The recent article on pediatric neuroenhancement is an excellent review of the ethical aspects of stimulant drug use.1 However, the authors may be off point. Most children initially receive stimulant medications from general pediatricians and family physicians who believe that they are treating attention deficit disorder (ADD). These physicians do not believe that they are prescribing drugs for neuroenhancement. It is rare for children taking these drugs to have received psychometric testing and these drugs are frequently started in elementary school with initial success.
A large segment of the medical establishment still believes that a positive response to stimulants is diagnostic of ADD, so this success is viewed as a validation of the diagnosis. After several years, when the drugs begin to fail, children are referred for a dose adjustment—or a new drug. At that point, a previously ignored learning disability is often identified. In pediatric neurology, we would do better by educating our colleagues in primary care that stimulant medications initially help almost every child do better in school, at the price of neglecting many important learning disabilities that merit early attention. If Graf et al. provoke us to do this, they will have provided an invaluable service to hundreds of thousands of children.
Author Response
In our recent ethics position paper, we defined neuroenhancement as “the use of prescription medication by healthy persons for the purpose of augmenting normal cognitive or affective function.”1 Thus, neuroenhancement should not be confused with the potential beneficial effects of medication in neurologic disorders such as attention-deficit/hyperactivity disorder (ADHD).
Dr. Rothman's comments relate to the indiscriminate use of prescription stimulants for children with other neurodevelopmental disorders such as specific learning disabilities and vaguely defined conditions such as central auditory processing disorder. In these disorders, signs of ADHD—including inattentiveness, impulsivity, and hyperkinesis—may coexist.2 Stimulants may show some benefit in these multidimensional disorders.3,4
Separate questions relate to diagnostic accuracy and whether any neurologic disorder exists at all. We agree with Dr. Rothman about the common misperception that “Ritalin-responsiveness” justifies an ADHD diagnosis. We are also generally concerned about the significant increase in the use of prescription stimulants and the possible overdiagnosis of ADHD. Nonmedical use of methylphenidate and amphetamines and the illicit diversion of these drugs to healthy students for neuroenhancement may account for some of the recent rise in ADHD diagnoses.
Public dissemination of information about the misuse and abuse of prescription stimulants is necessary.5
- © 2013 American Academy of Neurology
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