Dispelling the 'Paradoxical Effect' Myth About Stimulant Medication

A longstanding yet outdated belief suggests that stimulant medications have a "paradoxical" or calming effect in individuals with ADHD. That is, they work in an opposite way to how they would in a person without ADHD, who would become hyperactive if they took a stimulant medication. This post aims to debunk this myth, clarify how these medications work in treating ADHD and in individuals without the condition, and to discuss the implications that different methods of consumption have on the effects a person will experience with a stimulant medication.

How Stimulant Medication Works in ADHD

Neurotransmitter Regulation

Stimulant medications, such as methylphenidate and amphetamine preparations impact neurotransmitter levels—mainly dopamine and norepinephrine—in the brain. These neurotransmitters play a crucial role in regulating attention, impulse control, and executive functions. In people with ADHD, these medications hugely boost the availability of these neurotransmitters, aiding in symptom reduction.

Individual Variation and Diagnostic Implications

Not everyone with ADHD will respond to stimulant medications in the same way. In some cases, individuals may not respond to one or multiple formulations. This lack of response does not invalidate an ADHD diagnosis. Conversely, a positive reaction to stimulant medications should not be used to confirm a diagnosis since most people, whether they have ADHD or not, will experience improvements in focus and attention when taking these medications.

In my work with ADHD clients, I have had several for whom initially trialled stimulant medications have not worked well. These individuals often feel quite upset about this lack of response, and question whether they are imposters who don't have ADHD at all, or fear that they will be in the small minority of people for whom stimulant treatment does not work well.

What I encourage these clients to do is talk to their prescribers about another formulation or dose change that they could try. For people who in the end require an amphetamine rather than methylphenidate, the road to finding the right treatment can take a few months more than for those who respond well to methylphenidate, since almost everyone in New Zealand is started on methylphenidate.

I have seen just a few people who have found no stimulant medication to afford relief of symptoms. In these cases, the next step is to start systematically working through the non-stimulant medications. But for most people, the answer is to keep trying, not to give up at the first, second, or even third hurdle.

Consumption Methods: Prescribed Use vs. Misuse

When swallowed at the correctly titrated dose, stimulant medication is slowly released into the bloodstream, offering controlled and sustained symptom management. Different formulations do this in different ways, and over different time periods. This is the recommended and safe method of consumption for treating ADHD symptoms, and since we don't have transdermal patch options for medication in New Zealand (wouldn't that be nice), all stimulant meds here are taken orally.

For individuals without ADHD who take stimulant medication orally, they still experience an increase in alertness and focus by acting on the same neurotransmitters as for people with ADHD. Some people without ADHD use these medications for this very reason - think students taking a stimulant so they can focus on their study better, or for longer. There is no paradoxical effect going on here. They are just receiving the expected effects of this medication. This off-label use is both illegal and potentially harmful, possibly leading to side effects like elevated heart rate and high blood pressure, which are things that are monitored in people who are prescribed these medications for ADHD.

When stimulant medications are crushed and snorted or dissolved in water for injection, they enter the bloodstream rapidly (i.e. through a mucus membrane or directly into the blood stream) and can produce a high, along with many other physiological indicators or high stimulation. This kind of misuse can lead to dangerous outcomes, including increased heart rate, agitation, and addictive potential. There is a black market for stimulant medication because of its abuse potential, and this is a large part of why stimulants are a controlled substance, which brings with it issues of access for people with ADHD.

When people think about paradoxical effects of stimulant medications, they are imagining the above scenario of non-ADHD people feeling high when they take stimulants, but that people with ADHD are paradoxically calm. As I've described above, people without ADHD can experience the same increases in focus and attention when swallowing non-prescribed stimulant medication. Perhaps you aren't surprised by now to hear that people with ADHD are also able to get high on stimulant medications if they misuse them.

Conclusion

The notion of a 'paradoxical effect' of stimulant medications in ADHD is not supported by current scientific understanding or clinical experience. These medications work by boosting neurotransmitter activity, helping individuals with ADHD manage their symptoms more effectively. There are unpredictable individual variations in medication response when treating ADHD. Stimulant medications have similar alerting effects in people with or without ADHD, meaning that treatment response cannot be used to confirm or disconfirm that someone has ADHD. If the medication a person initially tries does not lead to a good effect, it doesn't mean they don't have ADHD, it means they need to talk to their prescriber about what their other options are.

• Here's an excellent one-hour podcast about stimulant medications and how to optimise them, presented by ADHD expert psychiatrist Dr William Dodson.

• This is a YouTube video presented by a psychiatrist who explains the ways that methylphenidate and dexamphetamine (the two stimulant medications available in New Zealand) work in the brain.

• ADHD expert Dr Russell Barkley talks about 12 myths about stimulant medications, including whether they are addictive, or if they lead to increased substance abuse (spoiler: neither is correct) in this brief video.

• Here is my blog post on the stimulant medications used in New Zealand for ADHD.

• Here is another blog post with more suggestions for what to do if meds don't seem to be working.