Hormones & ADHD Through the Female Life with Dr. Lotta Borg Skoglund: täielik transkriptsioon

to, to describe it. I don't know. And I think I don't think anyone could. Tell either you or me that we are right or we are wrong, but rather that the comorbidity is huge. And what we know from research is that if you have both conditions, you are probably extra vulnerable for other comorbidities to develop as well. So anxiety, depression, all that, that could come downstream from living with a  neurodevelopmental  diagnosis per se.  Yeah, in the range that I've seen is typically like 30 to 80 percent and I have a  theory that The 30 percent is that's brought down by ADHD people reporting or being diagnosed for autism versus the 80 percent is autistic people being diagnosed with ADHD. And my working theory is that it is all boiled down to ableism of ADHD people, not  understanding, but really not wanting the stigma because there is still so much stigma around being autistic versus, If you're already autistic,  identifying that you're ADHD is, it doesn't feel as much like a  boulder to cover. Yeah, I think you're absolutely correct there that we are when we talk to people outside of the neurodiversity community, I think we are a little bit more hesitant to talk about autism because we know how much stigma and how much, And misunderstanding it is around that diagnosis. And I think particularly around autism and empathy. And I think that might be the thing that scares other people the most. And that is fascinating though, because then if you are neurotypical, then you are supposed to have then a good empathy, right? At least that is what neurotypical people think about themselves, but you don't have enough empathy to actually put yourself in a situation where you are autistic, right? So there is some empathy problems there as well, because as a neurotypical, it's very difficult to understand how an autistic person thinks and function. So if we try to I like to switch the perspectives here sometimes and take a little a better look at our fears because if we are neurotypical and we fear or we feel like, okay, so I heard that she is, or he is autistic, that seems really scary, or that seems weird, or that is someone that you probably don't want to associate with. So what is actually  triggering that response in you? What is it that you don't understand about this person with autism? And what is it that you are scared about or feel that is, is makes you hesitant? To involve I think that's a really important thing to to ask yourself if you are neurotypical and if you fear that autistic people lack empathy, because they don't first of all most autistic people that I feel have a little bit too much empathy and that it can be a a severe problem for them and really a suffering because they go around feeling so much for so much. Many things and I have a hard time directing it. So it's like this energy loss that people with ADHD have due to problems with executive functions. I would say that energy loss is about equal for people with autism because there is like the constant movement of empathy going on for so many, and that I know. Anyway.  Yeah. And you shared recently, I'll put it in the show notes. Cause I just thought it was like the most clever, brilliant article. Clara Thornvall wrote, and it was exactly that. It was flipping the script of there's nothing wrong with you. You were just born this way. You are neurotypical. And I think it's in line. She has a book coming out summertime for you guys. I think she said it was July, but the whole perspective shift is just  I thought it was so clever because we see 400 articles a week of  you were born this way that you have ADHD and to see it flip that way. It just was so amazing.  But she's brilliant. And and she frames it like so you're ordinary. It's not your fault. Yeah,  just plain ordinary neurotypical, and that I think that's beautiful and it's really, thought provoking also because it is  Yeah, she is she really nails it. And she uses the, as you say, she uses the phrases and the rhetoric and the language that we use when we describe ADHD and ADD and autism, and just label neurotypical people in that sense. And that makes it, you really think right.  Yeah, it was just this like cheeky, I don't know, really clever way of writing. I enjoyed it, so I'm looking forward to the book also. Oh yeah,  you need to have  a session with her then, because I just re read it in Swedish, and it is also the voices of young adults. autistic people and with their examples of how they view neurotypicals and it's like this extremely intelligent and observational  like view and eyes on what people out there go around considering normal all the time. It's yeah, but if you break it down and look at it from the outside, it's just, so much of what we are doing is like absolutely not logical or making any sense at all. But we just do it because we are part of this kind of neurotypical tribe that are socialized into,  be very aware of following the tribe. Basically.   Yeah.  I'm trying to get through the English version of her first book.   There was one line in it that is like the most profound. It says, I've known I was autistic all along, but yet I had no idea. Yeah. Yeah. And I was like, yeah, I've always known I was different.  I am curious about in your experience, this is completely shifting gears 100%, in your book, you talk about the sex differences between males and females and how that begins in utero. I think most people think it begins at puberty, but really, You are designated, and maybe most women don't know, but you have the most amount of eggs you're ever going to have when you're in utero, and then they slowly start to decline. So can we talk,  if it's possible, in a brief way, and people can head to your book to read the really detailed version of the sex differences and how they happen, and then we'll jump forward 35 to 40 years and talk about perimenopause. Yeah.  Yeah, so I'm really puzzled by this as well. And again, this is how I have understood

the research. So this is basically what I tried to do in the book. I tried to Take it apart and then rewrite it in my own words so that I understand or try to understand what it, what the research is saying. Because when I talked to Helena Kopp Kellnar, my gynecology wing woman in research, she says, it's not really that much difference in boys and girls until puberty, as you say. And so I've taken that kind of as a truth. Until I started looking at the research from another perspective, because this is obviously from her perspective as a gynecologist, there's no, not really that much difference. But, as a psychiatrist,  there is, right? And neurodevelopmentally,  there might be. So then when you look at that kind of research, then it becomes a little bit more interesting because there is a sex difference. And this is on a group level of course, and we know also that sometimes these kind of natural  tracks or trajectories that we are supposed to enter when we get an XX  set of sex chromosomes, or we get an XY set of chromosomes and become like females and males. So we set out on these separate levels.  Tracks or trajectories, right? And so I was on under the kind of belief for a long time that nothing really happened there, but, it was all about how we're socialized. So it's okay boys are boys would be boys and they are encouraged to due to our kind of social expectations and all that. And that is a really important part.  But then there might also be some actual differences and looking at that literature, that's a literature suggests anyway, that on a group level, it seems like girls brains develop in a way that actually plays straight into this socializing idea of how girls think. should be, namely, they should be like attentive to other people's needs, they should be aware of what other people are adults expect from them, they should be and it seems like on a group level.  It seems and it's always super difficult of course to tease apart because when we socialize young  individuals into a certain pattern that also affects  the brain development so there might be causes that is genetic that makes biology want to prioritize a brain that develops in a female way. Biology might have its reason. To prioritize that, and that might be enforced by social influence that also have a an interest in socializing girls in this way, right? But looking at it then the hardcore biologists. would say that, okay so male brain prioritize connections and development of brains that goes within the same hemisphere. And that would result in you becoming better. For example, on motor and visual skills, so you might be better on realizing how to, you see a football, I should use my foot to kick the ball. That kind of  eye, hand, foot, motor coordination, but rather that the female brain prioritizes connections that goes, Between the brain's hemisphere, and that the theory then say that, okay, so then those kind of brains are more they are more appreciative of the context, and how is everything like fit together and, okay, so why is this not included in this? And so that would then if you are like, have that bio, biological standpoint, then that you would argue that females then are also perhaps better at observing. Social events or social gatherings and what happens between people and so on. And be more aware of who you are. in the larger context. So I find this really interesting, really fascinating, but also super difficult to actually make some sense out of it. And I think we have to, when we read this research, we have to have a sound skepticism also, because it is sometimes really hard to disentangle and tease apart what causes what right?   Our genes are constantly affected by the environment that these genes actually end up in. And  there is not always like just random, where Our genes end up so and that is well known when it comes to neurodevelopmental disorders that, for example, ADHD, autism, extremely high heritability, so it's not by chance that  children with ADHD  and autism  have a statistically much higher chance of having a parent. That is also struggling with his or her own difficulties, right? So  it's not always by chance and it's not always fair.  where our genes end up. And I think that's fascinating. And it makes me also understand things much better. And it's a good way of also yeah, understanding how neurodiversity can play out in so many different settings. And I guess to a good reminder and keeps us in check of  trying to better understand how, because I am part of what I call this wave of women who are now getting late diagnosis is late realization.  And part of it was because. There wasn't these red flags of how we were acting because if the rest of your family is neurodivergent, then the things you do aren't weird. It's just oh, these things our family does or like the running joke in my family is my mom and I  like you can give us 20 minutes or three hours and we can never be on time and we are always going to be late. And. forever that was a running joke and we would say it's genetic and like it is but now we know how it's genetic and  why  yeah  and i think that's so true when i was actually i was out lecturing last week and then a young woman i think she was 20 came up to me and she also emailed me afterwards and she said i'm so grateful that you highlighted how girls may struggle without being like recognized and detected and in my family I have a younger sibling that has intellectual disability and like ADHD and autism and my I think she said she also had a, an older sibling that had a very severe form of autism and nonverbal form of autism and she said,  I don't blame my parents but it's like I had to be the, what do you say the healthy one or the one without. Problems, because they just had to have one of those kids as well and she's always felt like the norm in her family was so way off the chart that it was impossible for her to actually communicate that she is a

quite severe form of ADHD and emotional dysregulation and so on. But that was still like nothing in compared to her two siblings. And I think. She said, I'm trying to I'm trying to come to terms with this and I do understand and sympathize with my parents. But I can't live my life like this either. It's like having this role and carrying this role for everyone else. And I thought that was a very, for me, that was a very moving and also a good, very good, like example of how  Relative. This is right. And that we talk about that all the time that ADHD, ADD, autism can never exist in a vacuum it all always is in relationship to the society we live in on, or the school system we design or like this workplace or that family is always in relationship to that. So basically, if we  think that there are too many diagnosis, then we have to consider also what kind of society we live in. We are, have made for ourselves because I think that is communicating like directly communicating entities.  Yeah. If you have such a percentage of your population that is really unable to fully participate for whatever reason,  and they can't cope and they're struggling then we have to make. Yeah. Adjustments.  And then you can either keep diagnosing more and more people or you can change how the school is designed or what is like the demands on different how normal do you have to be to make it through school, to survive the school system. So I think that's also something that we can be,  have to be quite self critical about, right? Yeah and it's funny you talk about school. My daughter's just turned three, but we're already thinking about school, and  luckily we're privileged enough to consider What some people would call like an alternative school, but it's because  we already know she's ADHD. I already know she's not  probably going to do well in a quote unquote traditional school setting. Plus I have my own like tangent about how I just don't agree with them, but we're planning to send her somewhere that really emphasizes play and nature and. It just feels a lot more in line for what like an ADHD kid would need and I just wish more schools were considering of that not just ADHD kids, but kids in general, like kids should not be sitting at a desk for eight hours a day. That's just, I think we will look back on this or maybe not us, but.  Our children's children, we look back on this school system and say but what were you thinking what did you expect? So you are, you're so concerned with like mental health and you're so concerned with all like neurodevelopmental diagnosis and, but what did you expect? Having six year old, nine year old kids sitting in a chair for eight hours. That's not according to what nature had planned for us, right? With a 20 minute break.  Exactly.  Yeah. And then shifting classrooms all the time putting so much responsibility on the child themselves to remember to bring their staff to school, to remember what classroom they're in, to be able to concentrate when there's like group events going on within the classroom. It's like this the school of today is. It's quite different than the school. And I don't say that it was better before, I'm sure it wasn't, but it was a different school anyway. And today when I look at my kids, I think this school today, it amounts a lot of children's executive functions. So I'm not at all. Like surprised that so many nine or  12 year old boys especially born in December have ADHD because they're relatively unmature. And if you have this high,  like expectations of kids being able to function on such an advanced cognitive level, then you will have a huge part of these kids that are just too vulnerable. They're just too unmature right now. So you don't have this kind of and deviation or possibility to deviate from the norm then you're like,  God. And that's one statistic that I've seen, I don't remember where, of course, that children who are the youngest in their cohort at school are more than more likely to be diagnosed ADHD. And I don't mean, I don't think that it obviously doesn't mean they're misdiagnosed or that they wouldn't be otherwise, but I think it just makes their attention and their developmental deficits.  even more pronounced.   They're probably diagnosed or picked up earlier because they have this vulnerability on top of their difficulties. Anyway so I think in some way it's good, but in some way it's also concerning that also the kind of relative immaturity does also play in because in the,  even though I am very pro and I think it's very important to get the correct and get the diagnosis that you have so much to, to gain from knowing what you're, I still have this kind of vision and dream that these diagnoses wouldn't need to exist and that there was like a society that could deal with neurodiversity and so I think when you look at it from that perspective, Aspect, then this kind of studies showing that you have an increased risk of getting a diagnosis when you were born in December. And when you were a boy, then that is a bit problematic because that speaks to this, school  that it's also relative immaturity in like in players. So I think that is something that we need to take really seriously and not say that too many are diagnosed, but rather say, okay, so now so many need a diagnosis to make it through school or to make it in this society today. that maybe we shouldn't just look at the individual and give more individuals diagnosis, but also at least on the, at the same time, look at the other end of the spectrum and see, okay, what can we do to make our society a better fit for neurodiverse people? Because I don't think that anyone's particularly is chasing a diagnosis. Like , what was the like fun with that? It's more like that. If I don't get this diagnosis, I won't be able to live a healthy and worthy life, basically. So that is what we are. And that's why we need our diagnosis.  And that kind of, that brings us in an odd way back

to perimenopause because the age that perimenopause happens, 35 to kind of 50,  55 for some is also the highest demographic for people committing suicide.  And I don't think it goes. in isolated things. I think it very much goes hand in hand that there is a reason that, and I'm not saying it's always ADHD or anything, but so many women do get through life and they make it to perimenopause. And then the quote unquote wheels come off and  the hormonal fluctuations that happen in perimenopause make it so they just can no longer cope completely. And unfortunately, I do think that some people then Are pushed to a point where they're not getting help from any resource  and  then they take it in their own hands. So I wonder what your thoughts are and your reading of the research and your understanding, how do we help perimenopausal women? Is it HRT or MRT  as it sometimes is called or  what's the options? So I think we have to keep all these doors open at the same time. And this is something that me and Helena Kopp Kellnar, we discussed that a lot at the moment because of the lack of research, but also because of what you are describing here, that we, as women, there are specific vulnerable periods in our lives that we know, Beforehand, that we should have a focus on the girls around puberty. We should have a focus on those suffering from PMS, PMDS, within a certain period of the menstrual cycle. We should have a focus on the pregnant women with neurodevelopmental  disorders, and especially after pregnancy, after postpartum.  And We have this window of vulnerability also around perimenopause and menopause. So we already know beforehand that we will be at risk. Didn't necessarily say that you will end up there or that I will. But as a group, we are at risk at certain periods of our life. And perimenopause and menopause is one of those. So I think, and then again, we know quite a lot about what we can do about perimenopause and menopause symptoms. And the interesting thing is Helena found a study that, that I can really recommend this webinars she had and it's on the LetterLife app so for all premium users you can watch her lecture there on it's really an ,  overarching  lecture, like a comprehensive. comprehensive, Thank you, of what menopause is how we can detect it, what we should do, the treatment. She's very also outspoken because I, what I like with her is she really tells it like it is. It's this is, there's evidence for this and this, and there is no reason for you to feel like this. This is not, no better to talk about. Just be natural and take it, but rather just get treatment. If you are in this and this category, then you should definitely get treatment. The risks are bum. So you can really take informed decision, I think, based on that.  And Helena found a really interesting study where the investigators and the researcher actually described  perimenopause and menopause as ADHD symptoms, like plain. It's okay, so during menopause, you get memory difficulties, you get problem sleeping, you get this emotional dysregulation, you get cognitive like your verbal memory decreases your process speed. So a lot of cognitive. and deficiencies that kind of decreases during perimenopause, it's and basically they summed it up. It's yeah, this is pretty much how we describe ADHD, right? So I think, and then if you have lived with ADHD, lived on like the maximum of your cognitive capacity, as you often have when you are a female, high functioning female with ADHD, it's okay, so I made it through this part of life as well. I made it through this. Yay, I did it. Like bum bum. And then you hit. menopause, and then it's like a double whammy. So then it's there's your ADHD brain, and then there's the cognitive hit to your brain from estrogen depletion and menopause. So I think, and I think it's really interesting that It is difficult to tease apart, and it is actually established that very much of the symptoms are are overlapping. And then we have to, I think, consider menopause no other like similarities intended, but as we do when we assess ADHD in people with substance use disorders, because that has also been a problem where, okay, so someone has developed an alcohol use disorder or used illicit drugs. And that per se can cause a lot of cognitive problems, a lot of psychiatric problems, a lot of. Of symptoms that we also see in ADHD, right? And then the story, how the story goes is like at least in Sweden, it's you also have an alcohol use disorder, so we can't know. We don't know. It's impossible to know, so it's no use doing an assessment. So then you are, your diagnosis is delayed. until your other condition somehow, miraculously should be treated by itself or by someone else. It's you should just deal with that and then I can tell you if you have ADHD or not. And it's a little bit similar for us when we come to menopause. It's I don't know, you, this can be menopause. So I can't assess you for ADHD because it can also be menopause. So please come back when, Okay. you stop  dealing with all these hormones or something. And that is really problematic as you say, because if you have struggled your entire life and ending up in this like situation where so much else. in life is also changing, right? So it's, maybe it's not just menopause, maybe it's you're also losing friends, or maybe you are like your kids are moving out from home, so you have an empty nest situation where you have, build your structure around everything that needs to be done for everyone else, and then poof, all the structure is gone, and you are post menopause brain, and you are having ADHD brain then that, that could be like too much.  For so many. So I think long long, short story long. And that's, that  this is a, an extremely important issue and time of our life that deserves so much more attention and so much more like proper treatment. And then your question was, so what do we do and then my answer would be there is no

like silver bullet. There is no like answer that goes for everyone, but rather that we can view it as we do when we assess substance use disorders. Okay. You may drink too much alcohol or you may be in menopause now, but we have to look back in time. Can we detect any symptoms that you have masked or that you have handled or found strategies for or that someone else has compensated for? And what about periods when those strategies were taken away from you? What about periods when you were pregnant or are postpartum or when you had small kids and couldn't sleep and what about when you changed work or what about when you moved away from home and all these Vulnerable periods of our lives, do we see any sign that there were some kind of impairment or struggles or difficulties there? If we do, oh, but then our suspicion of this may be not only being menopause, but also being some kind of struggle with a neurodevelopmental  disorder. Might have some actually have something in it. And, but if we see that, okay, but this just came now, this is just, this is a very isolated period of my life. I've been able to manage and, and everyone has their difficulties, but I don't consider mine being particularly, difficult. I don't consider myself being particularly vulnerable, but rather that I can't, this is something that I want to deal with because this is not how I want to live my life now. I don't feel good about myself. Then maybe we should focus more on the hypothesis of this being purely like hormonal perimenopause menopause issues.  And again, then it is Not certain that the person with  ADHD and menopause will be only helped or best helped by ADHD medication.  I have lots of women that with ADHD get their ADHD diagnosis and are in perimenopause and get H or M HT and get. rid of their ADHD symptoms as well. Or get their ADHD symptoms under control. Perhaps it's a better way of phrasing it. So that the estrogen, the added estrogen boost the cognitive functions so that they again can apply their strategies for their ADHD problems.  So there's no  or wrong answer for anyone here but rather to, to try to be as detailed as possible when we describe what is going on in this woman's life right now.  And to take in as much. collateral information as possible and longitudinal information as possible so that we get as a good picture as possible. For our hypotheses,  because the, let's face it, that's what  they are, our clinical kind of diagnosis and our clinical judgment. And then our treatment plans, they are like our best Available hypothesis of how we view this problem right now, and they might change if there is other information added to the story. In one treatment that I've heard of I don't know,  cause every country has different names for stuff sometimes, but  it's commonly called like guanfacine, intuitive, 10x, but I started seeing it. In the neurodivergent circles as being, it's a non stimulant. So being used potentially for emotional regulation. And there's a study  in children, but it's talking about how, especially for people who are autistic ADHD, it can really help with emotional regulation. And I thought I know this name, I know this name because I just turned 37. I'm right in. rabbit holes galore of perimenopause research.  And it is also used in perimenopause to combat hot flashes.  What?  Yeah. You need to send me this. I have missed that. I use this guanfacin all the time for, as you say, the emotional dysregulation for women. And it's in Sweden, it's only, The only indication it has is for like meltdowns in children. So like  aggressions and outbursts and impulsive emotional instability in children, but it's not indicated. It doesn't have any indication for adults, but you can use it off label of course. And I do that with, I think great success in so many women. I've never heard that. You need to send me that.  Yeah.  Because I think it originally, I think it was used as like a blood pressure medication or something. And then we found that it helps with emotional regulation. Go figure. Blood pressure regulate anyways. But yeah in  circles, some of the doctors are starting to use it to help with hot flashes.  So I'll send it to  you. You should need, you need just to put that that link to that study in the show notes. That's extremely interesting. Because as I said I find it extremely helpful in my clinic and that would that it is an alpha agonist. So it's like similar to beta blockers that you use for hypertension and for for pulse for tremors and for palpitations. So it is a. sister medication or cousin medication to the beta blockers, but it has somewhat different mode of action, but it has shown to work through norepinephrine,  so not dopamine. And that's why it's not a stimulant, but we know that norepinephrine and dopamine, they share a lot of their receptors.  Actually, when I explain it to my patients, like it, it is like a break on the sympathetic nervous system. So it's stay what that is so difficult, right. To just, be in the moment to stay because we are like. Want to, and that is,  so that is extremely interesting. I'm going to read that study with great interest.  Yeah, I'll send it to you. I actually have an appointment next month to try and  add it to my regime because  for me and actually you talked that recently on the LetterLife app, there's these ADHD school shorts that are like one to two minute little quickly breaking something down.  And I found. It's so interesting you talking about how  I think the title that was why won't my doctor give me short acting stimulant.  And you had said there was a graph and everything, but you had said basically a long acting say like Vyvanse or whatever other name it goes under.  It has a slow uptick and then obviously hours of It working and then it has a slow downtick versus and this is the thing that caught me maybe that go huh is you equated short acting stimulants to substances of abuse in that they have a very quick

uptick and then they only work for a short time and then you have a quick crash. Are you more likely  to, yeah, you you alerted me on that and that could be the interpretation of what I said, and I probably said it as well. And I think what I need to clarify then is that, Yes, it is the same thing. So that is why we think because ADHD, autism, all these diagnoses, they are like, they're not problems for two hours or four hours but rather like across the day. So that is also why we want to have this effect. But,  The thing is, and what people are often worried about, and parents often worry about, is that the stimulant medication, when you look at them on a molecular level, they are very similar or identical to  substances of abuse. So cocaine, amphetamine, that can be abused. Then number one, what we have to remember is that the dose is so much lower in, even in, if you were, if you take fast acting. So it's like a super low dose. And that is really important. The dose is always an issue here. So when you abuse substances and when you risk becoming addictive, then it's larger doses and the dose needs to be increased all the time because of tolerance. And then the next thing that we need to know about central stimulant medication is that when you we know that the doses is lower and also that you often when you take the short acting substances, you all, you almost always take them together with or in as an additive to a long acting  and then you have the protection. Is that how you  always. Yeah,  I very often prescribe it like that.  I try to always get the long acting to work. So it's just if it really doesn't work for any reason, then we go and try the short acting. But otherwise I can use like a long acting in the morning and then add during lunch. So you get two. Peaks and try to puzzle together in, in that sense.  But at the end of the day,  becoming addictive  is when a dopaminergic substance  comes into your reward system very fast, like nicotine, small molecule can access the central nervous system really fast after you have done something like smoke or snuffed or so. So the faster the root so intravenously.  Or snorting or taking it like in your what do you say, mucuses is much more has a much more addictive quality than swallowing a pill that has to, tumble around in your belly, then enter your intestines and then taking, be taken up. And that is actually what is.  With the short acting substances, they have to go through that route. So they are also safer than addictive substances, but they can, of course, be  administered  in another way. And the long acting can't really because you can't really take. The long acting dexamphetamine, or less dexamphetamine, sorry. It doesn't matter if you administer it through another route, because it has this molecule attached to it that doesn't allow it for entering the nervous system once like a hit in that sense. So there are a lot of reasons why we have more  I definitely can prescribe short acting, but I have the security system around it. And I'm always very like clear with my patients because I don't want to put my patients in a situation where they end up in a in at risk for this and without themselves knowing it or so I think that's an important aspect of it.  And entering fast and going out fast. So this peak is problematic, but short acting medications have things that will protect us from that, the lower dose and the oral intake.   That's interesting because myself, I'm only on short acting. My psychiatrist wouldn't give me the long acting due to the shortage. And.  I would say the majority of people I know they're right now on the short acting, and because if someone like me, I metabolize the short acting so quickly that there's days that I think it's not even worth it. So it's interesting saying that. how you prescribe, because I think it sounds like a better,  it's very individual and you have to listen to your patient. And I do have patients that don't tolerate the long acting and that their short acting is the only thing that actually works for them. And then you have to believe that. And then you have to, find a way to work with that. So I think that's extremely important that we don't like shame people for having short, I think that's absolutely not. So that's what I wanted to clarify. And I think I have to clarify that also on, on this small. No, I think  it was clear and it was clear also that it was an excerpt of a longer,  There was much more to what you would have said. I am interested for people who are either still only self diagnosed or still Figuring out we see all the time of different supplements. Take this. Take that.  Is there anything that you think people should absolutely be on? Or that has really actually been proven to work? And I guess if you want to also consider, do you recommend certain blood panels before or while people are figuring everything out for themselves?  We start with blood panels. I think if you if you get a lifelong neurodevelopmental diagnosis that can potentially have implications for your, at least when you're in Sweden, it can have implications of what occupations you can do. And if you can have a driver's license, I think it's pretty, okay, or fair to just check some things. Out so make sure that  this diagnosis is not caused better or better explained by something else. And then, obviously, and that is perhaps even more important when it comes to children because you have lived an entire life. It's really not. Likely that, that it should be better explained by what anemia like low blood count or hypo thyroidism.  Hypo or hyper can cause, you behaving in a way that people's oh, but that person has ADHD clearly, or that person has ADD because it's looks so zoomed out. And that can be due to to, for example the thyroid dysfunction. But otherwise I think it's a good just rule to make sure that there's at least nothing else.  worsening your ADHD. So then it's important to know that

your blood count, because if you're anemic, then you will have a harder time concentrating and regulating your emotions. And then have meltdowns and you have all that stuff but it probably won't explain your ADHD, but it can explain why Your ADHD is so difficult to medicate right now, or why is that so I would say, but I don't typically I don't use and I don't recommend any extensive like blood panels or blood works. I think the basic thing that you check sometimes regularly across your life. And if there is something specific going on in your life, you usually check like your blood works, your your hemoglobin.  It's like on a very, I would say on a very simple level. And then if you have had some other comorbidities,  then you might want to. Check something else in the liver status or something like that, but I don't use any extensive blood panels in my clinical practice.  I don't unless it's required for some kind of specific treatment but not for ADHD treatment in the arrow. No I do tend to listen to the medical history. I think that should lead rather than just, firing off. Some extensive blood panel  and it, when it comes to diets and specific supplements and so on I'm afraid I'm not really well read up on that I've tried and I've been in, in like periods of my clinical practice, but  for me, it's hands to like, Not be that relevant on the individual level. So there has been there was some research on like fish oil and omega 3 acids. And that seems logical and reasonable, but it also seems like you need so high doses and that it might be difficult to continue that over time.  Vitamin D, especially for people with darker skin during the winters, that seems to, not only for ADHD, but for mental health,  per se could have some protective effects, it seems. But it's, it is very difficult, I think, to interpret the research and say, with any like 100 percent certainty that this is what you should do. I think ADHD and autism and like neurodevelopmental disorders it's so much about moderation instead. And it's, the risk is rather that you do something too much and take too much of a supplement or do some diet a little bit too extreme. So I would say If it's possible not to listen too much to those kind of extreme supplement, or you should exclude this, or you should exclude that, but rather to see, is it possible to just be, and in Swedish, there is a perfect word for this. It's called lagom, but there's no word for that in other, in any other, I think language, but lagom means like just enough or, it is such a boring word because it's nothing has nothing to do with the extremes. It's just lagom. And  that is the most difficult thing when you have ADHD. It is never lagom. It is never like It's you tend to exaggerate in one or the other direction, right? So you tend to be too active or too passive. You eat too much or not at all. And so I think when these kind of discussions with supplements and diets and so comes on, I'd say my biggest challenge is, has always been to be log on, to be moderate and to stay there and just to endure The boredom of moderation,   which for an ADHD person,  yeah, torture, right?  I just wanted to ask about the pregnancy and breastfeeding if those hormones, obviously we know there's hormonal changes in pregnancy and breastfeeding and how those affect our ADHD.  So I, as I told you in the beginning I you wrote this question and I ended up in a rabbit hole of research which I thank you for, because it was really interesting but there was a lot of things that I haven't really. Reflected on basically and unfortunately I ended up with in a rabbit hole consisting mostly of what kind of medication you can use when you are breastfeeding. So that I know a lot about now, but.  Yeah, I did. I did look into also what happens like hormonally and how that can affect. And I think that's really interesting because I have had a lot of women now pregnant and having their babies. And I'm not sure what it's like at your place, but here in Sweden, we have had a very strong like tradition. of breastfeeding. It has been almost like sacred in the sense that you should do it. It is the best for your child. It is best for yourself and you can do it everywhere openly. And if someone like glances at you because you have your breast all over the subway then you just, tell them to go. themselves because you are breastfeeding. Basically that is, I am exaggerating. I have that tendency, but it is a little bit like that. So for me, when I got my kids, I was like, and I got two pair of twins, right? So for me, there was nothing else. It was like, okay, so now I have to breast feed them for a year, because that's what you do. And it's so important for their immune system and for the, like our attachment process and stuff like that. So I almost killed myself.  And I on trying to do that and I like depleted my all my energy levels and I didn't sleep anything and still I didn't stop and I had so many no sound and like wise friends like what are you doing just you know give them a bottle right and then I learned. So the next pair of twins it was like, never again I should not like.  Do this because it actually hurts the attachment process when you're so stressed out when you're so deprived of sleep. And when you feel so like stress is stressed and miserable about everything and so I, I would say.  that this is a really important discussion that you want to have with mothers to be. It's are you going to breastfeed? That is brilliant and great if you do that. It's perfect food for your kid. It is like the right temperature and you have it with you all the time. And it's it's no, like it's clean and it's without infection, hopefully, and all that stuff. Really great. But it is also not that ADHD friendly because you have to be on your baby's clock and you can't really schedule things that is really important for you now when you have all these new routines and stress in your life and new hormones,

because then you can't really schedule when you can sleep next time because you can be waking up any, second And that is it might be a greater stress for a neurodivergent mother than for a neurotypical mother.  And then there's the hormones also. So having this extremely high hormone levels of estrogen and progesterone.  during pregnancy. And then basically from one day to another, because the estrogen is from being produced in the ovaries for the non pregnant woman, most of the estrogen is produced in, in, in the placenta and that placenta just, gets ripped out with a kid. So then you go from like these levels to nothing in the matter of Minutes of hours. So that is a huge hormonal hit.  And then the the hormones that is active, prolactin that is active and that is that kicks in to start producing the the milk has a. It has a works as a break on estrogen and progesterone because you don't want to have ovulation and you don't want to have this kind of fluctuating hormones when you are breastfeeding. So then there are two other hormones, oxytocin and prolactin, that is the main hormones across your in the entire time that you actually are breastfeeding.  And you look, and when you look at mothers who decide not to breastfeed, they still have this high levels of prolactin up to a month actually. Even though they are  bottle feeding their kids and not lactating but it's like that those levels are  dragging along for a couple of weeks. Before they normalize and your usual like hormonal  cycle kicks in again. So there are I don't think when looking at it from that perspective, it's not a surprise that females are very vulnerable during that this is also like a vulnerable window of our female life both across pregnancy, postpartum, and then lactation. Like you said, it's  the hormones are a big part, but also the sleep factor, like  some people have unicorn babies, of course, that sleep  all night. And they're amazing. I didn't have one of those. A lot of people don't have. Where you're even getting decent trunks, a lot of the times it might only be  30 minutes, an hour, two hours.  And we know how sleep plays a role.   Yeah. And the constant stress of not knowing that is almost the worst thing. That's the torture, right? It's like there might be 30 minutes. It might be three hours. It might be 10 hours. I don't know.  That is that is one of the most difficult thing. That is the torture element of it. At least it was for me, because if I only knew then I can deal with this. Then I can try to maneuver. In life but not knowing in all these new routines, not knowing what child what is, who is this child? What is the temperament? Is he or she going to sleep? Is what, does he have a tummy ache? What is where are we heading now? So there's the sleep, there is the new routines, there's the stress, there is the like the comments and suggestions from people around you, perhaps judging, perhaps oh, it's okay, so you're doing it this way, you're not breastfeeding, okay, I thought everyone was like, there's so much things that, that people feel that they, are allowed to think about you and your motherhood and how you do things. And that is also something that I advise a lot of my patients just to armor themselves with really good arguments for, to shut people up because it's really not their business. And you have to make some sense of this yourself and to survive because that is how I felt a lot of the, I felt it was like, this is the most important thing. thing or person and period and everything. It's there was nothing, there's nothing to compare with the feeling that I got, just as, this baby arrives. I had no idea before. It's very hard time, like imagining what this would feel like. And then the baby is this, like the love story of the century. And then, Knowing that you want to do everything right for this little tiny creature, and then having people telling you what to do, not, maybe it's your first time as a mother and you don't know anything, and then you have all this good advice from people around you it can make you crazy. No, it really can. And it's all, mostly well meaning people, but it's still,  it's it, yeah, it, so many people drives crazy. And like for me, I forgot for a while that she was just a tiny human with normal biology, like I have. So I listened to all the quote, unquote sleep experts. And until I realized, Oh, no, I, I know about sleep. I just apply this to her.   Exactly. Yeah. You can so easily get lost because it's an important thing that you do and then you want to do it right. And if you have also, if you are a neurodiverse woman, you've probably become really talented of not listening to your gut feelings and to, to what's what you need and what you so that is also difficult then when you wanna, do right by your child and you haven't really done right by yourself in a lot of ways, right? Yeah. Yeah.   You're just such a wealth of knowledge that it's so Generous of you, honestly, that you'll just sit and share. And I've said it before. I said it all the time, actually, but if people do not have letter life, they need it because that is exactly what it is. Literally you just  putting your brain out there for all of them.   Yeah, it is. And I also need as many women as possible to feed back on that and to make sure that I. deliver the things that is valuable because I feel like I'm that I'm obliged in some sense to, to give back to what I've learned all this while working and, being educated and having, being blessed in that sense. So for me, I think,  Hopefully this knowledge can do some good out there and it's possible for, and I hope of course that I'm not overstepping any boundaries but you take it for what it is and everyone is unique. So it's not like I have any kind of solution or. Magic bullet for that will work for everyone. And I think I hope also that I constantly stress that how little we actually know from research, but also that we can't really just stand and wait for it. We have to also listen to all the testimonies and all the  knowledge that is actually out there and try to put that into. into a perspective. And that is what I'm trying to do in letter life, actually.   Wow. And it's such an amazing resource that everyone needs to get on it. So  great. Now I'm going to write about breastfeeding and medication because you inspired me. So now I've written an entire piece about that. So that is the next.   Yeah, because everyone thinks you can't, but really you can.