The Adderall Generation

February 13, 2013

mastrangelo

Introduction

The use of prescription simulants for academic achievement by high school students who do not have attention deficit hyperactivity disorder, ADHD, is a controversial topic in the United States.  Students without ADHD use prescription stimulants, which doctors routinely prescribe to treat ADHD, to improve their scholastic performance.  Prescription stimulants, such as Adderall and Ritalin, manage ADHD symptoms in people with the disorder.  Students without ADHD use prescription stimulants to enhance their concentration, energy, and focus (Schwarz).  College students without ADHD have used prescription stimulants for years; however, the use of prescription stimulants to boost grades is now prevalent in high schools across the United States.  Currently, there is a debate occurring over the fairness of prescription stimulant use by high school students without ADHD.  While the use of prescription stimulants for academic achievement troubles some people, others justify their usage.  After examining fairness and the goals of education, I believe that high school students without ADHD who use prescription stimulants for academic achievement have an unfair advantage over their peers while they are also being unfair to themselves.

I am a sophomore in high school, and the use of prescription stimulants for academic achievement by students my age is a relevant and important topic.  Because I understand the challenges faced by high school students today, I bring a unique perspective to this ethical issue.  This issue is a hot topic in the media, and headlines from major newspapers and news shows demonstrate its relevance.  In the New York Times, the “Risky Rise of the Good-Grade Pill” article brought national attention to high school students’ use of prescription stimulants for school purposes rather than for recreational reasons.  Countless other newspapers and news shows reported on the use of these so-called “study drugs.”  Behind the factual information in these news stories are high school students who are the next generation of leaders.  As a part of this generation, nicknamed the “Adderall Generation,” I believe that the use of prescription stimulants for academic achievement is a pressing issue that deserves a nation-wide conversation.

Prescription Stimulants

Doctors routinely prescribe stimulants for the treatment of ADHD.  Stimulants are a group of drugs that increase energy and alertness, heighten mood, and boost feelings of health (“Stimulants”).  Stimulants, such as amphetamine and methylphenidate, are the most common treatment of ADHD (Arnsten).  Amphetamine and methylphenidate are in a class of medications called central nervous system stimulants that doctors prescribe to control ADHD symptoms.  Children with ADHD have a harder time focusing, controlling their actions, and remaining still or quiet compared to children of the same age without ADHD (MedlinePlus).  In addition, doctors prescribe methylphenidate and amphetamine tablets to treat narcolepsy, “a sleep disorder that causes excessive daytime sleepiness and sudden attacks of sleep” (MedlinePlus).  The brand names of these prescription stimulants include Adderall, Vyvnase, Ritalin, Concerta, and Focalin (“Study Drugs”).  Adderall and Vyvanse are amphetamines, while Ritalin, Concerta, and Focalin are methylphenidate drugs .  Because of safety concerns, the government regulates these prescription stimulants under the Controlled Substances Act.

The Controlled Substances Act categorizes Adderall, Vyvanse, Ritalin, Concerta, and Focalin as Schedule II controlled substances.  In the Controlled Substances Act, there are three requirements for drugs and other substances in Schedule II.  The first requirement is that “the drug or other substance has a high potential for abuse” (Controlled).  Also, each drug or other substance must have “a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions” (Controlled).  The last requirement is that “the abuse of the drug or other substances may lead to severe psychological or physical dependence” (Controlled).  Possessing, selling, or distributing these stimulants is a felony.  In addition to the legal consequences of using these stimulants without a prescription, the stimulants have serious side effects.

Prescription stimulants are drugs and, therefore, have side effects.  Some side effects of amphetamine and methylphenidate include restlessness, headaches, and uncontrollable shaking.  They can also cause dry mouth, nausea, stomach pain, and mood swings.  There are more serious side effects, such as hallucinations, changed or blurred vision, seizures, weakness or numbness in the leg or arm, fast or pounding heartbeat, dizziness, and difficulty breathing.  Because prescription stimulants can cause a loss of appetite, some people use stimulants as an appetite suppressant.  Doctors do not suggest that their patients take these stimulants before bed because they can cause difficulty falling and staying asleep.  In extreme cases, the stimulants may cause sudden death due in part to preexisting heart defects or problems (MedlinePlus).

Prescription stimulants that treat ADHD work the same way in people, regardless of whether or not they have ADHD.  For many years, there was an assumption that simulants calmed people with ADHD and stimulated people without ADHD.  However, stimulants “increase executive functions in patients and most healthy normal people, improving their abilities to focus their attention, manipulate information in working memory and flexibly control their responses” (Greely).  The prefrontal cortex is the area of the brain that regulates behavior, attention, and decision-making.  The prefrontal cortex is weaker in people with ADHD than it is in people without ADHD; therefore, “ADHD drugs primarily target the prefrontal cortex” (University of Wisconsin-Madison).  The brains of people with ADHD have low levels of dopamine and norepinephrine, which are neurotransmitters that “play essential roles in attention and thinking” (Hunt).  Stimulants boost the low levels of these two chemical messengers to normal levels.

PET Scan

The image above is a positron emission tomography scan that displays the difference in dopamine levels in people with and without ADHD. The scan on the left is the brain of a person without ADHD. This scan has a “greater concentration of yellow, orange, and red in the nucleus accumbens,” which “reflects a higher amount of dopamine” (“Prescription Stimulants Affect”). The scan on the right displays the brain of someone with ADHD, and the brain has a lower concentration of dopamine.
Source for picture: “Prescription Stimulants Affect People With ADHD Differently” on the National Institute of Drug Abuse for Teens’ Website

Prevalence in High Schools

The use of prescription stimulants for academic achievement by students without ADHD is prevalent in high schools.  A survey sponsored by the National Institute on Drug Abuse in 2011, “Monitoring the Future,” reveals the percentages for the nonmedical use of amphetamines, Adderall, and Ritalin by 10th and 12th grade students.  Since 1975, the University of Michigan’s Institute for Social Research has conducted this survey annually.  The survey was completely anonymous for 10th grade students and confidential for 12th grade students.  In their answers, the students only included the use of stimulants without a doctor’s instruction.  The survey indicates that 6.6% of 10th grade students and 8.2% of 12th grade students used amphetamines without a prescription at least once in 2011 (“Stimulants”).  In addition to providing statistics for the nonmedical use of amphetamines, the survey includes percentages for the nonmedical use of specific stimulant brands, such as Adderall and Ritalin.  For example, it states that 4.6% of 10th grade students and 6.5% of 12th grade students used Adderall for nonmedical reasons at least once in 2011.  According to the survey, 2.6% of 10th grade students and 2.6% of 12th grade students used Ritalin for nonmedical reasons at least once in 2011. (“Stimulants”)

While the percentages of 10th and 12th grade students who used Ritalin for nonmedical reasons are identical, a larger percentage of 12th students used Adderall and amphetamines for nonmedical reasons compared to the percentage of 10th grade students.   The study also depicts the trends in the nonmedical use of amphetamines by 10th and 12th grade students.   Amphetamine use by 10th and 12th grade students increased in the 1990s.  However, the percentage of 10th and 12th grade students who used amphetamines in 2011 is lower than the percentage of students in the 1990s.  “Monitoring the Future,” is the most reliable survey that documents the prevalence of nonmedical prescription stimulant use.

There is a lack of research on the amount of high school students who take stimulants for academic success.  The “Monitoring the Future” survey is the most credible source of data, yet “experts note that the survey does not focus on the demographic where they believe such abuse is rising steadily – students at high-pressure high schools” (Schwarz).  Some students at high-pressure high schools estimate that roughly one-third of their classmates use prescription stimulants to meet rising academic expectations.  In fact, “doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent” (Schwarz).  Among the students interviewed in the “Risky Rise of the Good-Grade Pill,” the consensus was that the number of students without ADHD who use prescription stimulants was rising.  These claims can neither be supported nor discredited because there is a lack of data on the use of prescription stimulants to raise scholastic performance.  The accuracy of many studies is questionable because students who do not have ADHD and use prescription stimulants have an interest in avoiding detection and punishment for their usage of those drugs.  In addition, many teenagers are unaware that these study drugs are actually illegal to use without a prescription. (Schwarz)

Although there is a lack of data on the use of prescription stimulants for academic achievement, there is a wealth of information on the increase of prescriptions for ADHD medications.  According to the health care information company IMS Health, “the number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly” (Schwarz).  This number correlates to two million young people with prescriptions.  This increase indicates that students without ADHD have growing access to stimulants that they can use to improve their grades.  Students without ADHD can obtain these prescription stimulants in one of two ways: either through peers with prescriptions or through doctors (Schwarz).  Some students without ADHD fake symptoms of the disorder, such as inattentiveness and hyperactivity, in order to obtain prescriptions for stimulants.  The role of doctors in the nonmedical use of prescription stimulants is a large issue, which I will not discuss in this paper.  As the number of prescriptions for stimulants has increased, the accessibility of the stimulants to students without ADHD has increased as a result.

Reasons for Prevalence

Stress, pressures, and packed schedules are three reasons for the prevalence of prescription stimulant use for academic achievement.  Stress results from the many different sources of pressure on American high school students.  The pressure to perform starts at a young age and only increases as students move through their school years (Abeles).  In reference to our “pressure-cooker culture and education system,” Wendy Mogel, a clinical psychologist and author of The Blessing of a Skinned Knee, explains her fear that “our children are going to sue us for stealing their childhoods” (Abeles).  She discusses the high expectations that many parents place on their children, which exacerbates their stress.  Pressure on students often comes from the students themselves.  In a society obsessed with perfection, it is easy for students to put pressure on themselves to be perfect students and individuals.

The third source of pressure on high school students is the importance of attending a “good” college (Taing).  Over the years, the process of applying to college has become increasingly intense due to the rising cost of tuition and the decreasing acceptance rates among selective schools.  The acceptance rate at Harvard College, for example, has decreased for seven consecutive years.  In 2011, Harvard College accepted a mere 5.9 percent of the more than 34,000 applicants.  As the college admissions process becomes more difficult, “students push themselves harder and harder to excel, many of them are willing to do it at any cost” (Taing).  In order to get accepted into a top college, many teenagers pack their schedules with school, sports, leadership positions, extracurricular activities, volunteer work, AP classes, and SAT and ACT preparation.  This overload of commitments makes the majority of high school students overscheduled and tired.  Students not only go to school five days a week; they spend time after school participating in extracurricular activities and return home to hours of homework.  With packed schedules and high expectations, some students turn to prescription stimulants in order to achieve their goals.  While stress, pressures, and packed schedules are three factors in the prevalence of prescription stimulant use for academic achievement, the emphasis on grades in schools is another contributing factor.

There is a correlation between the emphasis on grades in school and the prevalence of the prescription stimulant use for academic achievement by students without ADHD.  The current United States’ education system rewards and incentivizes grades.  While the goal of education always has been to learn, there is a disproportionate emphasis on grades in high schools.   As Ally, a senior at Carmel High School in Indiana, stated, “High school is about learning how to pass tests” (Abeles).  Many students are willing to do whatever it takes to get the A, including use prescription stimulants.  Denise Pope, author of Doing School, explains in Race to Nowhere, “When success is defined by high grades, test scores, [and] trophies, we know that we end up with unprepared, disengaged, exhausted, and, ultimately, unhealthy kids” (Abeles).   There is a tremendous preoccupation with performance, and students are expected to produce and perform.  However, it is hard for students to learn when there is no room to make mistakes.  The analogy between school and competitive sports sums up the emphasis on grades and performance in the United States’ high schools.  In both sports and school, there is a competitive atmosphere and a pressure to succeed.  In school, there is pressure to perform as well as or better than other students.  Some individuals describe high school as a “race to nowhere” (Abeles) in which students feel intense pressure and competition to get into a good college.  Similar to athletes who constantly search for ways to improve performance, some students use prescription stimulants to improve their performance in school. (Abeles)

Different Perspectives on Fairness

The use of prescription stimulants by high school students without ADHD is a controversial issue.  A variety of reasons leads American high school students without ADHD to use prescription stimulants for academic achievement.  Recently, this usage of stimulants has gained media attention and remains in the national spotlight.  While people agree that the use of prescription stimulants for academic achievement by high school students without ADHD is prevalent, they disagree on whether the use is fair.

There are different positions on whether students without ADHD who use prescription stimulants for academic achievement have an unfair advantage over their peers.  In addition to different positions on fairness, there are many subjective definitions of “fairness” and “fair.”  A common definition of “fair” is “marked by impartiality and honesty” and “conforming with the established rules” (“Fair”).  People often use the word “fair” interchangeably with the words “just” and “equitable” (“Fair”).  Each person has their own definition of fairness, but for the purpose of this paper, the words “fair” and “fairness” include the definitions to be just, equitable, and play by the established rules.

Many people are troubled by the use of prescription stimulants for academic achievement by students without ADHD.  They believe that the stimulants give students without ADHD an unfair advantage over their peers.  They claim that the use of prescription stimulants for academic achievement is cheating, unnatural, and dangerous.  The students reap the benefits of the stimulants without having to exert much effort.  For example, students do not work for the improved concentration they gain from the stimulants.  In addition, the use of prescription stimulants is unnatural because the stimulants are invasive drugs.  Finally, the use of prescription stimulants by students without ADHD is illegal and unsafe.  It is illegal to use a prescription stimulant without a prescription.  Also, the side-effects differ from person-to-person, and it is dangerous for students to take medication for which they do not have a medical need.  For some students, “the pills eventually become an entry to the abuse of painkillers and sleep aids” (Schwarz).  In addition to stating that the use of prescription stimulants for academic achievement is cheating, unnatural, and unsafe, they believe that the stimulants create further inequities in the education system.

This group of people troubled by the use of prescription stimulants for academic achievement worries that the uneven distribution of stimulants is unfair.  This uneven distribution is unfair to students who do not have access to the stimulants.  This group argues that the existence of current inequities in the education system does not justify the introduction of a new inequity (Gould).  They cite the highly competitive environment in high schools as a reason that “concerns about fairness” cannot “be so easily set aside” (Gould).  They believe that allowing prescription stimulant use for academic achievement would cause indirect coercion.  If schools distribute prescription stimulants as a way of leveling the playing field, students would feel like they had no choice but to take the stimulants (Gould).  Even if schools create equal access by distributing stimulants to their students, the use of prescription stimulants by students without ADHD is unfair to the students with ADHD.

To support their argument that prescription stimulant use by students without ADHD is unfair to those with ADHD, individuals cite the idea of leveling the playing field.  Prescription stimulants prescribed for the treatment of ADHD help ADHD students focus so that they can perform at the level of a healthy individual.  Whereas when healthy individuals take these stimulants, they put the students with ADHD at a disadvantage.  If everyone takes the prescription stimulants, the students with ADHD are not able to perform at the level of their peers, and the playing field is no longer level.

The other side of the fairness debate on the use of prescription stimulants for academic achievement consists of people who justify their usage.  These individuals believe that students without ADHD who use prescription stimulants for academic achievement do not have an unfair advantage over their peers.  In short, they argue that the use of the prescription stimulants by students without ADHD is fair.  Henry Greely and his colleagues head the group of individuals who advocate for the acceptance of cognitive enhancement.  In “Towards Responsible Use of Cognitive-Enhancing Drugs by the Healthy,” Henry Greely and his colleagues argue “society must respond to the growing demand for cognitive enhancement.”  They view the use of prescription stimulants as such an enhancement.  Through inventions such as the written language, humans have enhanced their brains for years.  For instance, teachers enhance the brains of their students “both by adding substantive information and by showing them new and better ways to process that information” (Greely).  When humans exercise, sleep, and eat well, they enhance their brains.  Greely and his colleagues justify the use of prescription stimulants as simply another way to enhance humans’ brains. (Greely)

People who believe that the use of prescription stimulants for academic achievement is fair provide counterarguments to the claims made by those who think their use is unfair.  Those who think the use is unfair argue that cognitive-enhancing drugs should remain prohibited because they are invasive, not distributed equally, and do not require the user to exert much effort in order to reap the benefits.  However, Henry Greely and his colleagues believe that none of these reasons are justification for the prohibition of cognitive-enhancing drugs.  They state that drugs might seem different from other cognitive enhancements because they alter brain function, but all enhancements change brain function in some way.  For instance, research identifies beneficial changes in the brain caused by sleeping, reading, and exercise. (Greely)

There are three arguments commonly utilized against the use of prescription stimulants for cognitive enhancement by the healthy: that it is cheating, unnatural, and drug abuse.  People who justify their use refute the first claim by arguing that cognitive enhancement is only cheating if it is against the rules.  In order for it to be against the rules, there must be a set of rules that makes a distinction between the forms of enhancement currently permitted, such as tutors and coffee, and the new methods of enhancement.  Because humans live unnatural lives, the argument that the use of cognitive-enhancing drugs by the healthy is unnatural is untenable.  Humans use many cognitive-enhancing tools on a daily basis.  Therefore, why would humans draw the line at cognitive-enhancing drugs?  Proponents of prescription stimulants for academic achievement state that nonmedical stimulant use should not be prohibited simply because stimulants are drugs.  Drugs are regulated based on their “potential for harm from the very dangerous (heroin) to the relatively harmless (caffeine)” (Greely).  Due to this strong regulation,” the mere fact that cognitive enhancers are drugs is no reason to outlaw them” (Greely).  Prescription stimulants should be tested for safety in their enhancement uses to address safety concerns.  There should be “an evidence-based approach” to “evaluate the risks and benefits of cognitive enhancement” (Greely).  People who justify the use of prescription stimulants for academic achievement strongly refute the arguments made by people troubled by the use. (Greely)

People who support the use of prescription stimulants for academic achievement believe that whether or not their use is unfair depends on the stimulants’ availability and effects on students.  There is a concern about fairness and that “it would seem unfair to allow some, but not all, students to use cognitive enhancements, akin to allowing some students taking a math test to use a calculator while others must go without” (Greely).  Henry Greely and his colleagues state that “the fairness of cognitive enhancement depends on the availability of the drug” (Greely).  In addition, they believe that policies can address the concerns about fairness related to availability.  They state that all students must have access to prescription stimulants because fairness “in cognitive enhancements has a dimension beyond the individual” (Greely).  A solution to fairness concerns is that schools could give stimulants to their students during exam week.  While the distribution of prescription stimulants could lead to indirect coercion, it would level the playing field because all students would have access to the cognitive enhancements.  Schools should have “enforceable policies concerning the use of cognitive-enhancing drugs to support fairness” (Greely).  Schools are inherently unfair; there are socioeconomic disparities as well as differences in IQ and access to resources.  For example, some students are at a disadvantage because they do not have access to tutors or other helpful resources.  Therefore, one cannot justify the prohibition of prescription stimulant use for academic achievement with fairness concerns.  Henry Greely and his colleagues claim the fairness in use of cognitive-enhancing drugs by healthy individuals is based on the drugs’ effects in addition to their availability.  For example, they wonder if the drugs “actually improve learning” or if they “temporarily boost exam performance” (Greely).  If the drugs temporarily raise exam performance, it would prevent the tests from measuring the competency of the individual; therefore, the drugs would be unfair.   However, if the drugs improve long-term learning, they may be acceptable.  Some people believe that the stimulants’ availability and effects are the factors that determine the fairness of the use of prescription stimulants for academic achievement. (Greely)

My Perspective

I believe that the two main sides in the debate over the use of prescription stimulants for academic achievement do not address an underlying concern about the goals of education.  In my opinion, high school students without ADHD who use prescription stimulants for academic achievement cheat both themselves and others.  First, these students have an unfair advantage over their peers.  The people troubled by the use of prescription stimulants for academic achievement state that the drugs are cheating, dangerous, create an inequity, and lead to indirect coercion.  These reasons are valid and prove that the use of prescription stimulants to improve academic performance is unfair.  However, their argument that the stimulants are unnatural is irrelevant.  As those who support the use of prescription stimulants state, humans’ lives are already unnatural.

While the use of prescription stimulants for academic achievement by students without ADHD is unfair to all students, it is especially unfair to the students meant to benefit from the stimulants, students with ADHD.  Doctors prescribe stimulants to help students with ADHD control their symptoms and focus so that they can perform at the level of a healthy individual.  The drugs level the playing field for students with the disorder.  When healthy students use prescription stimulants, they put the students with ADHD at a disadvantage.  People who believe that the use of prescription stimulants for academic achievement by students without ADHD is fair believe that they can mitigate the access-based fairness concerns.  However, their suggestion to provide all students with equal access to stimulants does not solve the fairness issue.  Even if all students have equal access to the stimulants, the students with ADHD are still at a disadvantage.  Students with ADHD are at a disadvantage when students without ADHD use ADHD medications as an enhancement to become super students.

Not only is the use of prescription stimulants for academic achievement unfair to the other students, it is unfair to the students using the drugs.  Students without ADHD send a message to themselves and others when they use prescription stimulants.  When students rely on a drug, they believe that a pill can solve their problems.  However, the use of prescription stimulants masks the underlying problems rather than solving them.  For example, many students suffer sleep deprivation because of long nights spent studying and doing homework.  When sleep-deprived students take prescription stimulants, they can still function despite risks to their health.  Thus, students start to believe that they cannot perform on their own and that they need artificial means to keep up with their busy lives.  While coffee is relatively harmless and not as powerful as prescription stimulants, its use has a similar effect on its users.  Coffee also masks the effects of sleep-deprivation, and teaches coffee drinkers that they can be sleep-deprived and function without addressing the underlying problem, a lack of sleep.

When students take prescription stimulants, they miss an opportunity to grow as both students and individuals.  In an environment in which the goal is learning lifelong skills, students who use prescription stimulants miss an opportunity to learn these important skills.  They miss out on many character-building opportunities because the stimulants “erode the relationship between struggle and the building of character” (Carey).  These students may lose the skills of concentration and focus.  In high school, it is important to fail.  When students fail, they learn from their mistakes and take away important life lessons.  Prescription stimulants do not allow for this type of failure and the growth that results from it.

It is my belief that the number of students without ADHD who use prescription stimulants for academic achievement will reduce if schools shift their focus from grades to learning.  Today, schools focus on grades rather than learning for the sake of learning (Abeles).  When the goal of education is grades, the environment is similar to competitive sports.  In a sports race, the goal is to win.  In the academic “race to nowhere” (Abeles), the goal is to get good grades and, ultimately, attend a good college.  When high school students without ADHD use prescription stimulants in an environment that caters to grades, they put others at a disadvantage and help themselves achieve the goal of admission to a good college.  However, if schools shift their focus to learning, fewer students will use stimulants.  If the students choose to use prescription stimulants in an environment focused on learning, they are unfair to themselves rather than being unfair to others.  In the Bioethics Project, for example, the focus is on learning rather than on grades.  The project teaches many lifelong skills, including critical thinking, problem solving, researching, time management, and communicating effectively.  If students took stimulants to do well in this project, they would not learn these important skills and grow as students.

A problem with an American education system that emphasizes grades is that it does not leave room for failure.  Students need to learn and grow from their mistakes.  However, students cannot risk mistakes because the consequences to their grades are too severe.  When students are afraid to fail because they do not want to get a bad grade, they do not take risks with their learning.

It is time for educators, parents, and students to have an honest conversation about the goal of education and ways to make high school an environment in which the use of prescription stimulants for academic achievement is no longer prevalent.  At a focus group I facilitated at Kent Place School, students from all high school grade levels expressed a desire for less homework and later start times to their school day.  They stated that these changes would decrease stress and improve student health.  Schools across the United States should have similar conversations about ways to reorient the goal of education to learning.  In order to reduce the use of prescription stimulant by high students without ADHD, one must first address the underlying reasons for their use: stress, pressures, packed schedules, and an emphasis on grades.

 

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Madison Mastrangelo is a sophomore at Kent Place School. In The Bioethics Project 2012, she studied the use of prescription stimulants for academic achievement. This issue interested her because it is currently a hot topic among high school students, parents, and teachers. In the future, she envisions herself as a teacher who can use her bioethics training in an academic atmosphere. She would like to thank her mentor, Mr. Jacob Moses, for his support and guidance throughout the project. She hopes that you enjoy the Symposium as much as she has enjoyed her work in The Bioethics Project.

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