The ADHD Brain

Attention Deficit Hyperactive Disorder is a condition plagued with misconceptions. It is commonly believed to be a childhood behavioral disorder, usually conjuring images of rowdy little boys who just can’t sit still. However, as we have collected more research, we’ve come to learn that this depiction is not accurate. ADHD has a wide variety of different manifestations, many of which look very different from what we have come to expect. ADHD is a debilitating physiological condition found in people of all ages that deals with developmental differences in the prefrontal cortex and dysregulation of neurotransmitters and reward pathways in the brain. Understanding how ADHD physiology differs from non-ADHD physiology informs us of ways we can use medications and targeted strategies to work around and with the unique wiring of the ADHD brain and improve overall health and quality of life. 

Some ADHD misconceptions are fed by the name itself: Attention Deficit Hyperactive Disorder. The current name focuses only on the most easily observed outward symptoms, such as disruptive behavior, despite this being only one of many possible manifestations of the condition. It ignores the underlying mechanisms and draws our focus away from other common, but less obvious side effects of the condition. Because of this, many try to treat the condition using purely behavioral techniques, only addressing the surface level symptoms rather than understanding the complex physiology at the root of it all. In other situations, it may go entirely unnoticed and untreated, severely impacting quality of life, simply because the individual does not manifest the most obvious symptoms.

A better name for the condition might be Dopamine Disruption Disorder. Dopamine is heavily involved in reward pathways and is triggered by rewarding and pleasurable situations. It is the impairment of dopamine transmission in ADHD that is thought to underlie the core symptoms of the condition.While other neurotransmitters are certainly involved in ADHD symptoms, research has implicated faulty dopamine pathways in reward centers of the brain as one of the major causes of ADHD. DNA studies have found specific genes correlated with ADHD that dealt with dopamine regulation (Swanson et al., 2000) and brain imaging studies have found disruptions in dopamine transmission, especially in the accumbens and midbrain, reward centers in the brain (Volkow et al., 2009).

Those of us with ADHD essentially have a dopamine shortage, and so are constantly seeking for enjoyment or excitement (often unconsciously) to trigger enough dopamine to bring us up to equilibrium. People with ADHD are commonly driven to seek out anything that boosts those neurotransmitters, which may include excessive food, social media, video games, parties, alcohol, drugs, risky or promiscuous behavior, or other exciting or pleasurable activities. Of course, all humans seek pleasure and may engage commonly in these behaviors, but the drive is much stronger in those with ADHD.

Thus the reason why some children are loud and disruptive is because the excitement of making a scene is stimulating the release of dopamine and meeting their physiological needs. However, as mentioned previously, this is not the only way to trigger dopamine release. Others with ADHD may find quieter ways to seek stimulation, such as daydreaming, playing video games, browsing the internet, or reading and watching exciting media. Others still may be hypersocial and overly talkative, or addicted to working out or playing sports. It’s clear there are a numerous variety of ways ADHD may manifest itself, with all these vastly different behaviors designed to meet the same core physiological need.

Researchers believe this phenomenon of dopamine dysregulation is what is responsible for ADHD’s characteristic impulsivity and inattention. Although, it’s not so much inattention as it is inconsistent attention. ADHDers give their attention to whatever is providing them with the most satisfying stimuli. If a subject in school is particularly interesting to that individual, they may have no trouble giving it their full focus. If the subject is uninteresting, they will be driven to turn to other sources for stimuli. When one is starving for dopamine, it is very difficult to devote energy to an activity that holds no novelty. This is why parents often observe their children with ADHD devoting hours of intense focus to video games, but struggling to give as much attention to tasks in school (Berridge & Devilbiss, 2012).

People often underestimate how debilitating ADHD truly is. One of the most frustrating aspects of living with ADHD is the struggle with executive dysfunction. Executive functions are associated with dopamine dysregulation in the frontal cortex of the brain and deal with planning, organizing, managing time, delaying gratification, behavioral regulation, and behavioral and emotional inhibition (Arnsten & Li, 2005). Executive dysfunction is one of the most common symptoms of ADHD and severely impairs our ability to manage the aspects of life necessary to be healthy and successful.

We have to spend so much time and energy fighting (or giving up and indulging) our endless need for dopamine, that we struggle immensely to take care of necessary daily tasks. We battle procrastination non-stop, trying desperately to will ourselves to do that chore, make that phone call, or catch up on homework, despite our body screaming at us the entire time to go and fill our physiological need for dopamine. We often lose such battles, and then develop intense shame and low self-esteem as we fail to meet our goals. In addition, our behavioral and emotional impulsivity can lead to poor decision making and social missteps that interfere with our ability to develop strong interpersonal skills and relationships, further sabotaging ourselves and our future capacity for improving our quality of life.

Research has shown that the most effective way to address problems resulting from a shortage of dopaminergic activity is to safely boost dopamine transmission in the brain. A common way of doing this is by prescribing controlled doses of stimulants. Stimulants work by increasing the availability of synaptic dopamine, which helps improve the functioning of the frontal cortex and the reward pathways in the brain. Many studies have shown that these kinds of medications are very effective, significantly reducing symptoms of executive dysfunction, inattention, and impulsivity (Faraone et al., 2006).

However, many express concerns regarding potential pitfalls and misuses of ADHD stimulants. One commonly expressed fear is that stimulants could prove to be a gateway drug and lead to addiction in those who take it. However, the research has shown quite the opposite. Medicated individuals with ADHD are actually less likely to develop drug abuse problems than unmedicated individuals (Chang, et al., 2014). 

This phenomenon may be explained by the hypothesis of self-medication. The assumption behind this hypothesis is that individuals who are suffering with untreated conditions, such as ADHD, find relief from their situations in addictive substances. However, if there is another, safer way to provide that relief and satisfy their needs, it will remove the need to indulge in dangerous substances. In the article where this hypothesis is discussed, it was found that individuals who had already developed an addiction to cocaine could be effectively treated using stimulant medication (Mariani et al., 2013). This hypothesis certainly is supported by the body of literature supporting ADHD medication as a deterrent to drug abuse rather than a gateway, in addition to its efficacy in reducing negative ADHD symptoms.

Anecdotally, I’ve seen the effectiveness of ADHD medication and treatment in my own life. Where on unmedicated days, I can spend hours trying to motivate myself to get some work done, I have little trouble sitting down to work on days when I take my medication. But medication is not the only treatment I use to address my “dopamine shortage.” More often, I try to rely on strategies that incorporate other ways to meet my dopamine needs. To do this, I try to make daily life and tedious tasks as fun as possible, to trigger enough dopamine release to power me through each task. I might listen to audiobooks while cleaning, chew gum and listen to music while working on an assignment, or put study guides into text-to-speech software to listen to while playing video games (open world ones where you can turn off your brain and wander the woods.) These kinds of strategies allow me to satisfy my need for novelty and entertainment while I engage in less enjoyable tasks, allowing me to work much more efficiently. I would like to see more research exploring the use of this concept in ADHD treatment, see if anyone could replicate the benefits I’ve seen from my strategies in a controlled study.

While the current understanding of dopamine’s role in ADHD is still developing, and may be an oversimplified model of ADHD brain function, the research clearly shows that the impaired transmission of dopamine is responsible for much of the dysfunction associated with the condition. The dysregulation of dopamine in reward centers and frontal cortex seem to be the primary drive of executive dysfunction, impulsivity, inattention, and hyperactivity. Additionally, these symptoms may manifest in a wide variety of different ways depending on how the individual learns to cope with their brain chemistry. This means ADHD could look like anything from a bouncy little boy with too much energy, to an adult woman who struggles immensely to manage her time and relationships, to a quiet little girl who can never seem to turn her homework in on time. While only one of these three individuals seems to exhibit traits we commonly associate with ADHD, the struggles of each of these individuals can be traced back to the same common source, and all may find relief by meeting their neurotransmitter needs.

References

Berridge, C. W., & Devilbiss, D. M. (2011, June 15). Psychostimulants as cognitive enhancers: the prefrontal cortex, catecholamines, and attention-deficit/hyperactivity disorder. Biological psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3012746/.

Chang, Z., Lichtenstein, P., Halldner, L., D'Onofrio, B., Serlachius, E., Fazel, S., … Larsson, H. (2014, August). Stimulant ADHD medication and risk for substance abuse. Journal of child psychology and psychiatry, and allied disciplines. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4147667/.

Faraone, S. V., Biederman, J., Spencer, T. J., & Aleardi, M. (2006, October 5). Comparing the efficacy of medications for ADHD using meta-analysis. MedGenMed : Medscape general medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1868385/.

Mariani, J. J., Khantzian, E. J., & Levin, F. R. (2014). The self-medication hypothesis and psychostimulant treatment of cocaine dependence: an update. The American journal on addictions. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4227391/.

Nora D. Volkow, M. D. (2009, September 9). Evaluating Dopamine Reward Pathway in ADHD. JAMA. https://jamanetwork.com/journals/jama/article-abstract/184547.

Swanson, J. M., Flodman, P., Kennedy, J., Spence, M. A., Moyzis, R., Schuck, S., … Posner, M. (2000, January 12). Dopamine genes and ADHD. Neuroscience & Biobehavioral Reviews. https://www.sciencedirect.com/science/article/abs/pii/S0149763499000627.

Volkow, N. D., Wang, G.-J., Newcorn, J. H., Kollins, S. H., Wigal, T. L., Telang, F., … Swanson, J. M. (2010, September 21). Motivation deficit in ADHD is associated with dysfunction of the dopamine reward pathway. Nature News. https://www.nature.com/articles/mp201097?source=post_page.