People with ADHD exhibit altered brain activity before making high-stakes choices

New research sheds light on how the brains of adults with attention-deficit/hyperactivity disorder function differently when anticipating risky decisions. Individuals with ADHD showed reduced activation in key brain areas involved in self-awareness and decision-making. Among those with ADHD, women showed more activity in several of these regions than men, pointing to possible sex-related differences in how the brain processes decisions that involve uncertainty. The research was published in Brain and Behavior.

ADHD is typically thought of as a childhood condition, but it often continues into adulthood. Many adults with ADHD struggle with impulsivity, emotional regulation, and decision-making. These difficulties can translate into behaviors that put them at greater risk, such as reckless driving, unsafe sex, substance use, or gambling. While previous studies have explored how people with ADHD respond to the outcomes of decisions, less is known about what happens in the brain before a decision is made—especially in emotionally charged or intuitive situations.

To better understand this anticipatory phase, the researchers focused on the role of unconscious and emotional processes that guide decision-making. They were particularly interested in how bodily sensations—like a quickened heartbeat or a gut feeling—might influence behavior in people with ADHD. This idea is grounded in the “somatic marker hypothesis,” which proposes that the body’s physical response to emotionally relevant information plays a role in guiding choices. The study also aimed to explore whether men and women with ADHD might show different patterns of brain activity in this context, given known sex differences in how the disorder presents.

The research team recruited 38 adults, including 18 with ADHD (10 women and 8 men) and 20 without the disorder (10 women and 10 men). Participants were screened to ensure they met diagnostic criteria and did not have other major psychiatric or neurological conditions. Most of the participants with ADHD had been taking stimulant medication but were asked to pause use 24 hours before the study.

Each participant completed a task known as the Balloon Analogue Risk Task, or BART, while undergoing brain imaging in a magnetic resonance imaging (MRI) scanner. The task involved watching a virtual balloon inflate on a screen and deciding when to stop it before it popped. The longer they waited, the more points they could earn—but if the balloon burst before they stopped it, they would lose all the points for that round. This version of the task was designed to encourage fast, intuitive decisions rather than deliberate calculation. Reaction time—the delay between the start of the balloon inflation and when the participant pressed the stop button—was used as a behavioral measure of risk-taking.

While participants completed the task, researchers measured activity in their brains during the anticipation phase of each decision, before they acted. This allowed the team to examine what parts of the brain were engaged in preparing for the risky choice. They also compared results by group (ADHD vs. non-ADHD) and by sex.

In terms of behavior, participants with and without ADHD showed similar reaction times on average, suggesting that the groups did not differ in observable risk-taking behavior. However, the brain imaging data told a different story. Individuals with ADHD showed significantly lower activation in two specific brain areas: the right precuneus and the right superior frontal gyrus. These areas are thought to play important roles in self-awareness, internal monitoring, and integrating emotional information—functions that are often disrupted in people with ADHD.

The precuneus is involved in tasks that require self-reflection and awareness of internal states. It has also been linked to emotion processing and the ability to monitor bodily sensations. Meanwhile, the superior frontal gyrus is thought to help integrate cognitive and emotional information and is involved in controlling impulses. The researchers found that lower activity in these areas was associated with more severe ADHD symptoms, suggesting a link between brain function and the difficulties experienced by people with the disorder.

The study also revealed interesting differences between men and women with ADHD. While no sex differences in brain activity were found in the group without the disorder, women with ADHD showed greater activation in several brain regions compared to men with ADHD. These included the dorsolateral prefrontal cortex, the insula, the caudate, the cuneus, and the precuneus. These areas are associated with emotion regulation, attention, and self-monitoring. The findings may suggest that women with ADHD engage more of their brain’s regulatory systems during the anticipation of a decision, possibly as a compensatory strategy.

This result was unexpected, given that earlier studies have found that women with ADHD may experience more difficulties with emotional regulation and internalizing symptoms like anxiety. One possible explanation is that women with stronger emotional processing skills may show less neural activation during emotional tasks, suggesting a more efficient processing style. Alternatively, women with ADHD may develop strategies that mask their symptoms, including more active engagement of brain areas that help regulate behavior.

It is also worth noting that, despite these brain differences, men and women did not show significant differences in reaction time on the task. This suggests that people may arrive at similar outward behavior through different internal processes, a finding that highlights the importance of looking beyond surface-level performance in psychological research.

While the study offers important insights, it also has limitations. The sample size was relatively small, particularly when broken down by both sex and diagnosis, which limits how broadly the findings can be applied. Additionally, although participants were asked to stop taking ADHD medications 24 hours before the study, some effects of the medication may have lingered and influenced brain activity. The study also focused on young adults, so it may not capture how these processes change with age or in more diverse populations.

Future studies with larger samples and longer medication washout periods will be important for confirming and expanding on these findings. In particular, researchers may benefit from combining brain imaging with physiological measures, like heart rate or skin conductance, to get a fuller picture of how the body and brain interact during decision-making. This approach could help build a more complete model of how emotions and bodily signals influence the choices made by people with ADHD.

The study, “Neural Correlates and Sex-Specific Effects of Affectively Driven Processes Underlying Decision-Making in Adult ADHD,” was authored by Eva Halbe, Alec Jamieson, Moritz Bergmann, Aylin Mehren, Ben J. Harrison, Christopher G. Davey, Tony Stöcker, Alexandra Philipsen, and Silke Lux.