Brain Function 101- why medicine helps those with ADHD

Neurotransmitters are the messengers that bring information from one neuron to another. An imbalance in their levels can cause many problems. Medicines can help bring levels back to normal.

There’s a commonly held belief that people with ADHD should just try harder, but this doesn’t usually work. The symptoms of ADHD are caused in part by imbalances of neurotransmitters in the brain. Low norepinephrine levels lead to symptoms of ADHD. More and more evidence is showing the differences in the brains of people with ADHD compared to neurotypical (“normal”) people.

ADHD is real. You can’t just will it away.

Not everything gets better when people just try harder. Some things require a different approach. #adhdkcteen

What if no meds are used for ADHD?

Not everyone with ADHD is treated with medication. There are many reasons.

Some have never been diagnosed. Others don’t like medicine for whatever reason.

Many teens want to come off their medications. Some don’t like side effects. Others don’t want to be different.

Some can manage issues with alternative treatments and accommodations. Or think they can, but suffer from unrecognized complications of undertreated ADHD.

Some people simply forget to take it and then struggle with the consequences of being unmedicated.

Many families have a hard time affording the medicine or taking the time to do the required follow up with their physician.

I’m sure there are many more reasons people stop (or never start) medicine.

Neurotransmitters

Before discussing how the medicines work, it’s important to learn about neurotransmitters.

Our brain is of course very complicated in structure and function. There are millions of neurons that make up our brains. Between each neuron is a synapse, or space. Different areas of the brain serve different functions, and they all interact with each other. They also interact with other parts of our body and the outside world.

There are many pathways or circuits that bring information from one part of our brain to another. Neurotransmitters are the messengers that bring information from one neuron to another. They are made from amino acids.

Neurotransmitters each have a unique function but can be broadly classified into two categories: excitatory and inhibitory. Some neurotransmitters can serve both functions.

Neurotransmitters each have a unique function, but can be broadly classified into two categories: excitatory and inhibitory. Some neurotransmitters can serve both functions. #adhdkcteen

Excitatory neurotransmitters regulate motor movement, thought processes, anxiety, and more.

They can help us stay alert, but when they aren’t moderated by an inhibitory system, things can get out of control.

ADHD is like having a Ferrari engine for a brain with bicycle brakes. Strengthen the brakes and you have a champion. ~ Dr. Edward Hallowell #adhdkcteen

Inhibitory neurotransmitters act like brakes.

We need brakes so we don’t feel restless, irritable, and out of focus. When our brakes work, we can excel! Without brakes, we’re out of control.

Lock and key

Neurotransmitters act as messengers between different neurons. They are released from one neuron into the space between neurons called the synapse. They enter a neuron that has the proper shaped structure for it to fit.

Neurotransmitters are used to communicate from one neuron to another. #adhdkcteen

It works like a lock and key.

Each neurotransmitter is like a different key. They each fit certain locks, and often can fit more than one type of lock.

Neurotransmitter levels and ADHD

When neurotransmitter levels are too high or too low, we can develop anxiety, depression, and executive functioning disruptions.

It is important to understand that to some extent we can control our actions, but neurotransmitters are important in the aspects that are beyond our control. Sometimes we just feel anxious or sad. Focusing can be very difficult. Executive functions, such as time management, working memory, and more, can be hard to manage.

While we can’t simply will ADHD symptoms away, there are things we can do to improve our mood and executive functioning that don’t involve medicines. But medicines are an important treatment.

Norepinephrine

Norepinephrine is an excitatory neurotransmitter. It is primarily made and stored in neurons but is also found in the blood and a small amount is stored in the adrenal glands, which sit on top of our kidneys.

Norepinephrine is involved in focus, emotions, sleeping, dreaming, and learning. Too much norepinephrine can cause anxiety, but too little can lead to problems with focus and motivation.

It can raise our heart rate, increase blood flow to muscles, and increase our blood sugar level – all symptoms we experience in times of anxiety. These are helpful responses when stress is caused by physical danger and we need to run away, but not so much when we worry about a test or other common anxieties.

These symptoms can lead to distraction, self-consciousness, and poor focus and performance. This can look a lot like when norepinephrine levels are too low, which is one reason why anxiety and ADHD can mimic one another as well as exacerbate one another.

Norepinephrine: too much leads to anxiety, too little to poor focus and low motivation. #adhdkcteen

Dopamine

Dopamine makes us feel happy. Getting a bump in dopamine feels good.

I often joke that we get a dopamine hit every time we check social media or win a game. One of the reasons depressed people overeat comfort foods is that eating rises our dopamine levels, which makes us feel better. (At least until the heartburn sets in or we notice we’ve gained a few too many pounds to be healthy.)

Dopamine is one of the neurotransmitters that can be both excitatory and inhibitory.

Drugs like nicotine (yes, even from electronic cigarettes), opiates, and alcohol all increase dopamine levels. Eating foods can have the same dopamine increase, as can winning a game or doing anything else pleasurable.

We can all choose healthy options to get dopamine hits. Exercise. Playing games. Enjoying the company of friends and family. Helping others. All of these are healthy things that bring us happiness.

Negative things, such as drugs and alcohol or too much screen time, can lead to more problems than they’re worth. Even though they bring temporary feelings of happiness, they cause more problems in the end. Avoid these dopamine hits.

Drugs, alcohol, exercise, foods and any pleasurable activity can increase our dopamine level and make us feel happy. Not all are healthy ways to get a dopamine hit. #adhdkcteen

Dopamine can increase our alertness and help with memory and motor control in addition to giving us pleasure.

Dopamine can be converted into norepinephrine and epinephrine.

Low dopamine

Low levels of dopamine are associated with problems focusing, depression, the inclination to abuse drugs and alcohol, excessively playing games online or gambling , and overeating.

If the levels are low in motor areas of the brain, it can lead to the tremors commonly seen in Parkinson’s disease.

Low levels in other parts of the brain can lead to learning and memory problems, lack of energy and motivation, and a loss of happiness and interest in things that used to bring pleasure.

Low levels in the prefrontal cortex are associated with ADHD.

High Dopamine

High levels of dopamine can cause overexcitement and disrupted thoughts. They can even lead to anxiety and paranoia.

Serotonin

Serotonin is important in the regulation of anger and aggression, body temperature, mood, sleep, sexuality, appetite and metabolism. It can help us relax when serotonin is available in proper amounts. Stress can lower our serotonin levels as we use it up trying to relax.

About 80-90% of the body’s total serotonin is found in the gut. It is made by bacteria that live in our gastrointestinal tract. There are ongoing studies using probiotics (healthy bacteria) to alter the level of serotonin to help anxiety and depression. Unfortunately, as of now studies show mixed results, and at best only a minor benefit.

Low serotonin

Low levels of serotonin can result in depression, anxiety, anger, panic attacks, low energy, migraines, insomnia, obsessions, irritability, craving sweets or loss of appetite, focus and memory problems, aggressive behavior, slowed muscle movement and speech, and having a decreased interest in sex.

High Serotonin

High levels of serotonin cause diarrhea, headache, confusion, sweatiness, twitching muscles or stiff muscles, fever, high heart rate and blood pressure, seizures, and even death.

How do ADHD medicines work?

Stimulant medicines are considered the first line medical treatment for ADHD. The two types of stimulants are methylphenidates and amphetamines.

The differences in how these two groups of stimulant types work may explain why some people with ADHD respond to one type better than another.

Methylphenidates

Methylphenidates include prescription medicines such as Ritalin, Metadate, Concerta, Focalin, Aptensio, Quillivant and others.

The methylphenidates block the reuptake of dopamine and norepinephrine. This leaves more of these neurotransmitters in the synapse. Methylphenidates also help release these neurotransmitters from the neuron, again allowing more to be in the synapse.

Amphetamines

Amphetamines include Adderall and Vyvanse. They increase the release of dopamine and norepinephrine from their storage sites into the synapse. They also slow the reuptake of the neurotransmitters, but not to a large extent.

How do medicines affect neurotransmitters?

Medicines that affect neurotransmitters are used to treat ADHD, anxiety, depression, and low blood pressure.

  • Stimulant medicines (methylphenidates and amphetamines) increase norepinephrine and dopamine.
  • Atomoxetine (Strattera) affects only norepinephrine.
  • Serotonin norepinephrine reuptake inhibitors (SNRIs) are antidepressants that work by increasing serotonin and norepinephrine.
  • Tricyclic antidepressants also increase norepinephrine and serotonin, but are not often used anymore since there are many safer options available.
  • Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat anxiety and depression. They block the reabsorption of serotonin, which leaves more available in the synapse.
  • MAOIs prevent the breakdown of serotonin (and other neurotransmitters) but are rarely used due to significant adverse reactions.

For more:

In addition to the resources hyperlinked throughout this post, check out the following:

For more on the basics of the medicines used to treat ADHD, see ADHD Medications: Types and side effects.

Did you know that while stimulants that are used to treat ADHD can help people with ADHD, they can cause imbalances to neurotransmitters to those without ADHD? Learn how stimulants can make focus, attention, mood and more worse in Stimulants decrease brain function. Say What?

Dr. Russell Barkley has studied ADHD extensively and mentions neurotransmitters in his paper, What Causes ADHD?

Stimulants decrease brain function? Say what?

If you heard the recent news that stimulants decrease brain function, don’t freak out and immediately think you need to stop a medicine that helps you. The study was done in neurotypical (“normal”) people. There’s a big difference in what these drugs do in a brain that has imbalances of neurotransmitters and in a brain that does not, so don’t freak out. Read on to learn more!

If this is all too much information, you can jump to the TL:DR section, but it’s always good to learn the details!

What are stimulants used for?

Prescription stimulants are approved to use in the treatment of ADHD, narcolepsy, and obesity. They increase alertness and attention and often decrease appetite. Stimulants such as Adderall and Ritalin are considered safe for long term use in appropriate circumstances.

Stimulant misuse.

Misuse can lead to psychosis, anger, paranoia, heart, nerve, and stomach problems. Stimulants can cause heart attacks or seizures when used inappropriately. Misuse also can lead to addiction and tolerance, requiring higher and higher doses to get the same effect, increasing the risk of overdose.

Studies have shown that 20-30% of college students have taken a stimulant medication inappropriately within the past year.

The 2017 Monitoring the Future Report shows that 5.5% of high school seniors reported non-medical use of Adderall during the past year.

Adderall is the most commonly abused stimulant, but ritalin is used inappropriately too.

Why was this study done?

Many students believe that if Adderall and other stimulants help people with ADHD stay focused and perform better academically, it will improve their focus and make them smarter. Juggling school with all the extracurriculars, work and social life is hard. Many teens are sleep deprived and hope the Adderall will help them stay alert and study more effectively.

Since the use of stimulants by students without ADHD is common, many wonder if it’s true that they actually work to help focus in people without ADHD.

The big question:

Is Adderall safe and effective for those without ADHD?

What could be wrong with using it?

You might wonder why researchers care. Since many kids, teens, and adults are prescribed this medicine to help manage their ADHD, it should be okay for others to take, right?

Wrong.

There are many reasons to question the safety and efficacy of any medicine or supplement.

Drugs of abuse include stimulants but this does not mean they are dangerous for those who need them to treat a condition.
Source: https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts#prescription-stimulants

Legality

First and foremost, it is illegal to use someone else’s prescription medicine.

All prescription medicines are to be used by the person who it’s prescribed for. Stimulants are controlled substances. This means they are monitored closely by regulating authorities.

Controlled substances fall into various categories, ranging from Schedule I through V. Schedule I medications are the most dangerous. They have no known medical use, are unsafe, and have a high potential for abuse. The least dangerous category, Schedule V, has a small amount of narcotic quantity. Schedule II-IV fall in between.

Stimulant medications are in the Schedule II class. This class is considered to have a high potential for abuse and can lead to dependence. Please note that studies show that when children with ADHD take stimulants properly, they have a lesser risk of developing drug and alcohol problems. Even though there is abuse potential, the risk of all medicines should be weighed with the benefits.

When used properly, stimulants have medical benefits. If the medicine is prescribed to you, it is perfectly legal to have them in your possession and use them according to your prescription. But if they are someone else’s prescription, they are illegal to have and use. It is also illegal for you to sell or give your medication to another person.

Because these medications have resale value, it is recommended to keep your stimulants in a lock box when you live with other teens and young adults in college and early adult life. You can take a few out at a time to use as needed.

Right medicine at the right dose.

Most students who take stimulant medications have titrated their dose with the help of their physician to find the right medicine at the right dose. This can be a time of trial and error and needs to be monitored by a professional.

When friends share medications or people buy or steal stimulants from someone, they get what they get. They may or may not get a dose that is safe for them.

There are also fake drugs that are sold as stimulants but can be much more dangerous. It can be hard to tell the difference, so getting your medicine only from a licensed pharmacy is important.

If someone else is taking it, the person with the need doesn’t get it.

Many people downgrade their problems associated with ADHD. They might think they can get by with skipped doses, but they often underestimate the many benefits of their medication. Stimulants are not just needed for school.

Dr. Russell Barkley has been researching ADHD for 40 years and has found that ADHD is the single condition most associated with early death.

People with untreated ADHD tend to live up to 25 years less time than people without ADHD or with treated ADHD.

That means ADHD leads to early death more than tobacco, obesity, heart problems, and other chronic diseases when it’s not treated appropriately.

It makes sense that the issues associated with ADHD can lead to early death.

  • People with ADHD tend to be less focused. They are involved in more accidents when not medicated.
  • Many with ADHD impulsively overeat, which leads to obesity and the associated problems. In fact, obesity is five times more common in adults with ADHD versus the general population.
  • Many will self medicate with drugs and alcohol due to the secondary low self esteem, anxiety, and depression that is associated with ADHD.
  • The suicide rate is much higher for people with ADHD. They tend to have more depression and impulsivity than people without ADHD.
  • Risk taking behaviors are much more common in people with ADHD due to their impulsivity. They have a higher risk of starting negative habits, such as smoking, which are associated with shortening lifespan.

In short: don’t give or sell your medicines to anyone else. You need them!

A new study

When headlines say something shocking, don't just believe them. Read critically. The study that shows adderall decreases brain function doesn't apply to those with ADHD.
Stimulants decrease brain function? Say what?

Lisa Weyandt, a professor of psychology at the University of Rhode Island, studied how students without ADHD responded to Adderall. She wanted to test if it was true that Adderall could make people smarter and study more effectively if they didn’t have ADHD.

Study set up

It was a relatively small study. This means it shouldn’t be generalized yet. Bigger studies should be done.

She recruited 13 students to participate. They took a 30 mg dose of Adderall before one lab session and a placebo pill before another lab session. They were blind as to which pill they took each session. During the lab sessions passages were read to them and they had to answer a series of questions about them.

Researchers looked at how well they performed, their alertness, and their ability to focus on the Adderall and the placebo.

Results

Students showed improvements in alertness and focus with Adderall. Unfortunately these improvements did not help them think, remember or problem solve. They did not improve their reading comprehension, fluency, or recall of facts when they took the Adderall versus when they took the placebo.

Even worse: The Adderall actually inhibited their working memory. This is the ability to remember and use information to solve problems. People with ADHD often have problems with working memory and Adderall and similar medicines help to improve it. It appears that if your brain has normal function in this area, the Adderall makes it worse.

This makes sense. If your neurotransmitters are off, giving a medicine to stabilize them helps. If your neurotransmitters are at normal levels, giving a medicine that changes the levels hinders.

They also had elevations in their heart rate and blood pressure. If a student has an underlying heart condition, it could cause serious heart problems. This is one reason doctors ask about family and personal history before starting a patient on stimulant medications. If there is an increased risk, an ECG is recommended.

Without a physician monitoring the medication use, the risk goes up!

TL:DR

Stimulants have been proven to improve focus, attention, and working memory in people with ADHD.

When a physician prescribes stimulants, doses should be carefully titrated and routine follow up is required.

It is illegal to take stimulant medicines without a prescription.

Giving or selling prescription medicines to others is illegal.

If people take stimulants that are not prescribed to them or get them from a non-licensed pharmacy, they are at risk of getting fake drugs. Counterfeit drugs can lead to serious consequences.

When people without ADHD take stimulants, they may feel more focused, but their working memory is worse. This hinders their ability to perform well. They also suffer from physical risks without medical supervision.

When people with ADHD go without their medicines, their risks go up. Untreated ADHD is associated with early death. The risks are real if ADHD isn’t managed well!

Today we have so much information available to us through the internet, but you have to be very careful when you read it. Always remember to think critically when you read. Look at the source as well as the content. Don’t jump to conclusions – especially after just reading titles! A great read on this is An invisible unicorn has been grazing in my office for a month… Prove me wrong, so if you have the time, check it out!