Like for example, a behavior program at school which says.

You can go out to play at recess, but only after you drink this. And the child drinks it all down and goes out and in fact they are then well nourished for the rest of the day. Next slide. As I mentioned before, that the highest risk for weight gain is those who aren't eating all day, they're starving all night all day. So, you think that they're actually going to lose weight, but what they're doing is binging at night. And they're binging at night both because appetite rebounds when the stimulants wear off, but also very often they are binging at night because they're taking another medication for sleep such as mirtazapine or an antipsychotic for severe behavior problems, which is further increasing.

Their appetite and altering their metabolism so that they are pre diabetic and that can lead to obesity and be a significant problem. Next slide. So, what are the clinical pearls? The clinical pearls for dealing with diet, give medication after breakfast, allow kids to graze. If eating is boring, let them do something else while they eat. They can snack on something healthy in little bits while they watch a screen and with the understanding that if they stop eating, you'll turn off the screen. And if they don't eat lunch, then consider setting something up where they can drink. Next slide. Finally, if a child isn't eating during the day, they have to get all their calories late at night. In which case, not only will I give supper at 5PM.

But I'll give a second supper right before they go to sleep because they have to get their 4,000 calories in late in the day. And that becomes really important in terms of not losing weight and, maintaining adequate nutrition. The usual rules in families, eat at the table, the kitchen is closed, finish what's on your plate, only eat healthy foods are probably going to cause a lot of problems, more problems than they're helpful in ADHD children and lead to weight loss because all of those interventions will make it much more difficult for a child to be able to work around their attention problem and maintain adequate nutrition. Next slide. Lastly, evaluate the family's concept of nutrition. A lot of times mothers who are themselves obese.

Will feel that the best thing they can do is put their child on a diet that's right for them. But the diet of green vegetables and lots of lettuce that's right for the mother. Maybe exactly what's not right for a child with ADHD that's actually emaciated and consider giving vitamins. Next slide. In conclusion, education, support, praise, empowerment of the parent and the child are highly effective components of health coaching. I find that the relationship that I have, for example, the mother is going to be mirrored in her relationship with the child. When I find ways to catch the mother doing something right and positively reinforce it, she will start to do the same thing with her child.

Parents who succeed with behavioral management of these things that I've just described with screen time, sleep and diet, their skills in these areas transfer over to other areas such as management of homework. And when you address all of these health issues and the child has good nutrition, good sleep, it's not going to necessarily cure the ADHD, but the overall well-being of the family, the quality of life of the family, the health of the child and the joy of the child will certainly improve. Okay. Do you want me to do a very brief summary of the clinical pearls for sleep management since there was a problem with sound at that time?

I think people could hear. What happened was that the level of rustling got louder and then we which is when I jumped in. So I don't think there was Okay. Alright. Great. People couldn't hear at all. They they could. And I turned up your volume. But obviously, because we'd started, we couldn't hear at all. Didn't want to rock the boat. We very worried. Now we've got We've got hundreds of questions. We do we do have a good pile of questions. I pinned some, and we had some submitted before. So let me yeah. Let me let me ask. You talked about from M. A. Girati. You talked about supplementation. Is that the same for adults was the question?

You mean with a multivitamin with minerals?

Yeah. And I think you particularly talked about zinc, copper, and iron too.

Yeah. So if you take a multivitamin with minerals, you're going to get the minimum daily requirement for those minerals as well. Whether or not you need supplementation as an adult, I think depends somewhat on whether or not the adult has a healthy diet. But I would say the majority of adults with ADHD that I see do not have a healthy diet. They have as many difficulties with diet as the children. In which case, working on the diet and also taking a multivitamin with with minerals, which is going to include zinc, copper and iron, is not a bad idea. The issue with iron, of course, is also particularly important in women who often have very low ferritins because of blood loss.

And thank you. And just for clarity, the the issue on the the need for zinc, copper, and iron is not because someone with ADHD inherently needs it. It's because their diet means that they're more likely to be deficit for it.

Both are actually somewhat true. So yes, it's true that their diet might be deficient, but it's also true that those are what we call cofactors in the production of dopamine. So, if you have ADHD, your capacity to make dopamine, dopamine is what's going to remediate the ADHD, is going to be impaired if you don't have sufficient copper, zinc and iron. Which means that the deficits of those minerals will further exacerbate your difficulties with ADHD.

Thank you. That was important. You talked about melatonin, that people didn't change, that you could take it for the long term and that there wasn't a change. We've had someone say that Aaron has said, I've found melatonin only works for a week before my body gets used to it.

I would have to in order to be able to help you with that problem, I would have to know much more about, the quality of the melatonin that you're using, how you're using it, whether or not you're combining melatonin with good sleep hygiene. Remember I showed the slides, not just melatonin. Melatonin is not a sleeping pill. It's not a drop dead, go to sleep drug. And if you're using it that way, it's absolutely not gonna work. It might work initially, but it's not gonna work. It's only gonna work if it's combined with a regular sleep schedule and all the other sleep hygiene practices that I talked about.

I think that's really important, so thank you. We've had Maria ask, which she asked earlier in that section, which dosage of melatonin is safe? And I think they say they take two milligrams.

That's a very interesting question because remember I said that melatonin was one of the only drugs that I've ever seen that doesn't have tolerance. It's also a drug where if you take very high doses, you're just going to pee it out. So there's very little toxicity in taking too much melatonin. The sensitivity to melatonin varies a lot from individual to individual. So, I have individuals where one milligram knocks them out and it's too much and in fact they're tired and sluggish the next day. I have other individuals who are taking ten or twenty milligrams, and don't forget if you take long acting melatonin through the night, the dose goes up because you have to have enough melatonin throughout the night who have no difficulties.

Whatsoever. So, there is no ceiling dose, but there probably is very limited advantage for most people in going beyond ten milligrams. A typical starting dose of short acting melatonin is three to six milligrams and a typical starting dose of long acting melatonin which is being released throughout the night is exactly the same except it's ten milligrams because you're covering more hours.

Thank you. I think that's helped with that quest I had a question for you, like you are and which was on the Weiss impairment scale. Sure. Like, it's a I have to say, having done it and done it with people, like, it's tough because, obviously, it nails you. Right? Like, you're like, here's how you are this thing. Okay. I am not good at this thing. And it's incredibly insightful for that. One of the questions I find myself jumping over when I'm talking with people just is in life skills, you ask to people rate if they have problems with sex. What sort of what sort of things do you see issues do you see with people with ADHD and sex?

I say every kind of sexual problem that you can ever imagine just like the rest of humanity. So there are individuals with ADHD where they're using sex as a form of self soothing. And so I've had, couples come in and, I'm thinking of a particular couple. This man needed to have sex all the time because it was he just he had ADHD sex. Then I've had other individuals who can't focus. And I've had individuals just like I said, eating can be an attention demanding activity. Foreplay can be an attention demanding activity. Why would you fool around for a half an hour when you could just do it? So there are multiple ways in which ADHD can interfere with every life function. So we've talked about diet, sleep, screens.

And sexuality is no different.

Thank you. We've overrun because we had so many questions. And I'm very aware we've got our our next speaker in in in the wings waiting, Hage, who is a Israeli entrepreneur who's created incredible technology around helping track the impact of medication on children and looking looking wide. So professor Weiss, I'm so grateful for you being here. It's been incredibly interesting and hugely valuable. And I think you may have seen some of the comments come through of people just so enthusiastic. And we've had, you know, comments from Australia saying, I absolutely this is I love this. It's so interesting. But it is 1AM. I was just saying, I love this and more of the same. So it's been wonderful to see those, and thank you.

Thank you for having me.

Well, thank you so much. And, alright, we need to move on to yeah. Pass the next week. So thank you very much. Have a great rest of your day, and and thank you.