Addressing the problem of ADHD medication as neuroenhancements

Abstract

The prevalence of attention deficit hyperactivity disorder (ADHD) diagnoses is rising. ADHD is closely linked to its treatment with medications such as methylphenidate and amphetamines, which have popular appeal as neuroenhancement drugs by persons without a neurological disorder. The three main reasons for the increase in ADHD medication demand, production, and consumption are a) the inclusion of milder ADHD diagnoses; b) the vast marketing of ADHD medications by the pharmaceutical industry; and c) the illegal diversion of controlled ADHD medication to consumers seeking stimulants as neuroenhancements. Rapidly rising rates of any neurological disorder – especially a behaviorly-defined disorder closely linked to potent medications currently prescribed to more than 5% of the population – deserves ongoing scrutiny. Major social and ethical problems arise from vague-symptom medicalization, neurological disorder trivialization, medication overuse, and controlled substances diversion to healthy persons for nonmedical purposes. We argue against the ‘spectrumization’ of ADHD in an effort to curtail further diagnosis creep.

Keywords::

• attention deficit hyperactivity disorder
• autonomy
• DSM-5
• ethics
• ICD-10
• medicalization
• mental health
• neuroenhancement
• professional conduct
• stimulant medication

Financial & competing interests disclosure

SK Nagel receives research support from the German Federal Ministry for Education and Research [DLR - 01GP1010]. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The Diagnostic and Statistical Manual of Mental Disorders-5 appropriately reclassified attention deficit hyperactivity disorder (ADHD) as one of the neurodevelopmental disorders.

• As opposed to other neurodevelopmental disorders, ADHD is strongly associated with potent medical interventions, such as methylphenidate and amphetamine.

• ADHD is behaviorally defined and remains difficult to diagnose because of the many uniquely individual neurodevelopmental traits observed in children and adolescents during their early development.

• Remarkable cross-state and cross-national geographic diagnostic variations of ADHD are evident. Only approximately 20% of individuals diagnosed under The Diagnostic and Statistical Manual of Mental Disorders-5 would be diagnosed under the more restrictive International Classification of Diseases-10 diagnostic system.

• Explaining the surge in ADHD diagnoses and stimulant medication consumption requires appreciation of how ADHD is defined, how various physicians in various healthcare systems make ADHD diagnoses and why demand in black markets motivate medication diversion.

• It is not certain how much of the recent increase in ADHD diagnoses reflects earlier underdiagnosis, trend toward overdiagnosis, true increase of the disorder, societal changes, school accountability policies, the effects of medication marketing or some combination of these factors.

• Expanding categorical diagnoses (i.e., advocating the concept ‘ADHD-spectrum disorder’ in practice) would probably lead to more prescriptions for amphetamines but not necessarily lead to better long-term outcomes for people with milder ADHD traits.

• The most common nonmedical use of stimulant medications is by persons without ADHD who seek drugs for neuroenhancement.

• Pediatric neuroenhancement poses various social and ethical issues, including those on the process of developing autonomy and the fiduciary responsibility of physicians caring for children.

Notes