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The Neurobiological Aspect of ADHD: It’s Therapeutic Implications

Cheryl
ITP: Neurobiology/ Dr. Koga, MD
13-Dec-10

A person with ADHD often feels as if s/he are in a fog of diffused, dissipated attention

with little focus or direction. To understand this condition better, several topics will be explored.

First we will look at some of the symptoms of ADHD. Second a few of the important processes

of attention will be described. Third, we will look at the basic parts of the brain and the

neurochemistry involved in attention--followed by some of abnormalities in the brain structure

and the neurosystems of an individual with ADHD. After we gain insight into some of the

chemistry and functioning of the ADHD brain, the next question will be what strategies,

therapies, or treatments can we use to “reprogram” and “reformat” the brain (Hunt, 2006)

(Dziegielewski, 2010) (First, 2000)?

Symptoms of ADHD

According to the DSM IV-TR, the inattentive characteristics of ADHD can be

summarized as the following: fails to give close attention to detail/makes careless mistakes; has

difficulty sustaining attention to tasks; does not seem to listen; does not follow through on

instructions; does not complete tasks; has difficulty organizing tasks; easily distracted; loses

things for tasks; and forgetful in daily activities. A summary of the hyperactivity characteristics

include the following: fidgets or squirms; leaves seat often; runs about inappropriately; difficulty

playing quietly; acts as if driven by a motor; and talks excessively. Symptoms of impulsivity

include: blurts out answer before complete question is given; has difficulty waiting turns; and

often interrupts or intrudes upon others. There are three types of Attention Deficit Hyperactivity
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Disorder: Inattentive type; Hyperactive-Impulsive type; and Combined type. To diagnosis

ADHD, some of the symptoms should have been evident before age seven, six or more of the

characteristics of the specific type must have persisted for at least 6 months, and impairment

must have been found in at least two environments (First, 2000).

Basic Components of Attention

In this paper, we will focus on the attention aspect of ADHD. Attention is a complex

process that includes many skills, complex abilities, and integrated processes. Voluntary

attention links the thoughts and emotions we consciously choose to focus in our minds. Some of

the components of attention are arousal/alertness, external or receptive attention, internal or

reflective attention, process attention or selective attention, external or expressive attention, and

working memory (Hunt, 2006).

Arousal and alertness begin the executive functioning process of organizing components

and actions of goal directed purpose or intent. Arousal and alertness are connected to intrinsic

interest or external motivation. For example, you are motivated externally when you see a police

car and slow down.

External or receptive attention is based on sensory processing and interpretation. Reading

is an example of external/receptive attention. Internal or reflective attention is reflecting on

ideas or concepts. Internal/reflective attention also includes the aspect of executive functioning

of organization of projects/tasks.

Process or selective attention includes three main skills: focus, filtering, inhibition.

Deficits in executive functioning of organization of projects and tasks, along with focus,

filtering, and inhibitions, are key components in ADHD. Focus refers to tuning into an object or
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topic. Filtering is the signal:noise gradient which is the enhancement or activation of relevant

stimuli. Inhibition of sensation is selective sensory input.

External/expressive attention includes what we choose to communicate or express and

evokes the components of focus, filtering, and inhibition. (External/expressive attention is related

more to the hyperactive spectrum of ADHD instead of the inattentive aspect.) Finally, working

memory is the ability to retrieve information from the memory storehouse of the brain. The

working memory is the flow of information within the context of active thought.

Brain Structure Related to Attention

Although we will be talking about the brain one area at a time, all the areas are

interconnected and functions occur simultaneously. The following brain structures are related to

attention. The cerebellum coordinates the timing of movement, along with cognitive and

affective functions. Also the cerebellum links and integrates cortically initiated activities. The

thalamus is a large, deep structure of the brain that regulates many components of arousal. It

also facilitates a reciprocal relay between many sub cortical structures and the cortex. With its

central location it has an impact many functions such as language and mood. The basal ganglia

(caudate and putamen) is a critical area for the functions of motivation, intensity, and regulation

of movement. It works with the frontal lobes to interpret perceptual experience of instinctual

ritualistic and social behavior of animals and humans (Krain, 2006). Temporal lobes contribute

to language. The dominant TL contributes to language through word finding and word sequence.

The non-dominant TL contributes through syntactical aspects of language such as rhythm and

expression. Visual recognition memory is based here, along with effective response to visual

and olfactory stimuli. Bilaterally at the tip of the TL, the amygala is the early warning system of
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the brain and responds to change. The amygala is activated by threatening visual cues, not

benign ones. The anterior cingulate participates in many aspects of executive function such as

working memory (Hunt, 2006). It retains information in a state of expectant alertness, changing

when expectations shift or when the working instruction shifts, anticipating what to do next.

The prefrontal cortex is the Chief Executive of the Brain that integrates and manages

purposeful functioning of most other brain structures. While other brain regions perform

primary processing of stimuli and information, the frontal lobes interpret and provide meaning to

the experience. It is the main site of voluntary/conscious thought and planning. With conscious

perceptions of the environment, decisions are made as to how to react and how to affect our

world. The frontal lobes have numerous modes of operation. They are proactive, not just

reactive; receptive/contemplative, not just responsive or active. The primary experience of self

resides here. The main purpose of the prefrontal cortex is to facilitate living a life of purpose by

relevant integration required to connect long term goals with specific actions needed at the

moment. The frontal lobes issue commands turning plans into purposeful behavior to achieve

goals (Hunt, 2006). This is the area of the brain that is most dysfunctional in the person with

ADHD.

Neurochemistry and Other Factors in Attention

There are three neurochemical, dopamine pathways that convey messages for functioning

that are attentively linked. Path 1 is the Energy Pathway which connects the substratia nigra to

the motor cortex via basal ganglia and enhances physical energy. Path 2 is the Desire Pathway

which connects the caudate lobe to the premotor cortex via the orbital prefrontal cortex. The

desire pathway oversees instinctual, reproductive, urges and desires. Path 3 is the Pleasure
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Pathway. It connects the ventral tegmental nucleus (the origin of dopamine DA) to the olfactory

bulb and frontal lobes via the basal ganglia so that DA transmits mental energy, drive, and a

sense of pleasure. DA also transmits desire, pleasure, and interest that contribute to sustained and

selective attention. Norephinephrine (NE) supports attention through regulation of

alertness/arousal leading to cognitive, executive functioning, and extending attention into

thought. Attention and alertness are not only influenced by neurotransmitters, but they are also

influenced by hormones. Hormones also have a direct effect on DA as evidenced by changes in

the plasma metabolite (HVA). Another example, is that hormones from the hypothalamic-

pituitary-adrenal- axis as well as cathecholamine (flight or fight/physical action)

neurotransmitters, both facilitate attention. Hormonal activities occur over a longer period of

time, affecting the general neurobiological environment or substratum. On the other hand

neurotransmitter activity is almost instantaneous influencing momentary, specific events. These

events occur through neural networks involving simultaneous activation of multiple pathways

and through neurotransmitters functioning in concert (Krain, 2006).

Attention can also be influenced by non-cognitive factors from personality or psychiatric

considerations. These factors can alter the depth and breath of attention. Some of these include:

ADHD, fatigue, mania, OCD, depression, and anxiety. Effective attention is a balance of

alertness, mood, and cognitive flexibility.

Abnormal Brain Structures and ADHD

There is an agreement among scientists that ADHD is a condition resulting from

dysfunction in the brain. During the last ten years, magnetic resonance imaging (MRI) has been

used to examine anatomic differences in gray and white matter, along with prefrontal regions, the
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basal ganglia, the corpus callosum, and the cerebellum. Along with the smaller structure of the

right frontal lobe, dysfunction in the frontal-straital-cerebellar circuits is linked with deficits in

response inhibition and delay aversion (Krain, 2006). The frontal cortex, as we have seen, is

involved mainly with executive functions: such as, problem solving, attention, reasoning, and

planning. ADHD sufferers most often have significant challenges in these areas. Some brain

imaging studies have suggested that the right frontal lobe of a person with ADHD is smaller than

the control group. This data was supported by the similarities between ADHD symptoms and

people who have suffered frontal lobe damage to right hemisphere through illness or accident

(ADHD.org.nz, 2008).

Treatment and Challenges

One important aspect of living a fulfilled life depends on being able to focus our attention

upon what we need to accomplish and then plan the steps we need to act on to obtain our goals.

This process is called executive functioning— to have the capacity to do what we intend to do, to

sustain attention even with distractions in the environment, and to work through phases of

weakening interest and mounting fatigue. Since the lack of executive functioning in people with

ADHD affects several important areas in their lives—such as school, work, and environment--a

comprehensive treatment plan is important. A treatment plan for individuals needs to be flexible

enough to generalize in the different areas, but specific enough to enough to meet the

individual’s challenges.

Since it is generally agreed upon that ADHD is a deficit in mental processing resulting

from both the brain structure and the neurotransmitting circuit, medication seems to be the first

line of defense. Ironically with the influx of new medication, amphetamines still seem to be the
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preferred medication for ADHD. Several of the reasons for this preference first include effects of

the increasing alertness and active attachment which are prerequisites for problem-solving and

reasoning. The medication’s action occurs in a major site of D2 receptors located in the straitum

having projections to the mesocortical DA regions. The medication produces the secondary

effect of increasing the NE production and release. Also it provides an increased alertness which

enhances signal:noise differentiation, essential to sensory filtering and cognitive-behavior

organization. (Hunt, 2006)

After medication, goals should be included in the treatment plan with different tasks and

environments in mind. Here are some examples of goals:

1. Follow through on assignments/tasks from beginning to end.

2. Keep work space and personal space neat and organized.
3. Will adhere to firm schedule.
4. Will develop self-monitoring techniques and get on track immediately.
5. Reward and recreational activities are contingent on completion of daily tasks and
assignments.
Two of the concepts of neuroplasticity have some significant points. First if we remember that

neuroplasticity refers to the ability of the human brain to change as a result of one’s experience,

we can see the importance of making a routine out of the changes we want to take place in our

lives and our brains. Routine is especially important for a person with ADHD because it gives

her/him a structure and support to increase his/her executive functioning skills (Stein, 2003)

.Another concept of neuroplasticity is that one should push oneself enough to go beyond

previous levels to make significant gains (Stein, 2003). With these two insights we can create a

treatment plan that will impact one’s life positively. Having made that statement, the treatment of
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ADHD is never a treatment but is truly awareness, management, and commitment. (The

treatment is direct related to performance (even athletic-Fayoke)

Bibliography

ADHD.org.nz. (2008, 03 07). Retrieved 12 12, 2010, from The neurobiology of

ADHD: www.adhd.org.nz/neuro1.html

Dziegielewski, S. (2010). DSM-IV-TR in Action. Hoboken NJ: John Wiley & Sons, Inc.

First, M. M. (Ed.). (2000). Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV-TR). Arlington, VA: American Psychiatric Association.

Hunt, R. (2006, 9 25). ADHD. Retrieved 12 9, 2010, from MedscapeToday:

www.MedscapeToday.com

Krain, A. &. (2006, August). Brain development and ADHD. Clinical Psychology
Review , 433-444.

Stein, D. H. (2003). Concepts of CNS plasticity inthe context of brain damage and
repair. Journal of head trauma rehabilitation , 18 (4), 317-341.