Having prescribed drugs like Ritalin and Adderall to children for 35 years, I've participated with concerned fascination in the ADHD/ADD epidemic that has swept our country. Still, I was surprised that I felt so troubled when 16-year-old Joe's* mother, Susan*, called me the other day and asked if I'd be willing to prescribe him Adderall just for his finals coming up in two weeks.
I had evaluated Joe the year before for attention deficit disorder because he had complained that he couldn't concentrate. His grades had been inconsistent but included a couple of Ds. In my evaluation, I found Joe's abilities and academic performance to be at grade level. He could have been an A/B student with consistent effort. But Joe had major problems making himself do things he knew he needed to do and neither had his parents found a formula to help him get his homework done on a regular basis.
Psychiatric criteria require six of nine symptoms of inattention or distractibility to meet official standards for ADD (or technically ADHD-inattentive type). But Joe's disconnect between what he wanted and what he was doing has become the de facto clinical front-line rationale for both ADD and the use of prescription performance-enhancing stimulant drugs. Indeed, anyone whose temperament or talents fail to meet their goals or aspirations could present to a doctor for an ADD evaluation and medication and likely get both the diagnosis and drug.
Last year, I worked primarily with Joe's parents to help them organize a week-to-week academic contract for Joe. When I checked in with Susan this fall, she reported he had started his sophomore year positively. Thus, Susan request that I prescribe Joe Adderall for finals week surprised me some. Joe didn't want to take the medication on a regular basis because he was concerned about side effects but was willing to try it to help with his exams. A friend of his had a doctor who had prescribed the drug for this limited indication and use. Would I do the same for Joe?
I told her it was unlikely that I would give Joe medication just for test taking. I said I would reconsider starting Joe on a long-acting stimulant medication like Concerta or Adderall XR but that he would have to take it on a regular basis (e.g., five school days a week). I suggested that the parents and Joe come in to talk to me about Joe using Adderall. Susan said she would consult with her husband and son and get back to me. I didn't hear back from her and wonder if she called the other doctor.
I won't give Joe a prescription because I believe this type of "event-driven" dosing actually could facilitate an ADD lifestyle. High school and college students can act notoriously irresponsibly during the year and then want legally- or illegally-obtained Adderall to study and take exams at the end of the semester for finals. I'm prepared to help Joe if he wants to use the drug to improve his studying and homework completion on a weekly basis. I've stopped trying to decide who really does or doesn't have ADD. I just want the person to use the drug effectively and responsibly.
Then there are the societal concerns. Many students have raised fairness issues -- for the same reasons that athletes have complained when their colleagues/competitors are using performance-enhancing drugs. We ban these substances in sports for two reasons. We value achievement based upon effort and these drugs cheapen the achievement. But more critically allowing the use of these substances puts pressure on all competitors (athletes/students) to use them just to keep up. It's called "free will under pressure."
But there's a more Joe-specific reason for questioning using Adderall to try to improve his final exam scores. When Joe and his parents choose to use Adderall they prioritize simple achievement over other human qualities and values (like love or connections to others). They also permit Joe to skip, at least temporarily, a universal experience/maturation process that gets us to accept our own strengths and weaknesses. As we get older we get to "focus" on things we like and are good at.
We Americans live in a complete corporate meritocracy -- achievement at all costs. A college education guarantees a good job, earning power and happiness. Or does it anymore? The U.S. is 4 percent of the world's population but in 2010 produced two-thirds of the world's Adderall. In 2013 the Drug Enforcement Administration approved the production of 189 tons of legal speed (Ritalin, Adderall, Concerta, etc.) or 544 milligrams for every man, woman and child living in the U.S.
So I don't blame Joe's family at all if they wind up using Adderall for finals. I just know my limits as to how far I can ethically participate in this epidemic. But I suspect the other doctor will have no problem filling the prescription.
*Names have been changed.
For more by Lawrence Diller, M.D., click here.
For more on ADHD, click here.