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The "Paradoxical Effect" - From misunderstanding how stimulants worked to understanding wh

It seems paradoxical to prescribe a stimulant to someone who is already apparently overstimulated to the point that they cannot focus or are hyperactive and impulsive. In the 1990’s, it was thought that stimulants worked “paradoxically” in those with ADHD. That is, in people without ADHD, stimulants would cause agitation and over stimulation but in those with ADHD, they would act paradoxically and calm them down. In fact, it was considered by some to be a kind of diagnostic test- if the medication helped, then by default the person must have ADHD.

This is actually not the case.

We know today that stimulants stimulate the whole brain- in everybody. Those that have ADHD and those that don’t respond in kind. Stimulants can help everyone to focus, regardless of meeting criteria for a diagnosis of ADHD or not.

The issue isn’t whether stimulants stimulate the brain or not. It is about the brain itself- or rather, the parts. The parts make up systems. Each part/system has a special role to play and when stimulated, leads to a particular effect.

Understanding the parts of the brain/ systems affected by looking at the effects of the medication

Have you ever tried to figure out a maze? When you start at the beginning, it is hard to figure out how to get out. But when you start from the end, it is much easier to trace yourself back to the beginning. So too, with understanding where stimulant medications work on the brain.

The "wake up" system

Firstly, at even a low dose, we observe wakefulness. This is considered a “side effect”. What it tells us is that the parts of the brain responsible for wakefulness are also the most sensitive to being stimulated. Stimulant meds work on these structures located in the lower part of the brain. Stimulants in our food and drink, i.e. caffeine in coffee, tea, soda and stimulants in foods like chocolate will work. Sunshine works to wake us up. (In fact light can be a considered a medication as it can be dosed by intensity and length of time of exposure to treat SAD (Seasonal Affective Disorder). Of course, sound as a medication can also be dosed so that, if loud enough will stimulate us to wake up!

These structures will be affected by the lowest doses of stimulant medications. They will be the first to respond and the last to stop responding when the medication wears off.

The next structure, generally speaking, to respond to stimulant medication is the frontal cortex. This part of the brain is dedicated to attention, focus, concentration, delayed gratification, organization- executive functioning. When this part of the brain is effectively stimulated, we improve dramatically in all of these areas. And this can be clearly measured with a variety of psychological tests. Another way to assess the effectiveness of the medication is if a child’s grades improve or an adult’s performance at work improves. Those measures aren’t necessarily the best (as a child can choose not to study even if he is perfectly ready to absorb the information). However, that said, they are useful targets to aim for.

When a person has a beneficial response to medication, this can be thought of as the goldilocks dose- not too low but not too high. It’s just right. This is why when seeing the doctor, he or she will start prescribing stimulant medication at a low dose first and monitor the response. If the dose is ineffective or only mildly effective (without unpleasant effects) then the dose will be raised a step and the patient will return for another visit to assess the situation again. This process is repeated in a stepwise process until the right dose is reached.

If the dose is increased beyond the therapeutic point, the patient may start to feel agitated. They may notice that they feel jittery or nervous. They may notice a mild tremor in their hands. They may become irritable and impatient. They may notice that their heart is beating faster. Their mood may change from happy to nervous. They may lose their appetite.

With each clinical finding, we can trace back to the part of the brain affected.

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