Stimulants for Cognitive Enhancement – Social Justice or Cosmetic Psychopharmacology?

A thought provoking article in the NY times raises questions about the practice of giving stimulant medications to children who don’t meet criteria for ADHD but who nonetheless might benefit from their effects.   While the issue of stimulants being taken by competitive students trying to gain an edge in college has been well documented, this article describes the activities of at least one physician who takes a different (I might call it a “Robin Hood”) approach of prescribing these medications to younger children from lower socioeconomic groups in order to help level the playing field.  

The article raises some important questions and dilemmas that may be looming on the horizon for many physicians. The notion of “cosmetic psychopharmacology” gained popularity following Peter Kramer’s well known book Listening to Prozac in which he described cases of individuals who took SSRIs in the absence of major mental illness in order to “transform” their personality.  Some expected a flood of referrals for personality alteration to arrive as a result.  For the most part, they never came, perhaps due to the fact that such transformations were not as common as the book suggested.  Now, however, the idea may be returning not with antidepressants but with stimulants which are known to enhance some cognitive functions even in the absence of full ADHD.  For those interested in reading more, an entire chapter in my upcoming book, linked on this blog, is devoted to the topic of medications and temperament/personality change.

Unfortunately, however, the article also illustrates a number of lingering myths that continue to exist within the public and even in the medical community.  One of the physicians interviewed for the article claims that ADHD is not real because it is not binary (that is, existing in an all or none form).  While it is quite true that ADHD symptoms exist quantitatively, that doesn’t mean it isn’t real.  Hypertension, obesity, and high cholesterol also exist quantitatively with somewhat arbitrary cut-off points for “disease,” but that doesn’t mean those diagnoses are made up.  There is overwhelming evidence from genetic, neuroimaging, and other biological studies that ADHD has real manifestations in the brain (how could it be otherwise?).  I would also strongly disagree with the characterization of ADHD as “completely subjective,” although there is certainly some judgment that comes in when making the diagnosis.  It is similarly faulty logic to think that because there is an association between ADHD and low socioeconomic status (SES), that changing the SES would necessarily improve symptoms on its own.  It may help somewhat, but there is also evidence that even very robust nonpharmacological interventions result in only marginal improvement.  We need to be mindful of the possibility that some of the less enriched and more chaotic environments these children endure might partially represent a result of ADHD in the family, rather than a cause.

In addition, I don’t see the reason to be so hopeless about these families and these schools with regard to nonpharmacological interventions.  In the article, Dr. Anderson seems to be saying that he uses medications because he has given up on changing anything else.  I have found that many families and schools, even those with little resources, can take effective measures to improve their environment.  Indeed, it ironically seems a bit elitist to me to conclude that only higher SES families and schools are capable of behavioral change without medications.

The other question is what to do with using medication to treat mild or subthreshold cases.  If a child meets criteria for ADHD, even if it is “mild,” then I try to treat it not just with medications but with nonpharmacological interventions (school changes, exercise, good sleep practices, reading, limiting TV and video games, treating parents).  I have found this practice to be quite effective.

Currently, if a child or young adult does NOT meet ADHD criteria then I do not prescribe them medications.  To me, this is cosmetic psychopharmacology.  This article did get me to think again about this position for the future due to the inequalities of opportunities that are present and the idea that individuals should have the autonomy to make some of these decisions themselves, but presently I won’t do this because 1) not everyone has equal access to these medications, 2) it lowers the incentive to do other things to improve attention that would be more authentic and long lasting (what Dr. Graf in the article calls “authenticity of development” and 3) the potential long term risks are not well understood.

Putting aside the lingering misconceptions about ADHD and other emotional-behavioral problems, the article does sound the alarm bell that we as prescribing professionals and our organizations may need to think through these issues that may be arriving at our doorstep soon…and science, unfortunately, is probably going to make this issue more complicated, not less.

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