"Can you give me some Adderall that will help me get my homework done?" Joey, a 16-year-old high school sophomore asked me near the end of a meeting with his father and me. I was surprised by his request, but I shouldn't have been -- I've been prescribing drugs like Ritalin, Adderall and Concerta to children for more than 30 years. Yet Joey's request did catch me off guard because I had known Joey and his family for a dozen years for problems other than attention deficit disorder (ADD). He had always been an intense, persistent and socially-awkward boy, but now he wanted a medicine that could assist him in homework completion.
Joey's father had called me after an intense argument between them at home. Joey had pushed his father during the fight. His dad wanted to talk about Joey's one-day suspension from school. Joey had been verbally disrespectful to a teacher. Joey's grades had been borderline for all of his sophomore year. Now near the end of the term he was in danger of failing a class. Most of the session had been focused on his inconsistent school performance and increasing irritability. No one had mentioned medicine until Joey's question seemingly came out of the blue.
Many people remain unaware that the drugs called stimulants (various iterations of amphetamine) affect everyone the same. Low doses get people to stick with tasks they find boring or difficult. Impulsive hyperactive children often become more methodical and deliberate, which appears as "calming" them down. As the dose of amphetamine increases, hyperactive or distractible children will ultimately become more active, distractible and "tweaked," just like a methamphetamine abuser.
A "classic" study was published in 1980. Judith Rappoport, a child psychiatrist, now emeritus with the National Institute of Mental Health, wanted to prove once and for all that amphetamine "worked" on normal children too. Collecting a group of hyperactive children was relatively easy. Selecting a group of "normal" children was ethically dicey.
She and her colleagues decided to give 10 milligrams of Dexedrine to their own children and compared their performance to that of the hyperactive group in a series of simple but boring and repetitive math problems. What she found was that the stimulant improved the under-average performance of the hyperactive children to an average level, while the performance of the normal children increased to "supranormal" or above-average levels.
I knew Joey really didn't have ADD. But I was fairly certain that he was a bright enough child and would find getting his homework (boring and repetitive) done more efficiently and easier to complete on Adderall -- the stimulant of choice for college students who have discovered on their own prescription stimulants' effects on studying or cramming for a paper or exam. Why then, was I so uneasy about prescribing it to Joey?
As I said, I knew Joey didn't have ADD. Prior to high school he had always been a solid B student. But by his sophomore year his grades had declined to Cs and Ds. This decline in school performance (especially in boys) is common in early adolescence and is attributable to a concomitant decline in their motivation for doing schoolwork. Even without outright refusal, interest and persistence in school and homework become very inconsistent. Very bright children or those with particularly good study habits can survive this typical decline in motivation without a significant change at school, but for many teens performance and grades decline.
The good news is this trough is temporary for most children (girls are affected too). By mid to late adolescence most children begin to appreciate that grades now "count" for college and start to try harder.
Yet the behavior and symptoms of an inconsistently-motivated teenager are identical to the criteria of ADD. There are no brain scans or blood tests for any of the psychiatric disorders. All of them, like ADD, are lists of problem behaviors. Doctors routinely diagnose ADD in unmotivated teenagers with the implications that the problem is a biological, neurological, lifelong condition. Some of these children may actually have ADD, but in most cases the M.D.s are simply justifying to the child, parents, school and insurance company the use of these universal performance-enhancing medications.
Typically with a new family I would attempt to have the parents and school organize an academic "contract" with the teen that made rewards and consequences for school performance more immediate and meaningful in order to increase the teen's motivation. However, for many families (and I knew that Joey's family had already tried) this scheme doesn't work sufficiently. Then, I would prescribe a long-acting stimulant like Concerta or Adderall XR, making clear to the teen and his parents that I didn't believe I was treating ADD but, more honestly, a phasic decline in motivation.
That's what I did with Joey. He protested that he didn't need help with school during the day. His father felt he did. But I also felt uncomfortable with prescribing a drug for such a specific and limited problem as homework completion. The ethics and fairness of using performance-enhancing drugs is routinely challenged in sports but hardly discussed in academics. Somehow it's okay to use a drug to improve your school performance if there's a disorder, but it's "cheating" if you don't have a real problem and are just using it because you want to get ahead or you're a slacker.
I've drawn a line in the past when parents claimed ADD in their teen but said their child only "needed" the medicine when taking major exams. However, students report that this use, either officially supported or not by doctors, is widespread these days on college campuses.
No matter, doctors (and families) need to come clean about the ADD diagnosis. It is hypocritical and ultimately does true sufferers a disservice when we combine them with under-motivated normal children. The country is already quite cynical and suspicious of psychiatric diagnoses -- to wit the continuing controversies over the upcoming psychiatric bible of diagnosis, DSM-V.
Doctors routinely "upgrade" diagnoses to fit either a treatment or garner a reimbursement. But even erectile dysfunction to justify the use of Viagra for essentially enhancement purposes doesn't have the same lifetime implications of an ADD diagnosis for a teen who is only temporarily struggling with motivation. I suppose we need yet a new category in the DSM-V. I propose TMP, or transient motivation problem. Or we could just admit these are normal kids struggling to adjust to one of life's universal challenges.
For more by Lawrence Diller, M.D., click here.
For more on mental health, click here.
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