Medications often prescribed for attention deficit hyperactivity disorder seem to work differently than science previously thought. A study published in December by researchers at the Washington University School of Medicine in the United States has found that drugs commonly prescribed for ADHD — such as Ritalin or Adderall — "act primarily on the brain's reward and wakefulness centers, rather than on its attention circuitry."
The study shows what such stimulants can realistically achieve and what they can't, information important for people with ADHD because it demonstrates why some tasks suddenly feel less strenuous for people who use medication. It also explores why sleep deprivation is such an important factor.
ADHD is a neurodevelopmental disorder that begins in childhood. People affected by it often have ongoing problems with attention, impulse control and hyperactivity.
The Washington University research team, led by neurology professors Benjamin Kay and Nico Dosenbach, examined brain scan data from nearly 5,800 children. The researchers examined scans done with functional magnetic resonance imaging, or fMRI, which measures brain activity by detecting changes associated with blood flow. These show which areas of the brain are active at any one time.
'Alert and interested'
Scans found differences in how brain regions connect and communicate with each other in children with ADHD. People with ADHD often find it more difficult to stay focused and motivated, and to stop daydreaming when they need to concentrate.
The Washington University team also looked at longer-term data about the children's living environments. The researchers compared groups with and without ADHD, as well as children who had, and had not, taken medication on the day of the scan.
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They found that the medications acted mostly on the brain's centers for reward and wakefulness. They didn't "light up" the brain's attention circuitry, and this remained true even in an additional experiment done with adults.
The researchers interpreted this to mean that the medications "enhance performance by making individuals with ADHD more alert and interested in tasks, rather than directly improving their ability to focus" and help "make activities that the child normally struggles to focus on feel relatively more rewarding."
Children are more likely to persevere because learning feels less onerous.
Treating ADHD
The treatment guidelines for ADHD generally recommend a tiered approach. As a first option there is education and support for daily living designed to provide structure and establish routines. Depending on the severity of the disorder, psychotherapy can be helpful. In moderate to severe cases, medication might be used in addition to other remedies, or as an alternative to them.
Drugs such as methylphenidate, amphetamines, atomoxetine and guanfacine are all medications used to treat ADHD.
Ritalin, a methylphenidate, and Adderall, an amphetamine mix, are stimulants that rapidly increase dopamine and norepinephrine levels. This makes people more alert and more motivated so they can remain focused.
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Atomoxetine and guanfacine are "nonstimulants" and do not produce acute alertness or euphoria. Instead they tend to stabilize attention, impulse control and emotional irritability.
ADHD medications are generally prescribed as part of a more comprehensive concept for treatment and are only used under the supervision of specialized doctors.
Often treatment begins with behavioral therapy, during which people with ADHD learn to structure their day with the help of a therapist — for example: homework, work, leisure — and to break tasks down into manageable parts, to organize themselves effectively with tools such as calendars and reminder apps, and to better cope with frustration or with feeling overwhelmed.
This doesn't "cure" ADHD as such. But clear routines, reward schedules and self-soothing techniques are all strategies for managing symptoms.
Checking sleep habits
Therapy often involves patients' families, with homework assigned between sessions. In Germany and many other countries, doctors consider psychotherapy as effective as medication. In milder cases of ADHD, medication may be used in combination with psychotherapy because it makes it easier to implement the therapeutic methods being taught.
One of the most surprising aspects of the study was how stimulants helped children with ADHD who were sleep-deprived. The medications were associated with better school grades and cognitive performance. But this was not the case for children who were getting enough sleep and who didn't have the disorder.
For the children who don't get enough sleep, the stimulants essentially erased sleep deprivation from the brain scans. In the short term, the medications acted like an artificial substitute for a good night's sleep. But, the team warned, this wouldn't necessarily work in the long term. A lack of sleep is biologically harmful to humans, even if can be masked by medication for a short time.
ADHD patients must be carefully assessed for sleep deprivation and whether that could be the cause of their symptoms. It could be that simple adjustments to sleep hygiene, daily routines or stress reduction is what is needed most of all.
This article was originally written in German.
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