Stimulants as State Regulators

⚠️ Conflicting Evidence Prescription stimulants improve performance by regulating arousal and reward salience rather than enhancing attention networks.

CURRENT POSITION Stimulants increase attention as experienced and measured behaviorally by improving arousal, motivation, and task persistence, but they do not increase attentional capacity or strengthen canonical attention networks themselves.

KEY ASSUMPTIONS Attention networks (DAN, VAN, FPN) are not the main drivers of real-world task performance. Arousal and perceived reward value are prerequisite conditions for effective attention. Many ADHD symptoms reflect motivational and state-regulation deficits rather than core attentional impairment.

SUPPORTING EVIDENCE Large-scale resting-state fMRI analysis (ABCD Study, n≈11,875) shows stimulants alter somatomotor and salience/parietal memory connectivity, not attention networks. Precision imaging drug trial in healthy adults replicated stimulant-related connectivity changes linked to arousal. Stimulant-related connectivity patterns strongly resemble those associated with longer sleep duration and independent arousal biomarkers (EEG, respiration, norepinephrine transporter PET).

OPEN QUESTIONS Whether long-term stimulant use can safely substitute for chronic sleep deprivation without developmental costs. How these findings should reshape ADHD diagnostic criteria and clinical language. Whether task-based fMRI under high motivational manipulation would reveal secondary attention-network effects.

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