Allan Schwarz’s recent New York Times article “Attention Disorder or Not, Pills to Help in School” presented some controversial testimonials on the prescription of attention deficit and hyperactivity (ADHD) medications to low-income children. As science writer Emily Willingham points out, this article is part of a two decade long debate over the merits of medicating our nation’s children to increase academic performance. But what makes this piece particularly controversial is its exposition of the open, explicit, and unapologetic use of ADHD medications as cognitive enhancers for the healthy. In the last ten years, the media has played a large role in this reconceptualization of ADHD medications, labeling Adderall and the like as “brain boosters”, “smart pills”, or “academic steroids”, which offer an unfair advantage to their users. Ethical debates, such as those presented in Schwarz’s article, also presume the cognitive benefits of these drugs and produce normative arguments concerning medical risks of unsupervised and prolonged use, privileged access by the wealthy, and social pressures to solve nonmedical problems using these medications. In these conversations, the Adderall use is continually reduced to a pragmatic consumer decision by individuals seeking to increase academic performance.
In my own research with US college students, I depart from these discourses of consumerized cognitive enhancement and examine how students understand and use Adderall. During my twelve months of interviews and participant observation, I found that the “magic bullet” model of cognitive enhancement does not account for the multiple, complex, and often contradictory rationalities that encourage Adderall use. ADHD medications do not simply fill a pre-defined need for college students to manipulate cognitive function; rather, it is the pervasive normalization of their use which is setting new expectations of mental health, academic performance, and social success. For some, the Adderall experience produces new possibilities to access hidden academic and social potentials. For others, it is evidence that their brains are in fact diseased and they need medication to cope with the demands of college life. Thus, experiments with Adderall, rationalized as noble pursuits of health and/or performance, reflect how individuals are relying on pharmaceuticals to not only meet their responsibilities and aspirations, but understand them.
The Moral Economies of Adderall
Beyond the phenomenological experiences of students, I am also interested in how the desire to obtain Adderall influences their participation in larger medical, academic, and social networks. At the AAA meetings next month, I will be presenting my work on what I call, “The Moral Economy of Adderall” in the American University. By “moral economy”, I mean the system of relationships and moralized exchanges between the actors and institutions that facilitate the circulation and use of ADHD medications. This includes family, peers, educators, administrators, healthcare providers, as well as the pharmaceutical companies who produce and promote these drugs. As the consumers of Adderall, college students are the principal agents in this economy, mobilizing various resources in their pursuit of the drug. In this process, they enact particular subjectivities and develop certain ethical codes that help them both obtain Adderall and legitimize their behaviors. As a result of their participation, individual and cultural expectations of how to be a model “student”, “son/daughter”, “patient”, or “friend” are inevitably transformed.
As I read Schwarz’s piece, I began thinking about how this moral economy of Adderall compares to that of primary and secondary schools, as well as its influence of the agency of young children. Illina Singh (2012) addresses this issue in her article “Not robots: children’s perspectives on authenticity, moral agency and stimulant drug treatments”. She explains that “children report that stimulants improve their capacity for moral agency, and they associate this capacity with an ability to meet normative expectations” (1). However, I would take this a step further and argue that it is the normalization of Adderall use among children that influences a child’s “normative expectations” of his or her own behavior, performance, and relationships with others. We see this in Schwarz’s interview with 11-year-old Quintn, who now takes Risperdal after suffering from an Adderall-induced psychotic break. Quintn attempts to rationalize why he was put on Adderall in the first place, and why his parents would continue to medicate him despite the obvious medical risks involved. He explains:
“To help me focus on my school work, my homework, listening to Mom and Dad, and not doing what I used to do to my teachers, to make them mad… If I don’t take my medicine I’d be having attitudes. I’d be disrespecting my parents. I wouldn’t be like this.”
ADHD medications clearly facilitate Quintn’s relationship with both his parents and teachers. By giving him a point of reference for normal behavior, the drugs shape his understanding of the kind of son and student he is expected to be.
For college students, the decision to seek out and consume Adderall is ultimately their own. The right to make this decision for oneself is one of many freedoms granted to young adults as they enter their college years. It is also part of a larger ethos of responsibility for young adults to take charge of their own health, social development, and academic success once they leave the auspices of their pre-college life. In contrast, the decision for a child to take prescription medications falls on the network of adults who take responsibility for the wellbeing of this child. The difference here is not in the types of actors involved in this economy, but in the startling way adults are relying on ADHD medications to understand and fulfill own responsibilities as parents, educators, and doctors to these young children. In the remainder of this piece, I want to shift attention towards these individuals and how their behaviors are mitigating or contributing to the larger anxieties associated with pharmaceutical enhancement. While Schwarz explicitly touches on concerns of medical risks and shifting privileged access to the drug, the issue I found most striking was the tacit element of social coercion which permeated these narratives. Farah et al. (2004) discusses their concern with social coercion and argues:
“If neurocognitive enhancement becomes widespread, there will inevitably be situations in which people are pressured to enhance their cognitive abilities. Employers will recognize the benefits of a more attentive and less forgetful workforce; teachers will find enhanced pupils more receptive to learning.” (423)
Thus, coercion is not only about the pressure children feel to take these medications in order to please the adults in their life; it also includes the pressure on educators, parents, and doctors to buy into the model that the best/easiest/fastest/only way to fulfill their own responsibilities to these children is to medicate them.
For college students, the desire of an ADHD diagnosis is usually their own. They often view it as an explanation for their lack of performance and/or a way to access Adderall legally to meet their individual needs. For many of my informants, it also means reaping the benefits of this particular subjectivity; including extra test taking time, alternative test taking venues, and extensions on take home assignments. While some of the professors I spoke with didn’t mind making these accommodations; others were adamant that students were clearly taking advantage of the system. One professor I spoke with expressed his concern with the massive increase of students coming in with disability accommodations and felt it was irresponsible for doctors and the university to facilitate and normalize these practices.
For children, the signs of ADHD are often identified by parents or teachers long before they ever see the inside of a doctor’s office. The potential dangers of this practice, including misdiagnosis, are discussed by Dr. Nancy Rapport in her response to Schwarz’s article. Many of the college students I interviewed also expressed their discontent with educators whom they saw as frivolously labeling kids with ADHD in order to justify their own inabilities to adapt to their diverse learning styles. Some of these students look back and blame their teachers for their misdiagnosis. Others blame them for overusing these labels and diminishing the legitimacy of the condition for those who actually need medical attention. There are also those who sympathize with educators and fault the lack of resources that limit their abilities to succeed as teachers. Schwarz’s article is partial to this perspective and places the blame squarely on the economic burdens faced by public schools. He quotes an anonymous superintendent who explains:
“It’s scary to think that this is what we’ve come to; how not funding public education to meet the needs of all kids has led to this,” said the superintendent, referring to the use of stimulants in children without classic A.D.H.D.
What is missing from this perspective is an exploration of how medicating students might do more than make up for a lack of resources; it may also increase the chances of a public school to receive government funding. Programs like No Child Left Behind and Race to the Top are obvious motivations for teachers to produce not better just students, but better test takers. As teachers continue to accept medication as a reliable method of improving test scores, their own expectations of how a child can and should perform will inevitably transform. As Farah and colleagues put it “Teachers will find enhanced pupils more receptive to learning”. It is important to point out that there is no clear consensus among experts on the actual effectiveness of Adderall in enhancing different types of cognitive work (memorization, synthesis, composition, etc). But the fact that teachers believe Adderall can improves the academic performance of students on standardized tests significantly influences how they view these medications as a part of their own strategies of effective teaching.
I began my study of college students assuming that the desire to use Adderall would fall along academic lines, with overachieving, flash-card happy science majors as the primary consumers. Instead what I found was that academic major had almost no bearing on the decision to use the drug. What was a contributing factor was a student’s perception of parental values – of hard work, merit, and the importance of academic performance. However, these values manifested in a number of surprising and contradictory behaviors. For example, many students whose parents emphasized the importance of discipline and earned success felt that the primary reason they never tried Adderall, or concealed their use of the drug, was because they didn’t want to disappoint their parents. At the same time, there were just as many, if not more students who spoke openly with their parents about their illegal Adderall use. Some even felt their drug use demonstrated to their parents how seriously they took their new academic responsibilities. In come cases, when a parent finds out that their child is using Adderall for these noble purposes, they will offer to help their son or daughter obtain a legal prescription for the medication through their family healthcare provider.
While college students are the ones initiating this conversation, it is the parents who must convince young children of the benefits of taking the ADHD medications to meet their academic goals. For example, Ms. Williams, a low-income mother interviewed by Schwarz’s explains that all three of her children are prescribed medication, despite not actually presenting the symptoms of ADHD. She says:
“My kids don’t want to take it, but I told them, ‘These are your grades when you’re taking it, this is when you don’t,’ and they understood.”
Schwarz doesn’t provide commentary from the Williams’ children, but one has to wonder – how do they view their (reluctant) consumption of Adderall as part of a broader identity of being a “good” son or daughter? More importantly, how does convincing a healthy child to take powerful prescription stimulants contribute to Ms. William’s attempts to be a “good” mother? In this context, grades take on a double meaning, quantifying both her children’s performance as a student, and Mrs. Williams’s performance as a parent. In the U.S., grades have also come to signal a child’s potential for future success – without good grades, it is assumed you won’t get into college and get a good job. As Mrs. Williams clearly understands the limitations of her financial situation, and begins to see ADHD medications as a way to offset this disadvantage for her children.
Schwarz’s interview with Quintn’s parents, the Rocaforts, also highlight how the choice to medicate ones’ children is no longer about improving mental health, but explicitly about increasing their chances for success in school and life. He writes:
“Despite Quintn’s experience with Adderall, the Rocaforts decided to use it with their 12-year-old daughter, Alexis, and 9-year-old son, Ethan. These children don’t have A.D.H.D., their parents said. The Adderall is merely to help their grades, and because Alexis was, in her father’s words, “a little blah.” Acknowledging that Alexis’s use of Adderall is “cosmetic,” he added, “If they’re feeling positive, happy, socializing more, and it’s helping them, why wouldn’t you? Why not?”
The belief that a person can become less “blah” – less boring or somehow more meaningful – by taking a prescription pill is an important part of Mr. Rocafort’s relationship with his daughter. His goal is no longer just to see her grades improve but to fundamentally transform who she is as a person. By giving Alexis Adderall, he is fulfilling his moral responsibility as a parent to maximize her success, an advantage that outweighs the potential damage he could be inflicting on her in the long run.
Beyond the pressures to medicate one’s children to give them a competitive edge, there is also a growing trend among parents who are themselves are relying on ADHD medications to meet their own unreasonable expectations of parenting. This phenomena was showcased this in an early episode of Desperate Housewives titled “Anything you can do” in which Lynette, an overwhelmed mother of four, feels increasingly insecure about her parenting abilities when she sees the other mothers effortlessly balancing their personal, professional, and social responsibilities. When she finds out they are using their children’s Ritalin, Lynette follows suit in order to prove to the rest of the moms that she has what it takes to be a contributing member of the PTA. In this clear case of social coercion, perceived responsibilities and expectations of parenthood are dramatically transformed as soon as Lynette sees firsthand what is possible with the drug. Recently, ABC news aired a controversial story titled “Supermom’s Secret Addiction: Stepping Out of Adderall’s Shadow” in which mothers revealed that they had been stealing their children’s ADHD medication to successfully keep up with their daily responsibilities. Some of my own informants told me that they have been approached by their parents wanting to sample their Adderall as they learn about the benefits of the drug beyond the walls of the classroom. As parents are becoming comfortable enough to talk openly about these discretions, it is completely possible that their own desire to access Adderall will influence the prescription rates of these medications to young children.
When a college student decides to seek out an ADHD diagnosis, they usually go in with a plan of action. Because whether they believe they have ADHD or not, students must persuasively play the role of the patient in order to convince their doctor of the legitimacy of their suffering. This includes an entire choreography of exchanges between the two parties that ultimately may or may not result in the prescription of ADHD medications. At my field site, the demand for a diagnosis is so great that the university opened up a center which focuses explicitly on ADHD testing. On average, they test over 100 students a semester for the condition of which less than 20% are given a positive diagnosis for ADHD. A clinician at the center whom I will call Dr. Nicholson, admits that the majority of students are upset with his conclusion, some accusing him of being biased or unqualified. He explains to me that his responsibility is not to hand out medications, but to help them understand and deal with the underlying medical and nonmedical factors that are causing them to perform below their (sometimes unreasonable) expectations.
In contrast, Dr. Anderson, pediatrician to the Williams and Rocafort children, seems to have a much harder time saying no to his patients. When Schwarz asked why he would prescribe Adderall to a child whom he believes does not have ADHD, he explains:
“I don’t have a whole lot of choice… we’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”
Dr. Raghavan, a child mental health services researcher supports this view and explains:
“We as a society have been unwilling to invest in very effective nonpharmaceutical interventions for these children and their families… we are effectively forcing local community psychiatrists to use the only tool at their disposal, which is psychotropic medications.”
For Dr. Nicholson, the pressure to prescribe Adderall comes from his patient, an often desperate or confused college student who was unwilling to accept that the root of their problem was not ADHD. For the doctors in Schwarz’s article, the pressure is coming from “society” who is seemingly backing them into a corner and giving them no other option but to comply with the demand for these medications.
This image of the obedient doctor is a far cry from the “professional dominance” (Friedson 1970), “medical imperialism” (Illich 1976), and the problem of “expert control” (Conrad 1975) that medicalization scholars warned us about more than thirty years ago. In his most recent book, Conrad (2007) explains that the medicalization process has shifted towards a consumer-driven model of health where doctors are no longer the ones pushing diagnoses on their patients. New players have entered this economy including parents, educators, insurers, and pharmaceutical companies who can each benefit from seeing an increase in the prescription of ADHD medications for young children. As the participation and influence of these parties in the treatment process increase, doctors must actively renegotiate their relationship to their patients and society at large. Joe Dumit (2012) describes this trend as “doctor disempowerment” in which patients are taking advantage of the modern constraints placed on doctors to demand treatment for themselves (and their children). He writes:
“Doctors, in turn, because of the multiple pressures of limited patient time, keeping up with rapidly changing information, the constraints of health care maintenance organizations and insurance are quite vulnerable to these demands” (14).
As the blame is placed on doctors for giving into these pressures, some are developing a new set of ethical criteria to rationalize their actions. For Dr. Anderson, these criteria come from his perception of normalized Adderall use among wealthy students who are using the drug to enhance “already good grades”. As his patients are mostly low income, Dr. Anderson sees his distribution of Adderall as leveling the playing field for children who have no other option to increase their academic performance. He also explains that he won’t prescribe ADHD medications to any student who is getting “A’s and B’s”. Remarkably, none of these standards are based on his expertise as a trained medical doctor, which is what gives him the legal right to prescribe these medications in the first place.
Not surprisingly, Dr. Anderson received a significant backlash as a result of his statements in the NY Times piece. He responds to this in an interview with CBS Atlanta and explains:
“I am not happy to be doing this, nobody is happy to be doing this. But I am pleased to be able to offer something”.
Although the degree of agency Dr. Anderson feels he has in the treatment process is still unclear, it is evident that the normalized (albeit contentious) practice of prescribing Adderall to children has influenced his scope of responsibility towards these children.
As Americans continue on this path towards, what Stephen Colbert cleverly refers to as, “Meducation”, it is important to consider the impacts of normalizing Adderall use on the entire network of actors and institutions involved in this process. Giving a child ADHD medications is not just about enhancing academic performance – it’s about negotiating the moral responsibilities that come with raising, teaching, and treating a child in a pharmaceuticalized culture. As I end this piece, I can’t help but think of the kind of college students these “meducated” children will grow into; and how a lifetime of Adderall use will inevitably impact their own expectations as parents, educators and health care providers in the future.
Conrad, Peter. 1975. The discovery of hyperkenesis: notes on the medicalization of deviant behavior. Social Problems. 23:12-21
Conrad, Peter. 2007. The Medicalization of society. Baltimore: Johns Hopkins University Press.
Dumit, Joseph. 2012. Drugs for life: how pharmaceutical companies define our health. Durham and London: Duke University Press.
Farah MC, Illes J, Cook-Deegan R, Gardner H, Kandel E, King P, Parens E, Sahakian B, and Wolpe PR. 2004. Neurocognitive enhancement: what can we do and what should we do? Nature Reviews Science 5:421-425.
Friedson, Elliot. 1970. Profession of medicine. New York: Dod, Mead.
Illich, Ivan. 1976. Medical nemesis. New York: Pantheon.
Singh, Illina. 2012. Nor robots: children’s perspectives on authenticity, moral agency and stimulant drug treatments. Journal of Medical Ethics Online <accessed October 15, 2012>
Tazin Karim is a doctoral candidate in the Medical Anthropology Program at Michigan State University and Chair of the Alcohol, Drugs and Tobacco Study Group of the Society for Medical Anthropology. Her research is funded by the Wenner-Gren Foundation for Anthropological Research. For more information about Taz or her work in pharmaceutical anthropology, feel free to visit her website: www.tazinkarim.com or follow her on twitter @PharmaCulture
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