ANaturalFixofADHD

ATTENTIONdeficithyperactivitydisorderisnowthemostprevalent
psychiatricillnessofyoungpeopleinAmerica,affecting11percent
ofthematsomepointbetweentheagesof4and17.Theratesofboth
diagnosisandtreatmenthaveincreasedsomuchinthepastdecade
thatyoumaywonderwhethersomethingthataffectssomanypeoplecan
reallybeadisease.
Andforagoodreason.Recentneuroscienceresearchshowsthatpeople
withA.D.H.D.areactuallyhardwiredfornoveltyseekingatrait
thathad,untilrelativelyrecently,adistinctevolutionary
advantage.Comparedwiththerestofus,theyhavesluggishand
underfedbrainrewardcircuits,somuchofeverydaylifefeels
routineandunderstimulating.
Tocompensate,theyaredrawntonewandexcitingexperiencesandget
famouslyimpatientandrestlesswiththeregimentedstructurethat
characterizesourmodernworld.Inshort,peoplewithA.D.H.D.may
nothaveadisease,somuchasasetofbehavioraltraitsthatdont
matchtheexpectationsofourcontemporaryculture.
Fromthestandpointofteachers,parentsandtheworldatlarge,the
problemwithpeoplewithA.D.H.D.lookslikealackoffocusand
attentionandimpulsivebehavior.Butifyouhavetheillness,the
realproblemisthat,toyourbrain,theworldthatyoulivein
essentiallyfeelsnotveryinteresting.
Oneofmypatients,ayoungwomaninherearly20s,isprototypical.
IvebeenonAdderallforyearstohelpmefocus,shetoldmeat
ourfirstmeeting.BeforetakingAdderall,shefoundsittingin
lecturesunendurableandwouldloseherconcentrationwithinminutes.
LikemanypeoplewithA.D.H.D.,shehankeredforexcitingandvaried
experiencesandalsoresortedtoalcoholtorelieveboredom.Butwhen
somethingwasnewandstimulating,shehadlaserlikefocus.Iknew
thatshelovedpaintingandaskedherhowlongshecouldmaintainher
interestinherart.Noproblem.Icanpaintforhoursata
stretch.
Rewardslikesex,money,drugsandnovelsituationsallcausethe
releaseofdopamineintherewardcircuitofthebrain,aregion
burieddeepbeneaththecortex.Asidefromgeneratingasenseof
pleasure,thisdopaminesignaltellsyourbrainsomethinglike,Pay
attention,thisisanimportantexperiencethatisworth
remembering.
Themorenovelandunpredictabletheexperience,thegreaterthe
activityinyourrewardcenter.Butwhatisstimulatingtooneperson
maybedullorevenunbearablyexcitingtoanother.Thereis
greatvariabilityinthesensitivityofthisrewardcircuit.
Clinicianshavelongknownthistobethecase,andeveryday
experiencebearsitout.Thinkoftheadrenalinejunkieswhobungee
jumpwithoutbreakingasweatandcontrastthemwiththeanxious
spectatorsforwhomtheactevokesnothingbutterroranddread.
Dr.NoraD.Volkow,ascientistwhodirectstheNationalInstituteon
DrugAbuse,hasstudiedthedopaminerewardpathwayinpeoplewith

A.D.H.D.UsingaPETscan,sheandhercolleaguescomparedthenumber
ofdopaminereceptorsinthisbrainregioninagroupofunmedicated
adultswithA.D.H.D.withagroupofhealthycontrols.Whatshefound
wasstriking.TheadultswithA.D.H.D.hadsignificantlyfewerD2and
D3receptors(twospecificsubtypesofdopaminereceptors)intheir
rewardcircuitsthandidhealthycontrols.Furthermore,thelowerthe
levelofdopaminereceptorswas,thegreaterthesubjectssymptoms
ofinattention.Studiesinchildrenshowedsimilarchangesin
dopaminefunctionaswell.
ThesefindingssuggestthatpeoplewithA.D.H.Darewalkingaround
withrewardcircuitsthatarelesssensitiveatbaselinethanthose
oftherestofus.Havingasluggishrewardcircuitmakesnormally
interestingactivitiesseemdullandwouldexplain,inpart,why
peoplewithA.D.H.D.findrepetitiveandroutinetasksunrewarding
andevenpainfullyboring.
PsychostimulantslikeAdderallandRitalinhelpbyblockingthe
transportofdopaminebackintoneurons,thusincreasingitslevelin
thebrain.
Anotherpatientofmine,a28yearoldman,washavingalotof
troubleathisdeskjobinanadvertisingfirm.Havingtositata
deskforlonghoursandfocushisattentionononetaskwasnearly
impossible.Hewouldmultitask,listeningtomusicandtexting,while
workingtopreventactivitiesfrombecomingroutine.
Eventuallyhequithisjobandthrewhimselfintoastartupcompany,
whichhashimontheroadinconstantlychangingenvironments.Heis
muchhappierandlittlesurprisehaslosthissymptomsof
A.D.H.D.
MypatienttreatedhisA.D.H.Dsimplybychangingtheconditionsof
hisworkenvironmentfromonethatwashighlyroutinetoonethatwas
variedandunpredictable.Allofasudden,hisgreatestliabilities
hisimpatience,shortattentionspanandrestlessnessbecame
assets.Andthis,Ithink,getstotheheartofwhatishappeningin
A.D.H.D.
Considerthathumansevolvedovermillionsofyearsasnomadic
huntergatherers.Itwasnotuntilweinventedagriculture,about
10,000yearsago,thatwesettleddownandstartedlivingmore
sedentaryandboringlives.Ashunters,wehadtoadapttoan
everchangingenvironmentwherethedangerswereasunpredictableas
ournextmeal.Insuchacontext,havingarapidlyshiftingbut
intenseattentionspanandatastefornoveltywouldhaveproved
highlyadvantageousinlocatingandsecuringrewardslikeamate
andanicechunkofmastodon.Inshort,havingtheprofileofwhatwe
nowcallA.D.H.D.wouldhavemadeyouaPaleolithicsuccessstory.
Infact,thereismodernevidencetosupportthishypothesis.There
isatribeinKenyacalledtheAriaal,whoweretraditionallynomadic
animalherders.
Morerecently,asubgroupsplitoffandsettledinonelocation,
wheretheypracticeagriculture.DanT.A.Eisenberg,an
anthropologistattheUniversityofWashington,examinedthe
frequencyofageneticvariantofthedopaminetypefourreceptor
calledDRD47RinthenomadicandsettlergroupsoftheAriaal.This

geneticvariantmakesthedopaminereceptorlessresponsivethan
normalandisspecificallylinkedwithA.D.H.D.Dr.Eisenberg
discoveredthatthenomadicmenwhohadtheDRD47Rvariantwere
betternourishedthanthenomadicmenwholackedit.Strikingly,the
reversewastruefortheAriaalwhohadsettled:Thosewiththis
geneticvariantweresignificantlymoreunderweightthanthose
withoutit.
Soifyouarenomadic,havingagenethatpromotesA.D.H.D.like
behaviorisclearlyadvantageous(youarebetternourished),butthe
sametraitisadisadvantageifyouliveinasettledcontext.Its
nothardtoseewhy.NomadicAriaal,withshortattentionspansand
noveltyseekingtendencies,areprobablygoingtohaveaneasiertime
makingthemostofadynamicenvironment,includinggettingmoreto
eat.Butthissamebriefattentionspanwouldnotbeveryuseful
amongthesettled,whohavetofocusonactivitiesthatcallfor
sustainedfocus,likegoingtoschool,growingcropsandselling
goods.
Youmaywonderwhataccountsfortherecentexplosiveincreaseinthe
ratesofA.D.H.D.diagnosisanditstreatmentthroughmedication.The
lifetimeprevalenceinchildrenhasincreasedto11percentin2011
from7.8percentin2003awhopping41percentincreaseaccording
totheCentersforDiseaseControlandPrevention.And6.1percentof
youngpeopleweretakingsomeA.D.H.D.medicationin2011,a28
percentincreasesince2007.Mostalarmingly,morethan10,000
toddlersatages2and3werefoundtobetakingthesedrugs,far
outsideanyestablishedpediatricguidelines.
SomeoftherisingprevalenceofA.D.H.D.isdoubtlessdrivenbythe
pharmaceuticalindustry,whoseprofitabledrugsarethemainstayof
treatment.Othersblameburdensomelevelsofhomework,butthedata
showotherwise.Studiesconsistentlyshowthatthenumberofhoursof
homeworkforhighschoolstudentshasremainedsteadyforthepast30
years.
Ithinkanothersocialfactorthat,inpart,maybedrivingthe
epidemicofA.D.H.D.hasgoneunnoticed:theincreasinglystark
contrastbetweentheregimentedanddemandingschoolenvironmentand
thehighlystimulatingdigitalworld,whereyoungpeoplespendtheir
timeoutsideschool.Digitallife,withitsvividgamingandexciting
socialmedia,isaworldofimmediategratificationwherepractically
anydesireorfantasycanberealizedintheblinkofaneye.By
comparison,schoolwouldseemevendullertoanoveltyseekingkid
livingintheearly21stcenturythaninpreviousdecades,andthe
comparativelyboringschoolenvironmentmightaccentuatestudents
inattentivebehavior,makingtheirteachersmorelikelytoseeitand
drivingupthenumberofdiagnoses.
Notallthenewsissobad.Curiously,theprevalenceofadult
A.D.H.D.isonly3to5percent,afractionofwhatitisinyoung
people.Thissuggeststhatasubstantialnumberofpeoplesimply
growoutofit.Howdoesthathappen?
Perhapsoneexplanationisthatadultshavefarmorefreedomto
choosetheenvironmentinwhichtheyliveandthekindofworkthey
dosothatitbettermatchestheircognitivestyleandreward
preferences.Ifyouwerearestlesskidwhocouldntsitstillin

school,youmightchoosetobeanentrepreneurorcarpenter,butyou
wouldbeunlikelytobecomeanaccountant.Butwhatishappeningat
thelevelofthebrainthatmayexplainthisspontaneousrecovery?
Totrytoanswerthatquestion,AaronT.Mattfeld,aneuroscientist
attheMassachusettsInstituteofTechnology,nowatFlorida
InternationalUniversityinMiami,comparedthebrainfunctionwith
restingstateM.R.I.softhreegroupsofadults:thosewhose
childhoodA.D.H.Dpersistedintoadulthood;thosewhosehadremitted;
andacontrolgroupwhoneverhadadiagnosisofit.Normally,when
someoneisunfocusedandatrest,thereissynchronyofactivityin
brainregionsknownasthedefaultmodenetwork,whichistypically
moreactiveduringrestthanduringperformanceofatask.(In
contrast,thesebrainregionsinpeoplewithA.D.H.D.appear
functionallydisconnectedfromeachother.)Dr.Mattfeldfoundthat
adultswhohadhadA.D.H.Daschildrenbutnolongerhaditasadults
hadarestorationofthenormalsynchronypattern,sotheirbrains
lookedjustlikethoseofpeoplewhohadneverhadit.
WEdontyetknowwhetherthesebrainchangesprecededorfollowed
thebehavioralimprovement,sotheexactmechanismofadultrecovery
isunclear.
Butinanothermeasureofbrainsynchrony,theadultswhohad
recoveredlookedmorelikeadultswithA.D.H.D.
Inpeoplewithoutit,whenthedefaultmodenetworkisactive,
anothernetwork,calledthetaskpositivenetwork,isinhibited.When
thebrainisfocusing,thetaskpositivenetworktakesoverand
quietsthedefaultmodenetwork.Thisreciprocalrelationshipis
necessaryinordertofocus.
BothgroupsofadultA.D.H.D.patients,includingthosewhohad
recovered,displayedsimultaneousactivationofbothnetworks,asif
thetworegionswereoutofstep,workingatcrosspurposes.Thus,
adultswholostmostoftheirsymptomsdidnothaveentirelynormal
brainactivity.
Whataretheimplicationsofthisnewresearchforhowwethinkabout
andtreatkidswithA.D.H.D.?Ofcourse,Iamnotsuggestingthatwe
takeourkidsoutofschoolandheadforthesavanna.NoramIsaying
wethatshouldnotusestimulantmedicationslikeAdderalland
Ritalin,whicharesafeandeffectiveandveryhelpfultomanykids
withA.D.H.D.
Butperhapswecanleveragetheexperienceofadultswhogrewoutof
theirsymptomstohelpthesekids.First,weshoulddoeverythingwe
cantohelpyoungpeoplewithA.D.H.D.selectsituationswhether
schoolsnoworprofessionslateronthatareabetterfitfortheir
noveltyseekingbehavior,justthewayadultsseemtoselfselect
jobsinwhichtheyaremorelikelytosucceed.
Inschool,thesecurious,experienceseekingkidswouldmostlikely
dobetterinsmallclassesthatemphasizehandsonlearning,self
pacedcomputerassignmentsandtasksthatbuildspecificskills.
ThiswillnoteliminatetheneedformanykidswithA.D.H.D.totake
psychostimulants.Butletsnotrushtomedicalizetheircuriosity,

energyandnoveltyseeking;intherightenvironment,thesetraits
arenotadisability,andcanbearealasset.
RichardA.Friedmanisaprofessorofclinicalpsychiatryandthe
directorofthepsychopharmacologyclinicattheWeillCornell
MedicalCollege.