For decades, the story of how ADHD medications work seemed straightforward: they helped the brain focus. But recent research has completely upended that long-held belief. Today, we’re speaking with Ivan Kairatov, a biopharma expert at the forefront of neuroscience and innovation. He’s here to discuss groundbreaking findings that are reshaping our understanding of not just ADHD, but the very nature of attention, motivation, and even the critical role of sleep. We’ll explore the surprising discovery that stimulants don’t target attention centers directly, but rather the brain’s fundamental systems for arousal and reward. This conversation will unpack how this new perspective explains the paradoxical calming effect of these medications, reveals a dangerous link between ADHD symptoms and sleep deprivation, and points toward a more personalized future for treatment.
Your study challenges the long-held idea that stimulants directly target attention centers. What was the “aha” moment when the fMRI data first pointed you toward reward and arousal pathways instead? Can you walk us through how those brain activity patterns looked different from what you expected?
It was a genuine moment of discovery, the kind you hope for in research. We were analyzing fMRI data from a massive cohort—over 5,700 children—expecting to see a clear signal, a bright spot of activity in the prefrontal cortex and other regions classically tied to executive function and attention. The conventional wisdom I was taught, and what I’ve told patients, was that these drugs give you more voluntary control over your focus. But the data just didn’t show that. Instead of the attention networks lighting up, we saw this pronounced, consistent activity in brain regions related to arousal and reward. It was like we were looking for a spotlight in one part of the brain, but the data showed us the stadium’s main power generators humming to life somewhere else entirely. This wasn’t a subtle shift; it was a fundamental re-routing of our understanding.
The research suggests stimulants “pre-reward” the brain, making tedious tasks more engaging. Could you expand on this concept? From a child’s perspective in a classroom, what does this actually feel like, and how does it translate to them being able to sit still and focus?
“Pre-rewarding” is the perfect way to put it. Imagine a child in a math class they find incredibly dull. Their brain is essentially screaming for something more interesting to do. A stimulant doesn’t act like a set of blinders, forcing them to look at the worksheet. Instead, it subtly changes the internal calculus of the task itself. That worksheet, which was previously a ‘1’ on a reward scale of 1 to 10, suddenly feels more like a ‘5’ or a ‘6’. It’s not that the child is suddenly a math genius; it’s that the act of engaging with the problem becomes intrinsically more satisfying. From the child’s perspective, they don’t feel drugged or forced to focus. They simply feel more interested, more alert, and more motivated to keep going. The natural consequence of finding a task rewarding is that you pay more attention to it and, crucially, you remain seated to do it.
The research provides a new way to understand how stimulants reduce hyperactivity, which has always seemed paradoxical. Can you explain this connection between a task’s reward value and a child’s ability to sit still? How does this reframe our view of what fidgeting really represents?
This finding really solves a long-standing paradox. Why would a stimulant, something that energizes, help a child sit still? Our research reframes hyperactivity not as a random motor excess, but as a rational, reward-seeking behavior. When a child is presented with a task their brain finds unrewarding, they get fidgety. They get up, they look for something else to do, because their brain is driving them to find a more stimulating activity. The stimulant medication interrupts this cycle. By increasing the reward value of the task at hand, the drug eliminates the need to get up and find something better to do. The child can now sit still because the classroom assignment is engaging enough to hold their interest. Fidgeting, in this light, isn’t the problem itself; it’s a symptom of an under-stimulated reward system.
Your findings show that stimulants can mask the brain activity of sleep deprivation. What are the long-term risks of this “quick fix”? What specific steps should parents and clinicians take during an evaluation to distinguish true ADHD symptoms from those caused by a simple lack of sleep?
This is perhaps the most concerning part of our findings. We saw that for a child who got less than the recommended nine hours of sleep, a stimulant could essentially erase the brain signature of that sleep deficit. They performed better on cognitive tests, and their brain activity looked more “normal.” But this is a dangerous mask. You’re not fixing the problem; you’re just papering over it. The long-term risks are significant because sleep is when the brain clears waste and consolidates memory. Consistently overriding this with medication could lead to lasting damage. For parents and clinicians, this means a sleep evaluation must be a non-negotiable first step. Before an ADHD diagnosis is even considered, we need to ask: Is this child getting at least nine hours of quality sleep every night? A simple sleep diary or a conversation about bedtime routines could reveal that the root cause of inattention and hyperactivity isn’t a neurodevelopmental disorder, but simply profound exhaustion.
Based on your groundbreaking findings on arousal and reward pathways, what is your forecast for the future of ADHD treatment? How might these insights lead to new non-stimulant therapies or diagnostic approaches over the next decade?
I believe we’re on the cusp of a paradigm shift. The future of ADHD treatment will be far more personalized and nuanced. Instead of defaulting to stimulants, we’ll start asking more specific questions. Is this child’s issue rooted in an arousal deficit, a reward-processing difference, or is it a sleep disorder in disguise? This could lead to a new generation of non-stimulant therapies that specifically target these pathways with potentially fewer side effects. Imagine a medication that helps modulate the brain’s reward system without the broad-spectrum effects of a traditional stimulant. For diagnostics, we might use fMRI not just for research but to identify specific neural signatures that guide treatment. The ultimate goal is to move beyond a one-size-fits-all approach and tailor interventions—whether they’re pharmacological, behavioral, or even sleep-based—to the unique neurobiology of each individual child.
