This paper is a review of literature examining the pharmaceutical performance enhancement for children with ADHD.

1. Pharmaceutical Performance Enhancement for Children with ADHD
Beth Doss and Mollie McGee
University of Georgia

2. Introduction
Attention-deficit hyperactive disorder (ADHD) is one of the most prevalent diagnosed
neurobehavioral disorders in children. Sheir, Reichenbacher, Ghuman and Ghuman (2013) cite it
having roughly a 6-12% prevalence in children in the United States. ADHD is multifactorial and
consists of inattention, hyperactivity, and/or impulsivity that is not appropriate for their age
(Martinez-Raga, Ferreros, Knecht, Alvaro and Carabel, 2016). Pharmaceutical performance
enhancements, stimulants, are a treatment option for individuals diagnosed with ADHD. The
prescription of stimulants to children with ADHD remains controversial due to certain ethical
and developmental implications. By examining the benefits and potential implications in
children, it can be decided if the administration of stimulants to children with ADHD are the best
course of action as a treatment plan.
It is important to conduct a review of literature involving pharmaceutical enhancers in
children diagnosed with ADHD. First, the medical technology will be introduced. Then the
ethical and developmental implications will be discussed.
Background
Medical Technology
Pharmaceutical performance enhancements are a treatment option for children with
ADHD. The stimulants work to increase levels of norepinephrine and dopamine by regulating
their release in the prefrontal cortex of the brain (Sheir et al., 2013). This area of the brain is
associated with impulse control, so the result is increased concentration, reduced restlessness and
enhanced effort on demand (President’s Council on Bioethics, n.d.).

3. If an individual is diagnosed with ADHD and decides to follow a course of treatment
with pharmaceutical enhancers, they are just beginning their journey. There are a plethora of
medications available and varying dosage amounts for each along with options like
extended-release or immediate. The stimulant can be either an amphetamine, like Adderall, or
methylphenidate, like Ritalin (Sheir et al., 2013). There is no research supporting one being
significantly better than the other; it is rather an individual experience.
When discussing the use of pharmaceutical enhancers, it is important to note that ADHD
is considered both overdiagnosed and underdiagnosed, and the same follows for treatment. The
prevalence of ADHD throughout the world is increasing, which poses the debate if it is because
it is actually more prevalent or if it is increasing because of misdiagnosis (Kazda, Bell, Thomas,
McGeechan and Barratt, 2019). Kazda et al. (2019) discuss the dangers of overdiagnosing and
treating ADHD. Along with financial burdens placed upon the family, many children being
treated might experience negative physical and psychosocial effects. Part of the increasing
prevalence has to do with diagnosing and treating children with only mild to moderate forms,
whereas treatment with stimulants are recommended for children with moderate to severe
ADHD. On the other side of the argument, ADHD is also considered undertreated. French, Sayal
and Daley (2019) examine barriers in ADHD diagnosis and treatment. Four main themes
summarize their findings, lack of education on ADHD, misconceptions and stigmas surrounding
ADHD diagnosis and treatment, constraints with recognition, management and treatment and
lastly, multidisciplinary approach, which encompasses the roles of specialists, teachers, and
parents in the process (French et al., 2019). When conducting their research, the biggest barrier
overall was a lack of education on ADHD. French et al. (2019) suggest increased emphasis of

4. education on ADHD will hopefully reduce the gap by allowing recognition rates to improve,
benefitting the patient.
Ethical Implications
Many are opposed to treatment of ADHD in children with stimulants because they feel it
is opposing and interfering with the child’s “authentic self’’ and promotes social conformity.
Erler (2013) explains how many hold opinions that the goals and values of the stimulant
treatment for children is not their own, but rather their parents. There have been many reviews in
the literature like this. Many symptoms of ADHD overlap with characteristics of young
children, which creates criticism when choosing to medicate and control certain behaviors. The
President’s Council on Bioethics (n.d.) explains ethical concerns with conformity, explaining
how by medicating children allows parents, teachers and caregivers to intervene and comply with
their own “standard of conduct.” Many fear that medicating children interferes with the child’s
own path and potential (President’s Council on Bioethics, n.d.). Erler (2013) discusses how after
administering the medication that there were some, but not a significant amount, of responses
claiming the individual felt they were not as fun to be around. The concern of veering from their
authentic self can be settled by taking weekends, holidays and summers off of medication. In
addition, Erler (2013) points out that children will usually return to their “baseline” at the end of
the school day unless they are taking some sort of booster medication, so it should not be
interfering in their life dramatically.
There are some ethical concerns involving the health of the individual taking the
stimulants. Side effects of the medicine include decreased appetite, nausea, dry mouth,
dizziness, and potentially cardiac issues (Martinez-Raga et al. 2016). The most concerning side

5. effects is decreased appetite and increased heart rate and blood pressure. Some cardiovascular
issues include arrhythmia, heart beating too slow or too fast, and sudden cardiac arrest. It is
difficult to predict children's likelihood of falling in this category concerning safety since they
are so young and don’t have other health problems or lifestyles that predict. In addition,
Martinez-Raga et al. (2016) notes that cases of sudden cardiac death are extremely rare. In order
to limit the number of individuals put at risk for cardiovascular issues associated with the use of
stimulants, it is important for the physician to examine family and personal history. To address
decreased appetite, it is recommended that the medicine be administered after a large breakfast
and suggest caregivers allow extra after-evening snacks to prevent weight loss (Sheir et al.,
2013).
Developmental Implications
One of the strongest arguments for the use of stimulants in children diagnosed with
ADHD is related to academic achievement. By being able to focus in school, appropriate tasks,
and decrease certain behavior issues and impulses, a child can change their school experience
and outcome. When researching the impact of treatment on grade point average (GPA) for
children with ADHD, Keilow, Holm, and Fallesen (2018) found significant effects of treatment
on GPA. Medication is not the cure to addressing the GPA gap between children with ADHD
and their classmates, but it begins to alleviate the gap. It not only does this because of increased
classroom focus on tasks and behavior, but also because it influences subsequent educational
tracks, like post-secondary tracks and drop out rates (Keilow et al., 2018). Prased, Brogan,
Mulvaney, Grainge, Stanton and Sayil (2012) found that drug treatment for children with ADHD
displayed increased amount of seatwork completed and on-task behavior in the classroom.

6. Treatment of ADHD is considered cost effective (Martinez-Raga et al., 2016). When looking at
children specifically, Martinez-Raga et. al (2016) claims that the most cost-effective category
was pertaining to healthcare and education. This goes to show the emphasis and desire around
academic success. Most research supports improved academic success for children with ADHD
who are administered stimulant medication for it.
There is a stigma and concern around the potential of abuse and addiction related to the
prescription of stimulants to children. Sheir et al., (2013) note that most follow ups did not find
an increased risk for substance abuse or dependence and add that if anything, it has been related
to a reduced risk of cigarette smoking and alcohol use compared to untreated counterparts. In
addition, Chang et al. (2014) examine the relationship between stimulant medication and risk for
substance abuse. In their study, they examined around 40,000 individuals with ADHD over a 4
year time span and found no indication of increased substance abuse at follow up. Like most
concerns, it is recommended that even if research does not show increased likelihood of
substance abuse, individual factors and family history should be taken into account when
considering ADHD medication.
Concerning development, there is worry about how the stimulant affects height. It is
important to look at the research especially when the focus population is children because
usually the time of their diagnosis and treatment is when they are still growing. Goldman (2010)
examines ADHD stimulants and their effect on height in children. Goldman (2010) suggests that
research is lacking in having a significant claim on the effect of the stimulants on height. They
also suggest monitoring growth and development of children taking the stimulants. Goldman
explains how the rate of height loss usually seems small and is likely reversible with withdrawal

7. of the treatment. One way for children to minimize growth suppression while continuing
treatment is by taking summer breaks (Goldman 2010). This is a popular practice for children
with ADHD being treated with stimulants because it allows them to thrive during the academic
year but not experience side effects when not necessary.
Discussion
It is important to further discuss the most predominant side effects of pharmaceutical
performance enhancement for children diagnosed with ADHD. The most concerning are also
coincidentally the most recurring themes found throughout the literature, including the potential
for health implications, overdiagnosis, threats to autonomy, and increased academic performance
above peers. This subject has been controversial for years and although the research continues to
remain consistent despite further advancements, the use of prescription stimulants remains
prevalent in every region due to extensive benefits provided in countless settings.
There are a considerable amount of potential medical issues that may become prevalent
in children while taking these medications and beyond. The list includes but is not limited to
decreased appetite, tachycardia, and high blood pressure. When children are prescribed stimulant
medications, they are usually at a very crucial stage in human growth and development where
proper nutrition is key to optimality. A decreased appetite can lead to less energy, weight loss,
and poor nutrition. A parent cannot simply force a child to eat if the appetite is not there, so it is
extremely important to follow the proper dosing protocols of admintersing the medications early
in the morning with a meal. Also, tachycardia, or elevated heart rate, is likely to occur due to the
nature of a stimulant. An increased heart rate can lead to abnormal heart rhythms that can cause
sudden cardiac arrest but is very unlikely due to the age and lack of underlying health issues in

8. the diagnosed. Increased heart rate could also make a child feel jittery or extremely anxious,
which could also decrease the benefits of the drugs in terms of the ability to concentrate on the
specific task at need. These cardiac symptoms also include high blood pressure. Chronic high
blood pressure is one of the most common diagnosed medical issues in the United States and
these medications can predispose a child to a lifelong issue if use is not monitored closely.
Accurate monitoring may be hard to achieve due to lack of education among parents with
children diagnosed with ADHD. Parents may be so desperate to find a solution to their child’s
behavior and academic performance that they may overlook the medical side effects in hopes of
a break. Although the literature reports the impact of these side effects to be minimal, it is
important for parents to be aware of their existence in order to make the most beneficial decision
for the child at stake.
Overdiagnosis and underdiagnosis are very serious implications of the option for
pharmaceutical performance enhancement for children with ADHD. Parents must recognize the
need for pharmaceutical help when children are not able to manage symptoms of their own, just
as they must recognize that there is a fine line between over and underdiagnosis. Overdiagnosis
can occur, as previously mentioned, when a parent is desperate for a solution. ADHD is a
common diagnosis in our society and it is certainly easy for a parent to contribute behavior to
such without considering surrounding circumstances. Surrounding circumstances include the
environment in which a child is in, the amount of control they may feel, and the types of
stimulation they consider normal. One must consider if the child is receiving enough stimulation
throughout the day that allows for developmental needs to be met and also allows for an output
of built up energy. Overdiagnosis can certainly force negative psychological effects into a child’s

9. life that they did not experience beforehand. There is a serious threat to a child’s ability to make
autonomous decisions that should be highly considered. When a medication has the ability to
completely increase performance in a previously under-performing child, the role the medication
is playing in the child’s decision making process should be of more discussion. In theory,
children are making decisions that they may have not previously made before, altering their
personalities and threatening their need to be autonomous. This is a huge ethical issue that is
underplayed in the medical setting when these children receive an ADHD diagnosis, yet the
majority of cases continue to be reported as mild or moderate.
The use of stimulants to treat children with ADHD is overwhelmingly linked to academic
performance. It is not uncommon for a parent to notice questionable symptoms of ADHD and
begin to consider further options if their child is performing poorly at school. The use of
pharmaceutical enhancements for children with ADHD is a simple way to ensure higher test
scores, increased focus, and better social skills that allow a school day to flow more smoothly.
The majority of children who are diagnosed with ADHD and receive treatment are able to
benefit quickly and lessen behavioral disruption among peers. It is important to question the
fairness of the use of these drugs in comparison to peers that are not eligible for them. It’s not
wrong to assume that children with ADHD do have an advantage over those who do not take the
medications associated with a clinical diagnosis. They exhibit an increased amount of completed
seat-work and on-task behavior that other children may work constantly to discipline themselves
for. This is another ethical issue that forces one to question the fairness of stimulants in
comparison to one’s peers, which leads to a further assumption of how important an accurate
diagnosis of ADHD is when considering true academic performance. One child may truly need

10. enhancement while another may benefit from it, yet could totally function within their own limits
without it.
Future Directions and Implications
The majority of the previously discussed research is directed towards the majority
population. This includes the population of individuals who have access to healthcare, finances
to provide prescriptions, and the education to detect simplistic symptoms. It is no surprise that
this population is made up of white Americans who are among satisfactory socioeconomic status.
There is a huge lack of research among minority populations such as the African-American
community, Hispanics, and Chinese. This makes one wonder the true correlation between the
data, the benefits, and the reported performance in schools. In lower socio-econmic status areas
where one may see a constant trend of poor academic performance, it is important to consider the
resources this population has readily available to them. The health department does not offer free
ADHD testing for children who are performing poorly due to the costs of treatment drugs. The
children who are able to benefit from pharmaceutical performance enhancements are those who
have parents who are financially able to provide access to such. The schools may not have the
resources to properly educate staff on the options for poor performance or they may not even
have the resources for a stimulating environment to help lessen ADHD symptoms among
students. In these areas, the population is forced to continue to fight a constant battle with the
government for funding to use for academics due to the lack of production of performance. It is
also important to note other environmental and societal factors that could play a role in the data.
There may be a correlation between prenatal care, postnatal care, and home environment that
determines the results of research. If a child does not live in an area where it is safe to go outside

11. and play, they may bring that bottled up energy to school with them, forcing an over or
underdiagnosis of their behavior. This ultimately results in a lack of beneficence for all involved.
Society cannot achieve the ultimate good and achieve the most benefits as a whole if all who are
at stake are not considered at the same level. For future research, there should be a higher
emphasis on the environmental factors, such as parental guidance and home life, that lead to
certain behaviors that are correlated with an ADHD diagnosis.
Conclusion
To conclude, there are many factors that are not always considered when reaching an
ADHD diagnosis among children. There simply needs to be an increased focus on completing
developmental tasks rather than a focus on increased academic performance and parental
satisfaction. A child may be meeting all of the expected milestones at school due to medications,
but it’s just as important for them to reach developmental milestones at home, such as the ability
to make autonomous decisions. It is clear that the benefits of pharmaceutical performance
enhancement for children with ADHD outweigh any harm that is mentioned, but it is most
concerning for the potential for the dependence on such to continue seeing results.

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