Adventures in Dysfunction: The ADHD Brain

by Shara E.

In general, organization is not a word that many people would associate with me.  I am the first to admit that I can be, to put it mildly, a bit scatterbrained. On a daily basis, my attempt to keep up with the various tasks feels rather Sisyphean; never ending, and not something I’m likely to succeed at. For years, I thought this was due entirely to a lack of…something…on my part. If I could just try hard enough, it would be easy to to pay attention in class, do my coursework before the night it was due, and remember to pay my bills on time. Somehow, no matter how hard I tried, it was never enough. My brain always felt a bit like this:

“ADD” by XKCD , used under Creative Commons

This trap is what ADHD coach Kevin Roberts calls “living in the land in the ‘just’”, and is a common trait of individuals,  group which i happen to be part of,  with Attention-Deficit/Hyperactive Disorder (ADHD). ADHD is one of those behavioral disorders that seems to be the catchall explanation for any sort of forgetfulness or distraction. However, very few seem to understand what ADHD actually involves, instead staying in that “land of the just”, where if you would “just” do X, then all your problems would go away. Unfortunately, for the roughly 10% of children and 4% of adults  in the United States  who have ADHD, it’s not always about trying harder, but about dealing with actual, measurable physical and biochemical differences in the ADHD brain.

What is ADHD?

As with many mental health disorders, our understanding of ADHD is still evolving. Diagnosis is difficult, and symptoms are often mistaken for other disorders/syndromes, in part because there is still a significant amount of debate over what causes it.   The pursuit of understanding is further impeded by the high incidence of comorbidity in affected individuals, as diagnoses of obsessive compulsive disorder, bipolar disorder, anxiety disorders and ADHD frequently overlap.

The current criteria for an ADHD Diagnosis come from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR), however there are some fairly significant changes likely in the DSM V, which will be released in May 2013. As a result, I’m going to use the newer definitions and criteria from the DSM V (which are also accompanied by rationale for the proposed changes) as an in-depth reference for ADHD symptoms and difficulties.  The complete criteria from the DSM-V can be found below.

As a brief, and slightly less overwhelming summary, a diagnosis of ADHD requires the following:

1. The individual has at least six criteria/symptoms in one of two categories, or both, inattention and hyperactivity/impulsivity. While an individual may have symptoms from both categories, at least 6 from one are necessary to be diagnosed.
2. These symptoms have persisted for at least six months, are inconsistent with the expected developmental level, and have had a direct impact on the individual’s life.
3. Several of these symptoms were present prior to  12 years of age.
4. The symptoms can be seen in at least two settings in the individual’s life, i.e. home, work, or academic performance.
5. There is clear evidence that these symptoms interfere with the quality of the individual’s ability to function in these settings.
6. The symptoms are not attributable to another mental disorder, such as bipolar disorder or anxiety disorders, and are not due to a psychotic disorder, such as schizophrenia.

Looking at the in-depth list of criteria in either the inattention or hyperactivity and impulsivity categories, you might pick out one or two of the symptoms (or all of them) that you frequently experience in your own life.  Really now, who doesn’t feel disorganized sometimes? Who doesn’t have problems paying attention in a particularly boring lecture or meeting?

My personal guess is almost no one. The key differences in diagnosing ADHD versus general, everyday difficulties, lie in the persistance of symptoms for more than 6 months, onset before 12 years of age, and being able to clearly show that these symptoms have had a negative impact on the individual’s life, and ability to function in social, occupational or academic settings.

ADHD at the Biological Level:

Almost all of the symptoms mentioned in the DSM criteria for ADHD relate to difficulties/deficits in executive functioning, (also referred to as cognitive control impairment and response inhibition).  Executive functions can be broken down into two broad categories:

1. Organizational skills, such as the ability to plan in advance, remember details, and manage time
2. Regulatory skills, such as the ability to link past behavior with present action, and the power to exercise what I like to call the Edit Button. i.e. having the restraint to not blurt things out, or recognizing and limiting inappropriate behavior.

The frontal lobes, and particularly the prefrontal cortex of the brain are largely responsible for regulating executive functioning. Althoughother parts of the brain are also utilized in executive functioning, the majority of literature available focuses on frontal lobe activity and dysfunction as causal elements in executive function-related disorders, such as ADHD.

Studies have found evidence of reductions in overall volume of the frontal lobes, as well asother structural differences, decreased thickness of the cortex (the outermost layer of the brain), and atypical activity within the frontal lobes, particularly the prefrontal cortex.

At the chemical level,  almost all of these factors relate back to a neurotransmitter called dopamine, which functions as part of the body’s reward pathway, influencing your desire for certain activities. Your body craves the feeling you get when dopamine is released, so you modify your behavior in order to get to it. Many drugs, such as cocaine, interfere with these pathways as a means of increasing dopamine levels, thereby increasing the pleasure/reward feeling.

This pathway is the same one that triggers anticipation and cravings when you see or smell one of your favorite foods, and makes biting into that cheeseburger that much more pleasurable (and delicious). Your body develops cause and effect ‘memories’ of what can trigger the reward feeling, a method also known as associative learning.

In ADHD, dopamine pathways are improperly regulated, impacting an individual’s behavior.Impaired dopamine regulation means that associative learning is much more difficult and that complex cause/reward linkages are more difficult to establish. Without these linkages,the brain seeks more immediate rewards, hence problems in executive functions such as time management, organization and impulsive activities such as blurting out answers in class, all of which involve delayed gratification. For a more in-depth explanation of the impact of dysfunctional dopamine pathways,  see the video below.

Scientific understanding of the exact causes of ADHD is still evolving, but there is general agreement that alterations in the dopamine/reward pathway in the brain are involved.  ADHD people think differently. So what is a simple, or modestly unpleasant, or easy task for a ‘normal’ brain, can be substantially more difficult for someone with ADHD.  In essence, people with ADHD function differently, because parts of their brain chemistry are different.  So, while don’t think the “I’m sorry I didn’t do my homework, my brain is broken” excuse is a viable option, I do think that it’s worth bearing in mind that, for many, never-ending disorganization it isn’t because they aren’t trying hard enough.