by Dr. Steven D. Graham, Licensed Psychologist, in Tampa, FL

A Look Inside the ADHD Brain

If you could look inside the brain of someone diagnosed with untreated ADHD, what would you see? Would the brain look and function differently from a non-ADHD brain? If so, how? In this article, we will look at the neurocognitive functioning of the ADHD brain.

First, however, it might be important to ask what, exactly, is ADHD? Some mental health professionals still utilize the term “ADD.” What we used to believe was that someone had either an attention disorder or a hyperactivity/impulsivity disorder, or sometimes both; “ADD” was shorthand for ADHD without the hyperactivity. What we now realize is that ADHD is one disorder: sometimes the inattention is prominent; other times the hyperactivity or impulsivity seems to be. Often both sets of symptoms occur together.

Our Brains Can Heal!

Neurocognition refers to what happens in our brains and nervous systems that affects the way we think. You may imagine that if something is different or “wrong” in the brain, then the situation is hopeless. Indeed, in years past, neurologists would often shrug and say they could not do much if something were awry in our brains. But what we have discovered over the past 30 years, however, is the phenomenon of neuroplasticity, our brain’s amazing ability to repair, re-route, and restore functioning. Our brains find a way to heal! Often this takes time, but sometimes we begin to see glimpses of improved brain functioning within just a few weeks of beginning treatment. We have also learned ways of assisting that process, which we will explore in later issues.

This is good news for all of us, since many of us sustain some type of brain injury, including life’s traumas that come our way. And, once our brains begin to heal, the way we think and process information will improve. As a result, we can work to enhance how we take in information, how we encode and decode information, and how we store and retrieve data when we need it. We can also then enrich how we make decisions and exercise sound judgment. It is also amazing to see how individuals with ADHD often discover, on their own, workarounds and tools to help them achieve and succeed in life.

People with ADHD may be labeled as narcissistic, bipolar, histrionic, or some other disorder both by those frustrated with these behaviors and by professionals who are ill-informed. In either case, the person struggling with ADHD continues to feel unseen and misunderstood, which only deepens the sense of being an outcast.

What Causes These Particular Symptoms?

It is one thing to describe the symptoms of ADHD, but I think it is also helpful to understand what is taking place in the brain to produce those symptoms. It goes without saying that in this article I will not be able to explore everything in the ADHD brain, so I will focus on some of the most important highlights. According to the latest research,* the prefrontal cortex (PFC) in an ADHD brain is underactive. The PFC is the executive center of the brain, where we plan, organize, strategize, prioritize, exercise restraint, and make good decisions. What I want to do now is to look at three further differences in the ADHD brain.

Brain and Brain-Part Size

Functional imaging shows that the untreated ADHD brain is smaller than the non-ADHD brain. This difference is greater in children than in adults, revealing that the ADHD brain matures at a slower pace than non-ADHD brains. Further, the amygdala (which processes fear and threats) and the hippocampus (responsible for a great deal of learning and memory), both parts of the limbic system, the emotional center of the brain, also tend to be smaller, suggesting that regulation of oneself may be difficult without some additional help. (This information comes from the largest worldwide review of ADHD patient brain scans, conducted by Radboud University Nijmegen Medical Centre, Netherlands, in 2018.) For example, many with ADHD seem to have no fear. They sometimes take unnecessary risks or engage in hazardous sports or activities, while others can be particularly fearful and may wrestle with one or more of the anxiety disorders.

Neurotransmitters: The Communication System of the Brain

Arguably the most important finding regarding ADHD is the abnormally low levels of neurotransmitters in the PFC. This impacts a person’s ability to bypass urges or exercise discipline or make difficult choices. As previously noted, the PFC as the executive center of the brain (which we will discuss further in the next article) is responsible for planning, deciding, prioritizing, organizing, and everything necessary to resist impulses. It enables us to escape the cycle of stimulus-response by adding the important intermediate step of thinking.

Neurotransmitters are what our nervous system uses to communicate between nerve cells. The two most important neurotransmitters of the PFC are dopamine and norepinephrine. Without adequate levels of dopamine, we feel bored and unmotivated. Life can seem dull. Dopamine is largely associated with a sense of feeling rewarded. If I am not getting enough dopamine naturally, I will go after it in other ways, hence the attraction toward that which is fun, novel, or stimulating.

Norepinephrine, on the other hand, is associated with alertness and arousal and can speed up my reaction time. Without adequate norepinephrine, attention and focus can be blunted. Taken together, these low levels of dopamine and norepinephrine (along with the other developmental challenges of the brain noted above) impair one’s ability to be still, to self-regulate, to concentrate, and to make sensible choices.

Two Ways Dopamine Gets Released

Let’s dive just a little deeper into dopamine. We have found that dopamine is released in two fashions, essentially: by tonic release and by phasic release. Tonic release refers to the normal supply which is steadily released for us in the brain, while phasic release describes the process of getting dopamine from the environment. In the ADHD brain, tonic release basically underperforms while phasic release overperforms. In other words, in the non-ADHD brain, where dopamine is released normally, there is a steady, ongoing source of dopamine available, especially to the PFC. The opposite is true for the ADHD-brain: the tonic or steady release of dopamine does not occur efficiently at all.

Phasic release, on the other hand, which occurs when some stimulus from the environment enters the situation, boosts the dopamine in the PFC. In other words, if I am not getting enough tonic release of dopamine on a regular basis, then I am especially sensitive to anything environmental — phasic — which will produce dopamine. This means that when the brain is dopamine-hungry, it will get dopamine anywhere it can. If that happens naturally (as in the non-ADHD brain), we find ourselves easily rewarded and content. If it happens by outside stimuli (as in the ADHD brain), we will seek arousal and reward anywhere we can.

How It All Works Together

In summary, if we look at these three aspects of the brain and brain functioning — 1) brain and brain-part size, 2) neurotransmitter activity, and 3) less-than-adequate tonic release of dopamine — we begin to understand why someone might be hyperactive/impulsive along with inattentive. With the relative sizes of the amygdala and hippocampus, first, we see how someone with ADHD may have an impaired fear-response. We can also understand that if the hippocampus is affected, then my ability to put information into memory and be able to retrieve it might be compromised.

Second, if my PFC is not receiving adequate amounts of dopamine and epinephrine, then I will feel unmotivated to persevere, and my ability to delay gratification will be compromised. My life will feel drab unless I spice it up a lot, which can get me into trouble of all kinds. Third, if the tonic release system of adrenaline is underfunctioning, then I will rely on my ability to use the environment to enhance the phasic release of adrenaline, which will leave me distracted and searching for dopamine-producing stimuli.

I hope this brief overview helps to explain why ADHD symptoms exist just from a look inside the brain alone. When we focus on enhancing a healthy release of dopamine and norepinephrine in the PFC, function is dramatically improved. What is more, we are discovering ways of improving the size and action of the amygdala and hippocampus using both pharmaceutical and non-pharmaceutic means.

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*See CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder), founded in 1987, http://chadd.org. See also the research of Dr. Daniel Amen at www.amenclinics.com. In his Healing ADD: The Breakthrough Program That Allows You to See and Heal the 7 Types of ADD, Dr. Amen provides actual SPECT (Single Proton Emission Computed Tomography) images of the various types of ADHD from actual patients his clinic has treated.

I was convinced that Joe Smith—not his real name, of course—wrote his letter V’s wrong in the second grade, and I thought it helpful to inform him of such. After all, he needed all the help he could get, and I thought, as a precocious 7-year-old girl, I had a monopoly on how to craft the most beautiful V on paper—how clueless could Joe be, after all?

Much has been written in recent times about how learning styles are different, neurologically, between girls and boys. As a mother of two boys, this subject matter has come to the forefront in my own household and, in fact, smacked me in the face on occasion (metaphorically speaking). Eons past, I recall being able to sit (with ease and no second thought), criss-cross-apple-sauce, and keep my hands to myself during circle time. What was the problem with these darned, squirrely boys who just couldn’t sit still and wiggled and squirmed, waiting with bated breath for recess?

Well, fast-forward 35 years and enter my life as a mother of two boys. What a wake-up call it’s been! What an honor, privilege, and learning process it has been, and continues to be, to nurture, guide, and educate my precious boys. I am so sorry to Joe Smith and for my judgment of his V’s! Humor me with the following, if you are reading this, dear Joe.

Our culture at large needs to do more to support boys and their unique hardwiring in educational settings. Although my sons have the advantage of great teachers and a nationally respected school district, the structure of our educational system does not favor boys’ unique learning styles. For those with financial and geographical barriers to accessing educational support services (tutoring, etc.), the circumstances are much more grim. We, as a nation, are failing our young men in the area of educational support. And we need to change that.

Studies utilizing PET scans and MRIs show that boys learn very differently than girls. One of the pioneers studying gender learning-style differences, Michael Gurian, reports several key factors differentiating girl/boy learning:

• Boys show more areas in the brain dedicated to spatial-mechanical strengths, whereas girls generally demonstrate a focus on verbal-emotive processing.
• Girls are generally hardwired to be less impulsive, enabling them to sit still, focus, read, and write at an earlier age than boys.
• Boys are often misdiagnosed with learning disabilities and attention-deficit issues when educators are not aware of the delicate neurology of the male developing brain.
• Boys’ brains need more rest times during a day of learning. When bored, boys tend to “zone out” more than girls and require rest periods before reengaging in learning.
• Boys are hardwired to be single-task focused, whereas girls’ hardwiring demonstrates strength in multitasking. Transitions are more difficult for boys due to this lateralization of the brain versus typical female cross-communication of brain hemispheres.
• Less oxytocin in the brain of males leads to more aggression and playful rough-housing. Girls, on the other hand, are more predisposed to cooperative negotiation, have a much easier time with impulse control, and can sit “criss-cross-apple-sauce” in the reading circle with ease. Many boys have a difficult time sitting still to hear the teacher’s story, as they are movement-driven (kinesthetic) in their learning process (research and findings cited from Gurian, 2006).

It is no surprise that in one study by Gurian (2005), 75% of students in a special education classroom were boys. The vast majority of special education student populations are, in fact, boys. This finding is curious in that it highlights the following: Boys are diagnosed with learning disabilities at a much higher rate than girls due to possibly 1) educational settings that do not support boy-friendly learning environments, 2) boys’ neurochemistry is different and more vulnerable than that of girls, thus indicating the need for adequate educational support for both boys’ and girls’ learning styles, and 3) evidence of hyperactive behavior is more prevalent in boys, thus, perhaps, a bias more toward referral to special education for boys (Hallahan and Kauffman, 2003).

Taking into consideration the many variables that affect learning style, including culture, family environment, resilience, and temperament as it relates to motivation, genetics, and uterine environment during gestation, among other factors, researchers recommend the following tips for ensuring a boy-friendly educational environment:

1. Boys are energized and motivated by movement. Teaching styles that encourage the experiential/kinesthetic learning modality support boys’ natural biochemistry, helping them to stay engaged and focused. My son’s magnificent teacher sings with her class and plays guitar; she discovers earthworms and creates ice castles with her students. She is amazing. I only wish all boys could have Mrs. Overstreet as their teacher.
2. Spatial-visual tools (pictures/graphics) assist with boys’ neurological needs in achieving literacy. Storyboards depicting images a boy is imagining can assist with translating story into words.
3. “Boys do their best work when teachers establish authentic purpose and meaningful, real-life connections.” (Gurian, 2006). Topics of learning particularly interesting to boys include ideas they can directly apply to their lives (science projects involving the germination of a seed, etc.).
4. Single-gender groupings for projects can be beneficial. Girls tend to verbalize during problem solving via cooperation and interactive learning. Boys are single-task driven neurologically, and enjoy a gentle banter that may include a camaraderie of innocuous, aggressive male bonding in the form of sarcastic (but innocent) put-downs and/or rough-housing (kinesthetic bonding not unlike playing football or karate).
5. Allow boys to choose topics in reading that appeal to them (superheroes, nonfiction works, etc.).
6. Ensure the presence of positive male role models (teachers, parents, extended family, tutors, community leaders, etc.) who emphasize the importance of education.
7. Parental assistance with homework accountability. Help your son stay organized by overseeing weekly assignments and highlighting the importance of a designated homework time after allowing for kinesthetic movement and discharging of school-day stresses.

The above suggestions are by no means exhaustive but are applicable in educational settings, meriting further consideration to support boys in their journey toward self-confidence, purpose, and authentic contribution to society.

As a mother of two boys, I am both honored and obligated to ensure that my sons have the most appropriate supports to guide and engage them in their formal education. Much change is needed to help our future generations of boys to emerge from grades K-12 with confidence as they follow their dreams into adulthood.

For more on boys’ learning styles, please see:

1. Gurian, M. & Stevens, K. (2005). The Minds of Boys: Saving Our Sons from Falling Behind in School and Life. San Francisco: Jossey-Bass.
2. Gurian, M. (2006). The Wonder of Boys. New York: Tarcher-Putnam.
3. James, Abigail Norfleet (2007).Teaching the Male Brain: How Boys Think, Feel, and Learn in School.