ADHD may be more of a reward problem than an attention problem

[00:00:00] What do I do to give myself more incentives during the day? and how do I make my small tasks high incentive tasks? And I think I just use food most of the time. I run a lot, and I eat a lot of granola

Welcome back to How to Be Patient. This is a 100% solo episode with Preston again. So I know what you're thinking, "Oh my God, it's Preston, the guy who hosts the podcast that I listen to. Where's Margaret?" You might ask. Well, Margaret is working very hard, and she is recovering on her Pilates reformer, I think, right now.

She sends me pictures of it, and it's a really cool machine. It's expensive, but it just, it, always kind of gives me BDSM vibes a little bit. I feel like if you wanted to, you could get freaky deaky with the Pilates reformer. So either Jason, you can cut that, or Margaret, th- that's how... Those are, the thoughts that [00:01:00] pop into my head when I see a reformer.

But, you know, you can't argue with the results. it gets people snatched. And I've done Pilates, and it's really hard. But I digress. So I'm here rambling on my own. I... If y- you look in the back, I'm gonna move the camera a little bit. I just have a ton of junk everywhere, and there's boxes all over my apartment.

I'm actually moving this week, and moving is always more stressful than you think it's gonna be. I'm like, "Oh, I c- I'm, downsizing into a smaller place. It's closer to downtown." And my whole thought was, "Oh, this will be a launchpad into going to New England next year." So spoiler, I'm, going to fellowship almost certainly, and I'll be going up to the East Coast where housing is a lot more expensive, and I would probably play- pay double in rent [00:02:00] to live in a box.

So I was like, "What if I just practice living in a box now while I'm in Texas?" 'Cause, you know, why not? Well, it's, moving sucks. That's why not. And now I'm just getting, you know, torn up. I also went through this period where I thought, "Oh my gosh, I just need to sell everything I own. I hate this capitalist system that I live in, and, I just, wanna live out of a backpack on the side of the road and do art."

So w- we've, been unraveling a little bit. I've been stress eating a lot of granola and, totally neglecting to, to even look at my calorie tracker. And, none of this is actually what this episode is about today. Today, we're gonna be talking about ADHD, so I guess maybe the tangents are somewhat tangentially related to the topic at hand.

But w- what is interesting about the episode today is that- I, wanna talk about how this study that I read, [00:03:00] reframed how I was thinking about a lot of ADHD. and it- I always knew it had to do with the attention networks, and there's problems with reward, incentives, and procrastination. But I always thought that, like, fundamentally, it's that you cannot, even if you wanted to, you cannot sustain your attention.

Even, like, early on in residency, I would think, "Oh, maybe it's, like, more diagnostic of ADHD that people can't focus on the things that they want to do." But this study came out, back in 2010. I somehow missed it. You know, I think I was, 13 at the time. I was busy playing Call of Duty and being in middle school instead of paying attention to, this study.

But, fortunately, I have good professors who brought this up during our neuroscience curriculum. So we went through it, and I thought I would share it with you guys. Okay, so, so when we come back from this break, we were gonna talk about task-related default mode network modulation and inhibitory control in ADHD, the effects of motivation methylphenidate, which [00:04:00] sounds like a whole bunch of mumbo jumbo if you're not into neuroscience.

But essentially, it's basically how do doing tasks relate to our brain's ability to control attention in people with ADHD when they are motivated to do something or when they're given stimulants to do that thing? So let's find out

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And we are back to talk more about this study. So, a little bit of background on what they're even concerned about checking out. it's-- this is looking at the ways we switch on or off our attention networks. And, we care about this because that's how we get stuff done. You know, your, brain knows that time is money, and ultimately it has to figure out, where do I direct my time and my attention effectively because I need to get the tasks done that I need to do.

You know, executive function is adaptive in evolution. So the way our brains kind of solve this problem, the way we understand it in neuroscience, is that we have different networks that modulate our attention. We have one network that's called the default mode network, which is essentially our kind of idle [00:06:00] position, our daydreaming network.

It's where we, sit in this network when we're contemplating things, when we're, planning stuff, when we're imagining things. So those are all very useful, right? It's-- it helps you generate new ideas. And also, you're taking in information from your environment, and you're labeling it with certain levels of importance.

So your salience network, or salience meaning like, is this important or not, also plays a role in that. So you're kind of, you're wide open. Then when you want to focus on something, you actually turn off that network, and then you turn on this thing called the ventral attention network, which allows you to sustain your focus on that task.

We've seen studies in the past where in normal controls, they will have someone in an fMRI, and they'll be mapping that default mode network and then the other network, and they just kind of flip-flop on and off really effectively. But in ADHD, they don't always flip off one or the other. It'll be, like, actually harder for them to turn off the default mode network.

So, like, when they're [00:07:00] trying to focus on a task, they're still just kind of daydreaming a little bit more And I think if anyone listening to this has ADHD, they, would, probably relate to that, that when they're trying to do a task or something, they can only sustain attention for like short little bursts, but s- but there's still something else creeping in or something else that's, t- pulling away their attention.

This is important though because there are cases where patients with ADHD can sustain their attention, and that doesn't make sense to people. And I think a lot of this leads a lot of people to think, "Hey, this is all just behavioral. You know, I think he's just being difficult because how can my kid who likes to play video games sit there for four hours straight just staring at the video game and nothing else and not be distracted?

And then when he tries to do homework or chores or clean his room, he can't stay on task at all. To me, it seems like he just doesn't wanna do that." [00:08:00] And, that's not an unreasonable conclusion to make when you're watching the behavior of someone with ADHD. Actually, back in the day, it was called, before it was called minimal brain dysfunction, I think it was called like moral dysregulation.

Like, AD- ADHD was like considered a, moral problem before it was ever a neurologic problem. And even today it's still, still considered that way. So This, paper actually kind of explains that and gets at it a little bit. So, so that's the background context, and l-let's kind of get into to what the study's talking about here.

This, took place at the Oxford Department of Experimental Psych-Psychology in, 2010 and 2011, where they took 18 children who were diagnosed with ADHD. At, the time it was the DSM-IV combined type, but we still have, that in the DSM-V classification. And then we had 18 matched, typically developing individuals.

These are, children and teens between the ages of 9 and 15. [00:09:00] So they basically had two task-paced go, no-go conditions that they did under an fMRI. So basically, they have you play this, like, little simulated game, and some of them you get like rewards and tokens for the game. I think in some of these studies you get money or like candy, whatever is like relevant to the kid.

the actual nature of the game and the incentives aren't as important. It's just that in some scenarios, they generate high incentive for participating in the game. So if I'm playing Frogger and I know I get five bucks every time I get the frog to cross the highway, that's a high incentive game versus another game where I just have to drag and drop stuff and, you know, fill in data on an Excel spreadsheet.

You, you don't have to be a neuroscientist to know that if your job is data entry in like the early 2010s, that's a low incentive task, and you're just sitting there going, "Wow, I'd really love for something called ChatGPT to come [00:10:00] around and replace me," because anything to get me out of this cubicle. You know what I mean?

So that's the simulation. they put you in this fMRI and have you play video games. Some of them are exciting, some of them are not. And then here's where it gets interesting. So they did the controls and then the ADHD kids, and then they tried the ADHD kids again, but this time they gave them their medication.

So those are kind of the three different scenarios 'cause they wanna see, do the meds actually make a difference here? So the first finding was when they had boring tasks with no medication, the ADHD kids had a lot of trouble turning off their default mode network. Like, like they, they couldn't actually turn it off at all.

If you, if... We'll, paste a, copy of the graph up here, but essentially it was, just stuck, completely activated. And then they took the, control group, and they had them do the low incentive task, and they were still able to, deactivate their default [00:11:00] mode network. So even though it was boring, the typically developing kids in fMRI showed evidence that they were able to still activate their attention focus on there, where the kids, with ADHD couldn't.

And then in the next task, they did high incentive. So this is the exciting video game task, you know, where you're getting paid to, to play Frogger. The neurotypical kids went through the task again and Just like with the low incentive task, they were able to deactivate their default mode network, so they were focusing on it.

But what's interesting is that off medication, when the ADHD kids did this task, they also were able to deactivate their default mode network. So for the fun, exciting task, the ADHD kids were actually physiologically able to activate their attention centers in ways that were similar to normally developing kids.

It was just for the boring tasks, which is, really fascinating, and I think that kind of makes sense with the, video game observations that we're making. But then [00:12:00] you take the low incentive task, we, go back to it with the ADHD kids, and this time let's give them methylphenidate and see what happens.

And they actually were able to deactivate their default mode network and focus more similarly to the controls. So it was much easier for them to, divide and focus their attention on a stimulant for boring tasks. So, so this kind of reframes how you would think about ADHD. it's not necessarily that the attention system is completely broken and that you can't deactivate your default mode network and, activate your ventral attention network for any task at all.

But it's really the tasks that you're excited about. And it would suggest almost that ADHD has more to do with the rewards that you get for each task or, like, the perceived importance of it than the actual [00:13:00] ability to regulate and control your attention. And in theory, you could say that the, dopamine reuptake that's occurring in Ritalin may have more of an effect on your attention control via the reward system pathway, so essentially allowing you to simulate getting more of a reward from doing mundane tasks and therefore direct your attention towards it than actually correcting the infrastructure of your underlying attention network.

Really interesting stuff. And, also a, way to tell us, hey, th-this is something I, that I might have known for a long time because everyone who's had an ADHD kid in a classroom or at home knows that if you want to get them to focus on small things, you have to gamify it. You have to make it exciting.

You have to try to make the low incentive tasks a little bit higher incentive, whereas the stimulant just kind of wipes that wh-whole slate clean. It's all high incentive because the incentive [00:14:00] is, coming from somewhere else. So th-this is-- I think this is especially ironic because the most important tasks that we often have in our lives are boring School, work, like social obligations, working out, brushing your teeth, showering.

Like 90% of what any of us do during the day is low incentive and it's mundane. So that also I think especially highlights the dysfunction that someone with ADHD has, where they go through 90% of their day and they're trying their hardest to do each of these tasks and they just can't focus on anything that's like not exciting or not boring.

So it would make sense that they would want to do something that they are capable of focusing on. So I guess you can see how when people do find something that, sparks their interest, they just wanna hold onto it and, stick with it, even if it's at the expense of all the other boring or unexciting or, frustrating, tedious tasks.[00:15:00] 

The other thing to, to kind of take into account is that, methylphenidate is primarily a dopamine reuptake inhibitor. it has a slightly different mechanism than, Adderall, which in addition to dopamine reuptake also actually disperses dopamine from vesicles inside the synapse. So this study wasn't done with Adderall, which may have a different relationship when we're actually, s- simulating a surge or increasing the amount of dopamine in the way that it affects the attention networks.

Off the top of my head, I can't imagine anything that would be like too different about it, but, just something to take into account And, I guess kind of coming back to, the end of the study, it's really, interesting and it's also small. So this was with-- it's just 18 kids on both sides.

And the other thing that I would be curious about is how this occurs more in adulthood. So [00:16:00] ADHD has, ADHD can impact the rate of pruning and maturing of your, cortex or your gray matter. But a lot of people can actually normalize or kind of reach a similar threshold in adulthood. So some of those like really profound gaps that you see in adolescence, maybe they level out.

So I think it would be really fascinating, and it prob- probably or maybe exists, though it's not in the context of this podcast, a study on adults looking at, default mode, network deactivation using stimulants. And, I think it'd also be interesting to do it using various stimulants and also non-stimulant medications that impact similar, receptors.

So viloxazine or Qelbree, the new kid on the block, atomoxetine or Strattera, in addition to Adderall, Vyvanse, methylphenidate, Focalin. Like tho- those all maybe have subtle differences in the default mode network, activation, though the, [00:17:00] biggest challenge for a lot of these is that fMRI studies are super expensive, and you don't necessarily want to sit someone in fMRI and be like, "Okay, we're just gonna do a round robin of every single stimulant we can find.

We're just we're gonna see how your brain does, before it gets completely fried." So, that's-- it's kind of like the, biggest takeaway that I have, from today. I-- it, it really makes me wonder You know, what do I do to give myself more incentives during the day? and how do I make my small tasks high incentive tasks?

And I think I just use food most of the time. I run a lot, and I eat a lot of granola. Like, when I was prepping for this podcast, actually, I was kinda stressed about reading this paper and making sure I had something to do. And also, I don't know, I, maybe I seem comfortable right now, but it's kinda strange just, like, talking alone to the microphone.

No one's here to give you feedback, and also no one's here to disagree with me, so who [00:18:00] knows? but yeah, I was... I-- Just that Love Crunch, raspberry chocolate granola that you get at Whole Foods. I, read a little bit, write a little bit, go get some granola. Boom, high incentive task. Deactivated my default mode network like it's nothing.

That's most of what I, got for you today. I, don't know if I have anything else to say other than, like, keep in mind that, you know, ADHD might actually be more of a, salience problem and a reward problem than, solely an attention deficit. And it's really that your attention laser works right, and you just gotta know how to point it in the right direction.

this weekend's the move. It's about to, it's about to go down. I'm actually... I don't love using AI all the time, but I've been using it to do, like, mock-ups of the apartment, and that's actually been kind of [00:19:00] useful. I also, like, got one of these, like, apartment design, like, interior design programs, and I've been playing around with it.

These, things are not intuitive at all. But the, desire to, like, live in a comfortable place is high enough incentive that, you know, I think, anyone could stay locked in on it. So, I'm curious what you guys think, just about the paper in general or, how this kind of folds into your understanding of ADHD.

call into the pod or, like, go on our website and leave a voice note if, this resonates with you, if either with, you know, your own story with ADHD or, patients you've seen with ADHD or siblings and how, like, considering the reframe of it being more of a, reward problem than an attention problem, if that, is something that- that you find interesting or if you disagree with it because ultimately this is one study from [00:20:00] 15 years ago that looked at 36 people.

So you-- we, gotta spend a lot more time, fleshing this stuff out. But anyways, I'm, just gonna keep hanging out here by myself. I got Lilac in my lap. She's-- she doesn't know we're moving. l-- otherwise, you know, comment on Instagram. In those Spotify comments, let us know what you think of the episode.

you know, you can always find me @presro on TikTok and Instagram, and Margaret's @thatarteveryday on Instagram and Substack. she'll probably still respond to DMs even though she's not on the podcast right now. And, yeah, that's, it, guys. Thanks again for listening. I'm your host, Preston.

Our executive producers are me, Preston Roche, Margaret Duncan, Will Flanary, Kristin Flanary, Aron Korney, Rob Goldman, and Shahnti Brooke. Our editor and engineer is Jason Portizo. Our music is [00:21:00] by Omer Ben-Zvi. To learn more about our program disclaimer and ethics policy, submission verification and licensing terms, and our HIPAA release terms, go to howtobepatientpod.com or reach out to us at howtobepatient@human-content.com with any questions or concerns.

How to Be Patient is a Human content production.

Thank you for watching. If you wanna see more of us, or if you wanna see... This is Lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac, point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They pr- they probably exist for real.

But in the meantime, I'm just gonna pet Lilac, and then I'm gonna go dance in the [00:22:00] background