ADHD is viewed as a disorder of anger and aggression, and stimulant drugs are seen by children to improve emotional self-control, aggressive behaviours and moral decision-making. These niches are drawn sharply here for illustrative purposes, and are both softer and less distinct in reality. The proportion of children who report that stimulants help to improve classroom and academic performance.
This figure is only reproduced in colour in the online version. The proportion of children who report that stimulants help to manage anger and aggressive behaviours. In a conduct niche, children emphasise the improvements in their social behaviours with medication, particularly in relation to their capacity to make good decisions:.
It [stimulant medication] makes me like, helps me behave better but it don't make you behave better it can only help you, but it can make, help make better decisions for you. Roger, UK, age It is this capacity for reasoning, even in face of peer aggression, that constitutes what we might call good character:. Um, being good and bad is to do with thinking about your actions.
Um, and I think if you're bad, then you don't really think about your actions very much … Conrad, UK, age To the extent that medication is here engaged in performing moral social work, it operates within a complex social system of obligations and hierarchies. Unsurprisingly, then, conduct niche children occasionally refer to medication in emotional terms: it is like a friend. As a friend, medication reminds a child to weigh the aggressive act against its probable consequences.
Roger explains:. Helping me, means like just saying like, say if my mate was going to fight, or like if I was going to fight, my mate saying, you know you don't want to do it because you'll probably get arrested or something. It's like [the medication] is like saying, you're not going to fight and then like, them [friends] holding me back or something … So [medication] is like a friend but not it. If in a conduct niche, medication does overt moral work, in the performance niche, the work of medication is, overtly, more pragmatic.
Here, children are more likely to view the effects of stimulant drug treatments in relation to school work:.
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I think I might actually go back on medication because I'm, like, failing math right now … Myra, US, age 13, taking a break from medication. If I'm in school like yeah because it [medication] helps me focus on something … and it helps me like, okay, if I'm doing a math problem like do this and then do this and then do this. Adrian, US, age Parents and children frequently provide an instrumental rationale for why many US children stop using medication during weekends and school holidays: stimulant drug treatment is expressly for school.
As Adrian observes:. I'm always active, what I want to do. So I'm okay in the summer but not in school time. Performance niche children do occasionally make a direct association between cognitive achievement and moral behaviour—that is, with doing the right thing—thereby illustrating that despite the instrumentality associated with stimulant drugs, the treatments are doing work in a moral dimension:.
Valued cognitive capacities, such as intelligence and attention, constitute the right actions:.
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I pay attention a lot more … It feels great … The medication, it like, changes, like, what you're doing and, like what you're thinking. Like all of a sudden, like, you know that you're not doing what the teacher told you to do, so then it just changes what, so then, so then, you can do the right thing what the teacher told you, so you can pay attention more better. Camilla, US, age It is also clear from our interviews that academic achievement meets obligations children feel to their families. I got two As and a B on my report card and my mom freaked out, she was so happy.
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Oscar, US, age Um I got my name on a board, and I got Fs on my report card, and my mom was really mad. And she told me that you need to do better, and she, and I was really happy this year, that it's really good. But last year, I wasn't paying attention.
Rose, US, age Many children, and older children in particular, are aware that they live in conditions in which these obligations inform standards and expectations of behaviour. For the most part, they note these conditions with a degree of equanimity. Adrian goes on to say:.alexacmobil.com/components/hovaqow/dik-dati-cellulare.php
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The pill kind of like helps the mothers and the fathers and everybody else live peacefully … And moms won't be like frustrated because they have to do more work or something. We see that in this niche, children view medication as a tool that enables them to meet obligations to themselves and to others; and these obligations include cognitive self-care, a commitment to invest in and to cultivate the capacity to succeed in cognitive activities.
We are now in a better position to address the challenge to children's lack of concern about a threat to authenticity posed by stimulant drugs.
It seems clear that children associate stimulant drug treatment with improvements in their capacities to meet the normative expectations of their respective niches. Children value the promotion of these capacities, and many show awareness of their normative dimensions. Nevertheless, the argument that children's self-creative path is not free, in that medication is used as a norming tool, or as a means to make children more docile in face of possibly oppressive academic and behavioural expectations fostered in certain niches, seems plausible. On the self-creation account, acquiescence to normative niche expectations, through stimulant drug use, can be said to elevate the risk of a threat to authenticity.
Such acquiescence on the part of children and their families also raises the risk of other harms, such as medicalisation or the coercive use of drugs. Nevertheless, if under certain conditions stimulant drugs elevate the risk of a threat to authenticity, this still does not mean that stimulant drug treatments regularly violate authenticity. All children are subject to socialising processes throughout development, during which they must continually meet normative expectations. Arguably not all of these processes constitute actual threats to authenticity.
It is critically important that children have the capacity to protest norms, and in the first part of this article we saw that stimulants both allow and even promote decision-making capacity and moral agency in children. If stimulants do not generally undermine moral capacities, then we are faced with two difficult challenges: First, are the norms of performance and conduct to which children are subjected valuable?
If we think these norms are overvalued, then the solution is not to deny children the possibility of better meeting normative expectations. Rather, we ought to encourage non-accusatory reflection on the values embodied in these norms. Second, if stimulants pose potential harms and they have potential benefits on the journey to an authentic self, then how can we get better at maximising the benefits, and at recognising, describing and intervening in bad conditions, in which the use of stimulant drugs undermines children's moral or self-creative capacities?
A partial response to these challenges emerges when we acknowledge children's evident desire and capacities for agency. If a majority of children are not victims of stimulant drugs, then they can be engaged to help uncover threats to agency or to authenticity, and they can be constructively supported to protest normative expectations and the accompanying tools, as appropriate.
Children also need to be able to openly discuss the value of medication in relation to their capacity for moral decision-making and their capacities to meet standards of behaviour demanded of them in a given ecological niche. The demand to engage children in non-judgmental, reflective, supportive discussion about stimulant drug use involves parents, teachers and other caregivers, but it is essentially part of a clinical ethics.
As gatekeepers to stimulant drug treatments, medical professionals should take on the dual commitments of inviting a child to speak and of reflective listening, as part of an ethically informed clinical practice. This should be a relational and collaborative stance, rather than an authoritarian one: a genuine invitation to a child to speak recognises the child as at least a potential agent, capable of reason and reflection and worthy of dignity and respect.
A pharmacological treatment approach can include this kind of broader therapeutic orientation to the patient, where the point is to identify and manage the problems a child is experiencing, rather than just to diagnose and treat symptoms. Such an orientation acknowledges the child and indeed the physician as actors in a social world that gives moral weight to children's cognitive and behavioural capacities. Such a role places an enormous demand on medical professionals, when time, training and resources to talk, listen and build a trusting relationship with child patients are scarce.
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I've only just started going to the ADHD clinic, but I haven't actually been to it properly, like, I've seen the doctor and he's talked about [ADHD] and I get weighed … But … they don't, they'll just say like, parts of what it is but then, like, they'll stop, so they will only say some of it and then, like change the subject.
Only a handful of children in the VOICES study view medical professionals as a resource to talk to about difficult issues in relation to their diagnosis or treatment. The lack of relationship between medical professionals and child patients, and the lack of substantive discussion of normative issues in the clinical realm and elsewhere arguably contribute to elevating the risk of ethical harms of stimulant drug treatment. Therefore the lack of resources to build such a relationship is a clinical, societal and ethical concern that warrants interventions at the level of paediatric mental health policy, clinical ethics and medical education.
We have seen that children generally have positive responses to stimulant drug treatments. They primarily see stimulants as supporting their capacity for moral agency. Niche conditions influence how children express their experiences with stimulant drug treatments, and how they conceive the value and work of the drugs.
Most children in this study did not experience stimulant drug treatment as a threat to authenticity, but such a threat is a potential risk to children. It is possible to identify concrete steps to minimise the risks and to maximise the benefits of stimulant drug treatment: I have argued that medical professionals should take a lead in building on children's evident capacity for critical reflection on niche conditions, moral behaviour and the norming work of stimulant drugs, as part of a commitment to children's flourishing.
How do the perspectives of children move the Ritalin debates on? Let us say that after reading this article, a sceptic is not convinced that stimulant drugs can support children's flourishing. Plausible justifications for such a position certainly remain. However, the sceptic will now need to acknowledge that the debate cannot accurately be framed as one between absolute goods and absolute harms; for example, children's liberties versus Ritalin.
Children's perspectives show us, at the least, that it is possible to make important claims for stimulant drugs as a good. Perhaps the sceptic will be more inclined to have empathy with those who might suffer as a consequence of his or her position, as indeed, many children and families who are subjected to the debate in its traditional divisive form, suffer. I am hopeful that if we can change the nature of the debate, by framing the case of stimulant drugs as a problem of tensions among contending goods, we will get better and farther in our arguments, generate more insightful public discourse, and ultimately enable more relevant and more reasonable evaluations of the impact of stimulant drug treatments on children's flourishing.
More generally, as the arsenal of interventions into children's cognition and behaviour grows, balanced, deliberative and empirically grounded analyses should enable more accurate descriptions of bad conditions, in which children's vulnerability is increased by interventions. This accuracy should translate into identification of relevant means by which the social and moral development of children in general—but particularly those who are at risk—is promoted.
Huge gratitude to the children, parents, relatives and doctors who participated in the study. Special thanks to Hanna Pickard and the OCN reading group for insightful comments and careful reading of drafts. Thanks also to Brocher meeting participants for helpful discussions on authenticity. Competing interests: None. Provenance and peer review: Not commissioned; externally peer reviewed. However, given that this is a small, non-random sample, no general conclusions about national characteristics should be drawn from this data.