A Natural Fix for A.D.H.D

ATTENTION deficit hyperactivity disorder is now the most prevalent psychiatric illness of young people in America, affecting 11 percent of them at some point between the ages of 4 and 17. The rates of both diagnosis and treatment have increased so much in the past decade that you may wonder whether something that affects so many people can really be a disease.

And for a good reason. Recent neuroscience research shows that people with A.D.H.D. are actually hard-wired for novelty-seeking — a trait that had, until relatively recently, a distinct evolutionary advantage. Compared with the rest of us, they have sluggish and underfed brain reward circuits, so much of everyday life feels routine and understimulating.

To compensate, they are drawn to new and exciting experiences and get famously impatient and restless with the regimented structure that characterizes our modern world. In short, people with A.D.H.D. may not have a disease, so much as a set of behavioral traits that don’t match the expectations of our contemporary culture.

From the standpoint of teachers, parents and the world at large, the problem with people with A.D.H.D. looks like a lack of focus and attention and impulsive behavior. But if you have the “illness,” the real problem is that, to your brain, the world that you live in essentially feels not very interesting.

One of my patients, a young woman in her early 20s, is prototypical. “I’ve been on Adderall for years to help me focus,” she told me at our first meeting. Before taking Adderall, she found sitting in lectures unendurable and would lose her concentration within minutes. Like many people with A.D.H.D., she hankered for exciting and varied experiences and also resorted to alcohol to relieve boredom. But when something was new and stimulating, she had laserlike focus. I knew that she loved painting and asked her how long she could maintain her interest in her art. “No problem. I can paint for hours at a stretch.”

Rewards like sex, money, drugs and novel situations all cause the release of dopamine in the reward circuit of the brain, a region buried deep beneath the cortex. Aside from generating a sense of pleasure, this dopamine signal tells your brain something like, “Pay attention, this is an important experience that is worth remembering.”

The more novel and unpredictable the experience, the greater the activity in your reward center. But what is stimulating to one person may be dull — or even unbearably exciting — to another. There is great variability in the sensitivity of this reward circuit.

Clinicians have long known this to be the case, and everyday experience bears it out. Think of the adrenaline junkies who bungee jump without breaking a sweat and contrast them with the anxious spectators for whom the act evokes nothing but terror and dread.

Dr. Nora D. Volkow, a scientist who directs the National Institute on Drug Abuse, has studied the dopamine reward pathway in people with A.D.H.D. Using a PET scan, she and her colleagues compared the number of dopamine receptors in this brain region in a group of unmedicated adults with A.D.H.D. with a group of healthy controls. What she found was striking. The adults with A.D.H.D. had significantly fewer D2 and D3 receptors (two specific subtypes of dopamine receptors) in their reward circuits than did healthy controls. Furthermore, the lower the level of dopamine receptors was, the greater the subjects’ symptoms of inattention. Studies in children showed similar changes in dopamine function as well.

These findings suggest that people with A.D.H.D are walking around with reward circuits that are less sensitive at baseline than those of the rest of us. Having a sluggish reward circuit makes normally interesting activities seem dull and would explain, in part, why people with A.D.H.D. find repetitive and routine tasks unrewarding and even painfully boring.

Psychostimulants like Adderall and Ritalin help by blocking the transport of dopamine back into neurons, thus increasing its level in the brain.

Another patient of mine, a 28-year-old man, was having a lot of trouble at his desk job in an advertising firm. Having to sit at a desk for long hours and focus his attention on one task was nearly impossible. He would multitask, listening to music and texting, while “working” to prevent activities from becoming routine.

Eventually he quit his job and threw himself into a start-up company, which has him on the road in constantly changing environments. He is much happier and — little surprise — has lost his symptoms of A.D.H.D.

To compensate, they are drawn to new and exciting experiences and get famously impatient and restless with the regimented structure that characterizes our modern world. In short, people with A.D.H.D. may not have a disease, so much as a set of behavioral traits that don’t match the expectations of our contemporary culture.

Matt Leines