Adderall as a motivational enhancer

Prescription stimulant use is on the rise at college campuses, especially at elite schools where the pressure and demands can be overwhelming. Students have a variety of methods to handle the stresses of their studies, but the consumption of prescription stimulants, such as Adderall or Ritalin, has become more popular among healthy individuals. While this trend raises multiple important ethical issues, the interesting idea that prescription stimulants may be masking authentic versions of ourselves was the topic of the most recent Neuroethics in the News discussion. Facilitated by AJOB Neuroscience editorial intern Ryan Purcell and AJOB Neuroscience Editor John Banja, the discussion centered around a recently published article by Torben Kjaersgaard entitled “Enhancing Motivation by Use of Prescription Stimulants: The Ethics of Motivation Enhancement^."1

                                                                from Smart Drug Smarts

The cognitive enhancement debate is not new; scholars have been considering the ethical dilemmas, such as equal access, safety, coercion, and cheating, of healthy individuals seeking enhancement via prescription drugs for almost a decade.^2,3 There is also a debate surrounding whether or not current stimulants are even cognitive enhancers at all, which would render the discussion irrelevant.^4,5 Kjaesrgaard doesn’t focus on any of these issues though, and instead presents the ethical dilemmas associated with motivational enhancement of drugs such as Adderall and modafinil. He argues that these stimulants are not eliciting performance enhancement, but instead performance maintenance and sometimes increased motivation for a task, and this can often be ethically problematic. While the future may hold cognitive enhancers that have the ability to increase a person’s capability to solve a task or make an individual “smarter,” current stimulants promote wakefulness, arousal, and stimulation. The invocation of these emotions is related to motivation, and Kjaersgaard argues that motivation enhancement is an important but “neglected subitem in the bioethical debate on cognitive enhancement.”¹

 

 Motivation in this article is defined as a “broad set of affective states that influence whether a person will voluntarily use their cognitive ability in the performance of a task,” which comes from a paper by IIieva and Farah.³ Very few papers have reported on the reasons for consumption of prescription stimulants by healthy individuals, but the article alludes to a recent qualitative study published by Scott Vreko⁶ to show that students who take these stimulants are typically seeking to enhance their motivation and interest during an “Adderall” day spent studying in the library. Vrecko reported four experiential “feelings” that students experience when taking Adderall including feeling up, drivenness, interestedness, and enjoyment; feelings all related to motivation. Many of the students were unable to study unless taking the drug or felt they were more effective and interested when under the influence. It is possible that these students could be self-medicating depression or ADHD, and as problematic as that may be, what if these students are just lazy? (Kjaersgaard does note that many of the students only attribute their inability to study to factors related to school, suggesting depression is not an underlying factor). Is there really anything wrong with trying to become a more productive, studious person? If a boost in motivation is needed to study for a midterm or prepare a presentation at work, is there anything ethically fraught about seeking an external stimulant? Or, is intrinsic motivation somehow more meaningful than motivation induced by prescription stimulants? The answer, according to Kjaersgaard, is sometimes. 

Lack of motivation could be part of a much larger problem connected to the meaning, structure, and purpose in a person’s life. The constant use of prescription stimulants to get through four years of college or every task at work could signal feelings of alienation, and treating these feelings with pharmaceuticals is unethical.  A student who enjoys learning and finds it self-fulfilling, but needs to take Adderall to get through one class unrelated to his major is not participating in an unethical act because the one-time use does not change the course of his life or who he is. Most importantly, this student isn’t trying to escape from reality. However, Adderall is not helping the student that is trying to get through college as a biology major because his parents want him to go to medical school. In this instance, the student is on a path of becoming his least authentic self, a complex issue that should not be controlled with prescription stimulants. Continually using stimulants to overcome a lack of willpower means that “we risk losing touch with ourselves in some sense.”¹ When we start to regard lack of motivation as a physiological problem, instead of a vice, we are losing an essential part of the human condition and we are perhaps only masking the most authentic version of ourselves. 

                                                               from DistanceAdvising

 This twist on the cognitive enhancement debate is interesting because for the first time we live in a society where the quest to become what you may consider your most authentic self is actually possible.  Serfs in the Middle Ages were not questioning whether or not serfdom was their actual calling, and classes were still starkly divided as late as the 19^th century. Some have made the claim that we should take cognitive enhancers because we have an obligation to society to be the best, smartest, most productive versions of ourselves. But, do we instead have an individual obligation to become the most authentic, true version of ourselves? Is it even possible to find your most authentic self? And, as Dr. Banja pointed out with this Monty Python sketch, what if your true self is boring and dull? In this case the use of prescription stimulants may not be holding you back in the slightest.  

While it may be true that the fate of college students does not drastically depend on prescription stimulant use, perhaps rampant Adderall consumption is a chance to have a conversation regarding the collegiate atmosphere. In college and in life, we move at a faster pace than before and ubiquitous technology means that something or someone is constantly demanding attention. This can often make life seem overwhelming and challenging, but by accepting the occasional Adderall usage, are we ignoring other fundamental problems with our social structure? Maybe prescription stimulants are a solution for the vast majority of people that are unsatisfied with their jobs, especially if income is a priority over authenticity. But, does society suffer at all if every person is trying to be productive, but is sacrificing essential pieces of what makes us human to get there? 

References: 

(1)          Kjærsgaard, T. Enhancing Motivation by Use of Prescription Stimulants: The Ethics of Motivation Enhancement. AJOB Neurosci. 2015, 6 (1), 4–10.

(2)          Chatterjee, A. Cosmetic Neurology: The Controversy over Enhancing Movement, Mentation, and Mood. Neurology 2004, 63 (6), 968–974.

(3)          Ilieva, I. P.; Farah, M. J. Enhancement Stimulants: Perceived Motivational and Cognitive Advantages. Front. Neurosci. 2013, 7.

(4)          Lucke, J. C.; Bell, S.; Partridge, B.; Hall, W. D. Deflating the Neuroenhancement Bubble. AJOB Neurosci. 2011, 2 (4), 38–43.

(5)          Smith, M. E.; Farah, M. J. Are Prescription Stimulants “Smart Pills”? The Epidemiology and Cognitive Neuroscience of Prescription Stimulant Use by Normal Healthy Individuals. Psychol. Bull. 2011, 137 (5), 717–741.

(6)          Vrecko, S. Just How Cognitive Is “Cognitive Enhancement”? On the Significance of Emotions in University Students’ Experiences with Study Drugs. AJOB Neurosci. 2013, 4 (1), 4–12.

Want to cite this post?



Strong, K. (2015). Adderall as a Motivational Enhancer. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2015/04/adderall-as-motivational-enhancer.html

Psychostimulants in preschoolers: Panacea or Pandora's Box?

Victoria became pregnant at a young age. During her pregnancy, she was unable to consistently make responsible choices for herself and her developing child, often indulging in alcohol and drugs. As a result, her son Brian was born prematurely at 7 months. By the time Brian entered preschool, he became increasingly difficult for Victoria and his teachers to control, his interactions with other children at times violent and aggressive. Desperately trying to manage Brian’s outbursts, Victoria confides in a child psychiatrist who puts Brian on Ritalin. Within a couple of months, Brian’s outbursts subside, and much to everyone’s relief (Brian’s included), he is now able to sit through his preschool classes with limited distraction. He begins to enjoy relating with other kids and no longer receives negative attention at school. Several years later, Brian, now a very diminutive 9 year-old, writes a paper for a class assignment in which he suggests that everyone should have treatment like him to “make them behave,” and that “all kids with broken brains should have them fixed, too.” When Victoria learns of this, she speaks with Brian, who says he is confused why some kids can “be good without pills,” and wonders if people would “still love him if he stopped taking his.”¹ 

To some, this story tells of the triumph of administering drugs like Ritalin to children with certain behavioral profiles, such as attention-deficit/hyperactivity disorder (ADHD). Before being treated, Brian is uncooperative, anti-social, and unresponsive to linguistic persuasion. His behavioral disposition persisted and continued to worsen before treatment, and his prenatal exposure to toxins suggests that Brian may have suffered neurodevelopmental abnormalities that contributed to his social dysfunction. By comparison, Brian’s treatment is a successful attempt to bring him “up to speed” with his peers: he now exhibits self-control, can develop meaningful relationships, and attends to his schoolwork.

However, to others, this story highlights concerns about identity formation, self-worth, and growth retardation in drug-treated children. The issue is that Brian has begun to realize how he acts, what he thinks, and how he feels are all in some way a result of the treatment, and that this sets him apart from his “good” peers. Brian’s perception of himself in relation to the world around him has been changed in a fundamental way that will shape his identity as he matures. The hope is that Brian’s caretakers will support his healthy exploration of these concepts and reassure him that his worthiness does not depend on drugs. Also of concern is Brian’s stunted growth, which may be a result of long-term Ritalin treatment.

As a whole, Brian’s story illustrates both the successes and perils of psychopharmacological treatment in very young children. With respect to social functioning, there may be clear, long-lasting improvements for some with ADHD; others may fail to respond, or worse, experience adverse side effects. This brings up the issue of safety, which has been studied to a very limited extent in young children and begs the following question: “Despite their psychosocial benefits, how safe are these drugs for the vulnerable brains and growing bodies of preschoolers?” In order to address this question, I’ll provide an overview of the current body of research into the safety and efficacy of these drugs, along with current trends in ADHD diagnosis and treatment.

Methylphenidate, often referred to by its trademark name Ritalin, and amphetamine (trademark Adderall) are by far the most commonly prescribed drugs used to treat ADHD in preschoolers 4-5 years of age. Both drugs are psychostimulants, meaning they can enhance alertness, and have been shown to reduce classical ADHD symptoms of hyperactivity and inattention. While the exact data on how many prescriptions have been issued to preschoolers alone are unclear, the CDC estimates that just over 4% of all children aged 4-10 took psychostimulants as of 2007². Trends have been increasing since the early 1990’s and can be expected to continue. Aligned with this expectation is the American Academy of Pediatrics’ (AAP) October 2011 release of new clinical practice guidelines supporting the use of psychostimulants in 4 and 5 year-olds³, which the CDC also endorses⁴. The AAP claims, “there is now emerging evidence to [prescribe to] preschool-aged children.” What is this emerging evidence, exactly?

Of the two psychostimulant drugs most commonly prescribed to preschoolers (and there are a handful of others), only Adderall has received Food and Drug Administration (FDA) approval for use in children this young (also keep in mind that a clinician may prescribe an FDA-approved medication to treat basically any condition in any person, a practice known as “off-label” usage; so, prescribing almost any drug on the market to preschoolers is fair game). One might expect that FDA approval would be based on studies illustrating that Adderall is safe for preschoolers; however it is worth noting that no double-blind, placebo-controlled clinical trial of Adderall in preschoolers has ever been conducted. This basically means that tens if not hundreds of thousands of children are currently taking a drug without most stringent science to back it up, which even the AAP notes has “little evidence to support its safety and efficacy.” On the other hand, Adderall has been studied and deemed safe for older children (6+ years); however, studies have shown decreased drug metabolism and clearance in preschoolers, making the FDA’s extrapolation problematic⁵.

Ritalin’s effects in preschoolers are better characterized, though the FDA has not officially approved its use in children this young. While a dozen or so studies have examined the effects of Ritalin in preschoolers, only one double-blind, placebo-controlled trial has been carried out. This study, known as the Preschool ADHD Treatment Study (PATS) was completed in 2006 and forms the basis for the AAP’s statement that “methylphenidate is safe and efficacious for children in this age group.” The findings of PATS are encouraging and corroborate the AAP’s claims of efficacy: nearly 2/3 of the 140 children who received 10 months of continual treatment had improvements in ADHD symptomatology⁶. However, some safety concerns were raised. A small number of subjects dropped out of the study due to adverse side effects, but more concerning was that the Ritalin-treated group experienced 20% less than expected height gain, and 55% less than expected weight gain compared to their unmedicated peers. A similar study in older children suggested that growth-suppressed children never catch up to their unmedicated peers⁷, and this effect could be even more pronounced when medication is begun earlier in development.

It is clear that additional research studies are necessary. The aforementioned trials only begin to address issues of safety and efficacy, and given the (increasing) prevalence of ADHD diagnoses, the AAP’s recommendation to its 60,000 clinicians to provide drug treatment seems premature. It is important to mention that the AAP recommends Ritalin as a secondary treatment option; behavioral therapy is first, and ideally combines parent, teacher, and peer-based programs. However, the CDC indicates that over 2/3 of children with ADHD currently receive drug treatment⁸, and a recent study found a 4.9-fold increase in the rate of doctor’s office visits resulting in both an ADHD diagnosis and psychostimulant prescription over the past 18 years⁹. So, either the behavioral therapy isn’t working, or is being bypassed altogether in favor of pills. Keep in mind that behavioral therapy requires a large time commitment by parents and teachers, and the benefits are often not seen for months. In contrast, pharmacotherapy requires relatively little time and energy, and the effects on a child’s behavior may be seen within days. Obviously, the latter option is far more accessible and alluring.

For Brian, we can only hope that his caretakers will continue to closely monitor his behavior and make the best possible decisions with respect to his course of treatment, whether or not that necessitates the use of Ritalin. But not all kids are so fortunate. The reality is that many children are not surrounded by engaged parents and educators willing to put forth the time, effort, and patience required for behavioral therapy. These children, such as those in foster care or from underserved communities, may be particularly vulnerable to being unnecessarily medicated, over-medicated, or both. Evidence for this comes as early as 1999, where data from the Michigan Medicaid system showed that 57% of children aged 3 and younger with ADHD were treated with as many as 22 different medications in 30 combinations and monitored less than every 3 months¹⁰. Although most prescriptions written for preschoolers are psychostimulants, off-label use of antidepressants and antipsychotics is prevalent, and these drugs often have never been tested in young children.

We all want our children and adolescents to thrive and develop into well-balanced, happy adults. This motivation has driven more than two decades of research into ADHD diagnosis and treatment. But it is exceedingly important that we proceed with caution and not be clouded by delusions that a drug, whether now or in the future, will act as panacea. The neurobiological underpinnings of ADHD are complex and vary greatly across individuals. As we have seen, considerable variation also exists in terms of drug sensitivity and metabolism. So while some children have and will continue to benefit greatly from psychostimulants, others will not. Consequently, it is imperative that as ADHD research progresses, scientists and clinicians devote time and resources to developing multimodal treatment strategies that blend behavioral therapy with pharmacotherapy and can be tailored to the individual needs of the child. Multimodal strategies are recognized as the most effective form of treatment for ADHD in children¹¹. On the social level, we must have adequate safeguards in place to advocate on behalf of children most vulnerable to overmedication. We should also be prepared to confidently address the inevitable questions of identity and self-worth that our children will quarrel with, as well as to retrospectively defend our decision to medicate them.

--Jordan Kohn

Emory University

Neuroscience Graduate Program

Want to cite this post?

Kohn, J. (2012). Psychostimulants in preschoolers: Panacea or Pandora's Box? The Neuroethics Blog. Retrieved on
, from http://www.theneuroethicsblog.com/2012/04/psychostimulants-in-preschoolers.html

1. This story was adapted from Stein Z, Chiesa BD, Hinton C, Fischer KW. “Ethical issues in educational neuroscience: Raising children in a brave new world.” The Oxford Handbook of Neuroethics. Ed. Illes J and Sahakian BJ. New York: Oxford University Press, 2011. 803-819.  



2. Visser SN, Bitsko RH, Danielson ML, Perou R, and Blumberg SJ. (2010) Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children – United States, 2003 and 2007. Morbidity and Mortality Weekly Report. 59(44): 1439-1443. 



3. Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S. (2011) Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 128(5): 1007-1022.



4.Recommendations from the American Academy of Pediatrics (AAP). http://www.cdc.gov/ncbddd/adhd/guidelines.html. Accessed 28 Mar 2012.



5. Wigal SB, Gupta S, Greenhill L, Posner K, Lerner M, Steinhoff K, Wigal T, Kapelinski A, Martinez J, Modi NB, Stehli A, Swanson J. (2007). Pharmacokinetics of methylphenidate in preschoolers with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 17 (2): 153-164.



6. Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skrobala A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. (2006) Efficacy and Safety of Immediate-Release Methylphenidate Treatment for Preschoolers with ADHD. J Am. Acad. Child Adolesc. Psychiatry. 45(11):1284-1293.



7. Swanson JM, Elliott GR, Greenhill LL, Wigal T, Arnold LE, Vitiello B, Hechtman L, Epstein JN, Pelham WE, Abikoff HB, Newcorn JH, Molina BS, Hinshaw SP, Wells KC, Hoza B, Jensen PS, Gibbons RD, Hur K, Stehli A, Davies M, March JS, Conners CK, Caron M, Volkow ND. (2007) Effects of stimulant medication on growth rates across 3 years in the MTA follow-up. J Am Acad Child Adolesc Psychiatry. 46(8):1015-27.



8. Attention Deficit/Hyperactivity Disorder: Data & Statistics in the United States. http://www.cdc.gov/ncbddd/adhd/data.html. Accessed 1 April 2012.



9. Sclar DA, Robison LM, Bowen KA, Schmidt JM, Castillo LV, Oganov AM. (2012). Clinical Pediatrics. E-pub ahead of print. Accessed 1 April 2012.



10. Rappley MD, Mullan PB, Alvarez FJ, Eneli IU, Wang J, Gardiner JC. (1999). Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children. Arch Pediatr Adolesc Med. 153(10): 1039-1045.



11. National Resource Center on ADHD: Diagnosis & Treatment. http://www.help4adhd.org/en/treatment/treatmentoverview. Accessed 1 April 2012.