AAN Takes a Position on 'Neuroenhancement' in Children

Pauline Anderson

March 13, 2013

Neuroenhancement — the use of prescription stimulants or psychotropic drugs to augment cognition or function without a diagnosis of a neurologic disorder — is not justified in legally and developmentally nonautonomous children and adolescents, a new position paper released by the Ethics, Law, and Humanities Committee of the American Academy of Neurology concludes.

And prescribing these drugs for nearly autonomous adolescents is inadvisable because of numerous social and neurodevelopmental issues, although the fiduciary obligation of the physician may be weaker in these cases, note the authors.

Their position paper is published online March 13 in Neurology.

More information is needed on the long-term effects of stimulants, such as amphetamines and methylphenidate, on the developing brain, said the paper's authors, led by William D. Graf, MD, professor, pediatrics and neurology, Yale University School of Medicine, New Haven, Connecticut.

In tackling this topic, the committee looked at "multiple principles and multiple arguments," Dr. Graf told Medscape Medical News. "If you put these all on a scale, it tips toward caution in vulnerable populations. We have this obligation not to misuse medications, an obligation to protect vulnerable populations, and to screen for coercion at various levels, whether it's parents coercing children to get good grades, or peers who are pressuring others, or children who are just following the crowd — the idea that everybody's doing it so I have to do it, too."

The aim of the paper, added Dr. Graf, is not to lay down any laws. "This is an ethics paper; we're looking at what is the right thing to do."

Tipping the Scales

Physicians and parents share in decisions pertaining to the medical care of babies and young children, but as the child gets older and approaches the age of majority — typically 18 years — the physician's fiduciary obligation to protect that patient lessens, said Dr. Graf. Adolescents gradually take on more and more responsibility as their decision-making capacities mature.

And this is the age when overuse or misuse of stimulants, such as amphetamines and methylphenidate, can become a problem.

Physicians have an ethical obligation to evaluate requests for neuroenhancement drugs and consider the possibility that requests for these drugs may reflect other medical, social, and psychological motivations or concerns, according to the paper. A physician should refuse a request for a neuroenhancement drug from an adolescent if the parents advise against it, and they should also refuse a request for such a drug from parents of a decisionally incapable child, to protect the best interests of that child, the authors said.

In the case of a "nearly autonomous adolescent," it becomes less clear, the authors suggest. "[T]he fiduciary obligation might be weaker, but prescribing should be nonetheless discouraged due to the numerous social issues, neurodevelopmental uncertainties, and the threat to professional integrity," they write. "Physicians have the authority and the obligation to refuse requests for inappropriate treatment."

According to the paper, the number of prescriptions for US Food and Drug Administration–approved stimulants and psychotropic medications has substantially increased among US children and adolescents over the past 20 years. Recent parent report surveys showed an overall 21.8% increase in attention-deficit/hyperactivity (ADHD) prevalence and a 42% increase among older teens. Costs for ADHD treatments may exceed $10 billion annually.

The United Nations International Narcotics Control Board has stressed on numerous occasions the importance of education and training for health professionals on the rational use of psychoactive drugs to prevent abuse. According to its 2012 report, "the significant increase in the use of stimulants for ADHD treatment in many countries could be attributed to possible overdiagnosis and overprescription."

We are not saying anything in this paper against the diagnosis and treatment of ADHD, which all neurologists believe is a true neurological disorder; that's not the message here. Dr. William D. Graf

But Dr. Graf stressed that the current ethics paper is not a comment about treating ADHD. "We are not saying anything in this paper against the diagnosis and treatment of ADHD, which all neurologists believe is a true neurological disorder; that's not the message here."

The problem, the paper suggests, may lie, at least in part, in the nonprescription use of these drugs, especially among older teens. Evidence indicates that stimulant use is increasing beyond the original and standard indication for ADHD.

The manufacturing, production, and consumption of these drugs has been rising steadily, said Dr. Graf. "There has been a 10-fold increase in production over a 20-year period. And there has definitely an increase in diversion although we can't measure that directly because it's illicit."

According to the UN Board's report, the United States has traditionally been the major manufacturer and user of methylphenidate, in addition to being the major importer of amphetamines used in the manufacture of preparations to treat ADHD. In the United States, says the report, the use of methylphenidate and other substances for the treatment of ADHD is heavily advertised, including directly to potential consumers, and is promoted at schools.

Dr. Graf and his colleagues pointed to data for 2008 from Monitoring the Future, a longitudinal study assessing drug use among students. It indicates past-year nonmedical use of methylphenidate by 1.6% of 8th graders, 2.9% of 10th graders, and 3.4% of 12th graders. Amphetamines rank third in past-year illicit drug use among 12th graders.

Competitive Edge

College-bound students who want a competitive edge on their entrance exams make up one of the biggest groups taking these drugs, particularly amphetamines, said Dr. Graf. They might start abusing them by taking higher and higher doses, and then become addicted, he said.

A second group of abusers are those who crush and then snort, dissolve, or inject substances such as methylphenidate, or mix them with street drugs to create what is called a "speedball."

To illustrate how widespread this use is, Dr. Graf recounted raising the issue of neuroenhancement with Yale medical students. "This is a population of high-functioning, and high-achieving kids, and they all of them knew about this use."

ADHD medications may cause effects on the central nervous system and the cardiovascular system, including transient tachycardia and hypertension. Common dose-related central nervous system adverse effects of stimulants are nervousness, appetite suppression, and insomnia.

But more information is needed on long-term effects of stimulants on the developing brain, said Dr. Gaf. This is especially true, he added, if stimulant use is here to stay.

"As we wrote this paper, we wondered how it would read 20 years from now as a point in history. People have argued that this is not going to stop; it's going to continue."

Stimulants — in the form of caffeine — have been used for centuries. In fact, said Dr. Graf, huge strides were made in terms of productivity and "enlightenment" when populations began drinking coffee every day back in the 16th century.

Drawing the Line

Commenting on the paper, Michael Goldstein, MD, a neurologist with Western Neurological Associates, Salt Lake City, Utah, and past vice president of AAN, said it was "excellent" and helps to raise awareness on a controversial topic about which physicians tend to have strong feelings.

"This puts everyone on notice that this is a problem and that the physician has to pay attention to it and deal with it appropriately," he told Medscape Medical News.

Dr. Goldstein said he agrees completely with the authors "that to take a nonmedical problem and treat it as a medical disorder is not appropriate."

It's often difficult to know where to draw the line when it comes to prescribing these drugs, and the paper helps guide physicians to find that line, said Dr. Goldstein who has written books on ADHD. "While this paper doesn't tell a physician where to draw the line, it highlights the fact that each physician must decide for him- or herself where that line is. Sometimes it's clearly over the line, and sometimes it's clearly appropriate, and there's a lot of grey area."

In today's society, people are looking for "an edge," whether it be at school or in sports, he said. "To compete, I have to do more than the next guy; that's the nature of competition; the question is, what is appropriate, and where do we as a society draw the line?"

And if high school students are taking high doses of stimulants or other drugs to excel, Dr. Goldstein wondered whether that puts those who don't take these drugs at a disadvantage.

Dr. Graf has disclosed no relevant financial relationships.

Neurology 2013;80:1251-1260. Abstract