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    ADHD and mind enhancement

    Questions for modern medicine


    Lawrence Rifkin, MD
    It's a busy day in my pediatric practice. Cal, a high school junior, has always had difficulty concentrating and focusing.

    Although he has found ways to compensate, Cal feels his lifelong difficulty paying attention has significantly impaired his ability to do schoolwork and has interfered with his academic potential.

    With SATs coming up, Cal and his parents want me to prescribe medication for attention-deficit/hyperactivity disorder (ADHD).

    Here's the kicker: Cal is a B+ student. He's doing fine in school and fine socially. So the question is: Even though Cal formally meets diagnostic criteria for ADHD, should I treat him? Is it worth changing his brain chemistry to make a B+ student an A– student?

    These questions become even more pointed for me later that afternoon when I see another patient, Michael.

    Piled in front of me is a mountain of paperwork from school evaluators clearly indicating that Michael has ADHD.

    His condition dramatically affects his behavior, ability to make friends, and academic performance. His diagnosis is affecting every dimension of his childhood.

    Michael's parents are adamant. There is no way they are putting their son on medication. They hear rumors about adverse effects. It is not acceptable, they feel, to put a child on this type of medicine. The issue is not open to discussion.

    Are Michael's parents wrong to withhold a medication that will in all likelihood dramatically enhance their child's social and academic success?

    In reality, parental judgment is often the deciding factor, and perhaps that's how it should be. My gut reaction was that Cal should not get the medication, but Michael should.

    But is this gut reaction correct? Why should Michael any more than Cal be given access to a medication that will allow him to be the best he can be? Is it right to prioritize bringing the bottom up, rather than bringing the top to even greater levels?

    It is time for our society to more openly debate the big questions about mind enhancement.

    One question is how we frame conditions. Attention-deficit/hyperactivity disorder is not a disease, I like to explain to parents. It's a mismatch between a person's natural ability to focus and concentrate relative to our specific societal expectations. We expect our third graders to sit and focus for long periods of time, but in many other cultures and through most of our evolutionary history this was not considered the norm.

    Mind-enhancement medications usually enhance everyone who uses them, not just those experiencing the most problems. In the future, should we deny those in the middle or at the top the opportunity for better intelligence, grades, creativity?

    The questions for us as a society run deep. There are access issues. Is it okay if only those of means have access to new medications?

    There are issues about equality of opportunity. Does it destroy competitive fairness if some students take ADHD and similar medications but not others? Who decides?

    Is it fair to Michael that his parents have the final say about whether or not he receives medication that could significantly enhance his school performance and social acceptance?

    Is using mind-enhancement medication even moral? Or alternatively, as humans who have the power to make the world better, is enhancing human potential an ethical duty?

    Medication for ADHD is already a significant reality. A review of 21 studies representing 113,104 participants reported rates of nonprescribed stimulant use to range from 5% to 9% in grade school- and high school-aged children and 5% to 35% in college-aged persons. The inclusion of prescribed stimulant use would raise these figures much higher.

    Additional mind-enhancement medications targeting a wide range of mental abilities are probably not too far away.

    I questioned Cal and his parents about whether they really wanted to use a mind medication when he was basically doing well. We tried alternative behavioral strategies. They didn't work. At a later visit, I ended up prescribing Cal an ADHD medication. It worked dramatically.

    As for Michael, I expressed to his parents how I thought they should seriously consider an ADHD medication for him and provided information about the medication risks, benefits, and adverse effects. They refused. We tried alternative behavioral strategies instead. They didn't work. Michael continues to struggle personally and disrupt his class.

    There are no simple answers. But these are real issues, relevant now. And with additional biomedical mind enhancements in the future, these concerns will soon become even more relevant. These are not just issues for academics or ideologues. It is time as a society to openly start asking these big questions.

    DR RIFKIN is a pediatrician in Bloomfield, Connecticut.

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