The Last Normal Child

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Little Helpers in 2024

Brain Enhancers or Bust?

This past December the prestigious British journal, Nature, published a commentary entitled "Cognitive Enhancers," in which the authors proposed reevaluating the ethics of using drugs that ostensibly improve the brain's performance. Their position likened taking a drug such as Adderall - an amphetamine, legally prescribed primarily to treat attention deficit disorder (ADD), but now increasingly used by college students as a study and exam taking aid - as not too different from the wearing of glasses, prepping for the SAT with a private tutor or simply taking vitamins.


Then in April of this year, the New Yorker Magazine published a lengthy rather sympathetic essay on the use of stimulants like Adderall at prestigious American colleges. While the tone mildly questioned the values espoused in the pursuit of goals aided by the elective (and illegal) use of Adderall, the author flatly stated that "cognitive enhancers cannot be banned."

Up until recently, amphetamine abuse and addiction have been a relative risk in the unsupervised use of this drug. But Shire, the drug company that markets Adderall (the drug most frequently abused - crushing and snorting it like cocaine to study or get high) has recently promoted a new product, a pro-drug, called Vyvanse. Vyvanse is amphetamine linked chemically to a safe amino acid, lysine - which when they are bound together makes the amphetamine pharmacologically inactive. Only when Vyvanse is swallowed does the amphetamine cleave from the lysine via digestive enzymes and the amphetamine part of the pill becomes active.

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Shire clearly hopes to position its product as safer than any other kind of stimulant (Ritalin, Concerta, etc.) by making crushing, snorting or even intravenous injections useless for abuse. Technology appears to be continuing to improve the safety and perhaps, even the effectiveness of amphetamine like drugs such as Vyvanse or Concerta (the first twelve hour stimulant). No surprise really, as the demand for these product enhancers seems unending and forever growing.


Drugs like Ritalin and Adderall are now routinely prescribed to children who only in the broadest sense have trouble with attention and focus. For example, children with learning problems who only have concentration problems in school (and sometimes only for a particular subject) regularly get medication from most doctors. Similarly, academically unmotivated younger adolescents "meet" ADD criteria and receive medication without much controversy these days.

Increasingly older high school and college students and parents of younger children are asking pediatricians and psychiatrists for medication just for specific times of the week or just for studying and exam taking. The medical use of Adderall for these limited purposes are more questionable both clinically and ethically. However, some doctors are complying with these requests.

 

Meanwhile, there is much illegal diversion of Adderall for studying or getting high on college campuses. Some surveys report up to 35% of college students at particular campuses have admitted using Adderall or its equivalent legally (with a prescription) or illegally. With these trends in mind and with respected scientists seeking to justify the ethical use of cognitive enhancers, I imagine the following scenario for a child I'll call Winston. Winston (named after the protagonist from an infamous future dystopia) is a nine year old boy living in Esalen, a now thriving exburb of Palo Alto, California in the year 2024.


Winston's parents have been asked to attend a meeting at his school with his teacher, Mrs. O'Brien (also intentionally named for another "teacher"), the school psychologist/developmentalist and principal. Mrs. O'Brien opens the meeting, "It would appear that Winston has been mightily struggling at school and also trying to keep up with the homework we give him in the ‘enhanced' class setting. We're not sure if he should continue in the class unless somehow he can take one of the ‘little helpers' successfully."
Winston's parents knew exactly to what Mrs. O'Connor was referring. Just earlier in the morning Winston's mother had once again begged his father to reconsider yet another drug for Winston. "You know everyone in his class takes a ‘little helper.' He just doesn't have a chance to make it unless he gets the same fair assistance that all the other children are receiving," she told her husband.

"But you know Winston's situation, honey," the father replied resignedly, "we've tried any number of helpers to assist Winston and either they haven't worked or he can't tolerate them. It's truly unfortunate." Indeed, Winston had experienced multiple performance enhancers but he seemed to be the unlucky one in ten kids who physically or emotionally did poorly on products like Focusyn (where he developed nasty headaches), Execution (a rise in his blood pressure) or Simulex (the worst, when he peed blood).

Winston could overhear his parents' conversation and felt miserable. He knew he was disappointing them and his teacher. Without the pills that all his friends and classmates took, he just couldn't keep up with his peers in subjects like advanced algebra and Bernakian economics which were typical for a fourth grade enhanced class. He cried as he murmured to his parents, "I'm just a failure."

But that was earlier in the morning. Now Winston was invited to join the meeting with his parents and the school officials. Mrs. O'Brien spoke kindly to the family, "In light of your efforts to try to help Winston compete, we are entirely sympathetic, but we just don't believe it is good for you, Winston, to continue in the enhanced class. We strongly recommend to the three of you to consider having Winston join the ‘normal achievement' fourth grade class at the school. You will certainly continue to learn, Winston, albeit at a natural pace. And you never know, you could easily catch up at some point in the future."

"The normal class!" thought Winston. The normal class had only twenty students, not the forty-five Winston was used to. Winston's parents knew there was much more time for "soft" subjects like art and music in the normal class. There was even a period of time, twice daily, called recess where children were not engaged educationally and played outside.

After the meeting, Winston's parents noticed his looking quite glum. They tried to cheer him up. "Come on now, Winston," his father said, "most of the children who attend the normal class aren't bad. They're a lot like you. Most of them also just can't handle those pills that make you work harder, concentrate longer and more efficient with your time. Without those medicines, most kids, not just you, simply can't handle the enhanced class."

His mother tried to be helpful, "Winston, I do believe there are even some children in the class whose parents simply didn't want to give their kids helpers. I admit some of their values are bit old fashioned but there's something to be said about doing things naturally."
His father added, "You know, Winston, the state of California, doesn't force parents to give their kids helpers. It's up to us to decide. That's why they do still have these normal classes to accommodate a range of choices for families. Just because most kids take helpers, that doesn't mean everyone could or should. I actually think this new class is going to work much better for you and us."

Winston was barely relieved. Secretly, he hoped that the Company would come up with yet a new product for him to try so he could stay with the kids he knew and do the best he could in the enhanced class. He could see his parents were hopeful which cheered him a bit. But he remained very worried -- especially about this subject he knew hardly anything about - recess.

A version of this essay first appeared in the September 2009 issue of Communique, the national newspaper for the National Association of School Psychologists.

Lawrence Diller, M.D., practices behavioral developmental pediatrics and is on the faculty at UCSF Medical School. His books included Running on Ritalin and The Last Normal Child.more...

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