8. Cognitive enhancement in children by using prescription drugs

Sebastian Sattler
Institute of Sociology and Social Psychology, University of Cologne
Germany
Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal
Canada

Imagine the parents of a ten-year-old. Unsatisfied with their child’s school grades, they approach a doctor to check if a medical condition causes this poor school performance. The doctor confirms that their child is in perfect health. Unsatisfied, the parents search the Internet and find other parents talking about medicating their healthy kids with the intention of boosting their performance at school. They then decide to find a doctor with a reputation for prescribing drugs that are not medically necessary, and request this for their child. This short narrative describes the phenomenon of “pharmaceutical cognitive enhancement” (PCE) or more colloquially, the use of “study aids,” “smart drugs” or “homework drugs”. This chapter on PCE in children will cover: 1) what PCE is, 2) how it is discussed ethically, 3) what we currently know about its prevalence, 4) factors driving and mitigating its use, 5) strategies to prevent risky use, and 6) what future research should target. By “children”, this chapter refers to individuals aged up to 18, however in the absence of data for some sub-topics, some data on older individuals are used.

Cognitive enhancement, in general, describes a set of practices that aim to increase cognitive functions such as short and long-term memory, concentration, the capacity for decision-making and wakefulness (Bostrom and Sandberg, 2009[1]; Greely et al., 2008[2]; Sahakian et al., 2015[3]; Sattler, 2016[4]). This is often referred to as augmentation beyond “normal”, “natural” or “average” functioning of “healthy” individuals, i.e. an intervention “beyond what is necessary to sustain or restore good health” (Juengst, 1998, p. 29[5]). However, due to changing norms about what is “normal”, “natural”, “average”, “good health” or “healthy”, there are shifting boundaries and grey zones especially in terms of cognitive processes such as attention or learning ability, for example. Such boundaries might also be intentionally shifted by the pharmaceutical industry to extend the circle of users.

Very broadly defined, cognitive enhancement includes practices such as substance use, physical exercise, meditation, genetic modification, mnemonics or brain stimulation (Coates McCall et al., 2019[6]; Dresler et al., 2013[7]). Taking prescription drugs is currently the most frequently discussed form of enhancement (Nagel, 2019[8]; O’Connor and Nagel, 2017[9]; Sahakian et al., 2015[3]; Schelle et al., 2014[10]) and the focus of this chapter. Such PCE includes off-label prescription drug use of mainly modafinil (e.g. Provigil®), methylphenidate (e.g. Ritalin®) and amphetamine-dextroamphetamine (e.g. Adderall®), as well as donepezil (e.g. Aricept®) and beta-blockers (e.g. Inderal®). These drugs have been developed and approved to treat conditions like attention-deficit hyperactivity-disorder (ADHD), sleep disorders, dementia or high blood pressure, and not intended specifically for PCE. For example, the use of these drugs in children diagnosed with ADHD is intended to calm them down and help improve concentration.

Due to ethical reasons, studies of the impact of these drugs on “healthy” children do not exist (as far as we know). Studies and subsequent meta-analyses with older populations reveal that such drugs can increase cognitive performance in “healthy” individuals (Battleday and Brem, 2015[11]; Caviola and Faber, 2015[12]; Repantis, Laisney and Heuser, 2010[13]; Smith and Farah, 2011[14]). The strength of the effect is low to moderate and depends on the type of drug, its dosage, characteristics of the user (e.g. responsiveness to the drug), the situation of use (including the task at hand) and the targeted cognitive function. Effects sometimes seem to be only subjectively perceived rather than objectively verifiable, suggesting that placebo effects exist. Thus, user expectations may partially exceed the actual effect. Preliminary research with healthy college students suggests some improvements (e.g. on attention), but also impairments (on working memory) after Adderall® was administered (Weyandt et al., 2018[15]).

Is PCE morally acceptable? How does it affect personhood? Is PCE different from private tutoring or drinking coffee? Who may benefit legitimately or illegitimately and who may be harmed from this practice? These and other questions are challenging and the use of PCE across the life-cycle offers material for intense ethical discussions. While some arguments favouring or dismissing PCE as acceptable or non-acceptable are very general, others apply to children in particular. These arguments can be grouped into those focusing on a) how PCE relates to traits or motivations of (non-)users (i.e. the agents), b) whether PCE can be judged as a “right” or “wrong” deed to conduct, and c) whether PCE has “good” or “bad” consequences for (non-)users or others (Dubljević, Sattler and Racine, 2018[16]; Racine, Sattler and Boehlen, Under review[17]). Some arguments relate to more than one of these three groups. This chapter highlights six common arguments for and against the use of PCE in children (see Table 8.1).

PCE has been seen as a means to help humans become “better” and overcome currently believed limitations concerning what we are able to memorise, how long we can concentrate, or how efficiently we can make decisions and adapt to challenging environments (Bostrom and Sandberg, 2009[1]). For example, having a good memory might be generally valued and thus positive for users. And indeed, key features of humankind have been changing over the centuries due to better health-care, vaccination or food. One hope is that PCE can amplify human capacities for more autonomous agency and complex judgments and that its intake may even result in changes of character traits that could be beneficial for users, such as improved self-confidence (Flanigan, 2013[19]).

However critics argue that PCE can undermine authenticity and thereby a child´s personality, because for individuals who use PCE, the attribution of what contributed to successes or failures – the pill or the person – might become blurred (Graf et al., 2013[18]). One related argument against PCE is that it will negatively change other elements of a child’s character, since drug using children will be less trained in meta-skills such as overcoming crises. As a result, their self-confidence, sense of agency and autonomy might be reduced, and this can be detrimental for further achievement and development (Racine, Sattler and Boehlen, Under review[17]; Sattler, 2016[4]; Walcher-Andris, 2006[20]).

Deed-related arguments

Some scholars claim that PCE increases cognitive functioning similar to other means such as tutoring or drinking coffee and thus should be allowed (Flanigan, 2013[19]). However, due to the negative consequences related to its use (see below) and more acceptable non-pharmaceutical options, it cannot be considered legally and ethically similar to private tutoring or coffee (Gaucher, Payot and Racine, 2013[21]). This is also why prescription drugs can only be legally obtained with a prescription (although there is variation across countries about what constitutes a prescription drug).

Proponents of PCE argue that with increasing maturity, adolescents should be granted the right to decide for themselves and be considered medically autonomous (Flanigan, 2013[19]). The ability to understand risks and benefits increases with age and maturity, therefore adolescents should be able to decide which risks are acceptable even if they are prone to engaging in risky behaviours. However, while physicians have a duty to acknowledge the autonomy of their patients, they must also intervene if health decisions fall below established thresholds (Forlini, Gauthier and Racine, 2013[22]; Gaucher, Payot and Racine, 2013[21]).

Given the potential of performance improvements with PCE, scholars have critically discussed PCE as being unfair and cheating (Schermer, 2008[23]). Achievements with PCE are seen as different from those involving purely hard work. Additionally, a fair performance assessment might be difficult if some individuals use PCE and others do not, although it has to be acknowledged that children already vary in starting conditions, e.g. due to the human and social capital of their parents (Bostrom and Sandberg, 2009[1]). In this sense “cheating” must be clearly defined. For example, because of concerned students, Duke University in the United States lists “the unauthorised use of prescription medication to enhance academic performance” as one form of academic dishonesty in their university policy (Duke University, 2019, p. 16[24]). Proponents, however, argue that if everybody had legal access to PCE (as some schools offer computers to all students), it can be considered equivalent to other means of performance enhancement (Greely et al., 2008[2]; Kayser, Mauron and Miah, 2005[25]). Some scholars even suggest subsidised access for disadvantaged groups (Bostrom and Sandberg, 2009[1]) but who would pay for this and how this would be organised for PCE is not clear.

Proponents of PCE in children hope for positive gains in cognitive functioning, enjoyment of work and better well-being, even if only due to placebo effects (Flanigan, 2013[19]). Such improvements might also be societally relevant since “smarter, wiser or more creative” individuals may help solve pressing societal and economic problems (Bostrom and Sandberg, 2009, p. 328[1]; Beddington et al., 2008[26]). They also argue that disadvantaged healthy children should be given PCE to counter potential inadequate schooling and teaching – especially if society seems unwilling to pursue other required policy changes (Bostrom and Sandberg, 2009[1]; Flanigan, 2013[19]; Ray, 2016[27]). However, turning social inequality into a medical problem, for which the hoped remedy is probably ineffective (see next point) causes further problems such as stigmatisation (Ketchum and Repantis, 2016[28]; Sattler and Singh, 2016[29]; Warren, 2016[30]).

Critics of PCE in children highlight its poor cost-benefit ratio (Graf et al., 2013[18]; Sattler and Singh, 2016[29]). While clinical evidence for positive effects in young healthy people is very limited, PCE can have negative short- and long-term health consequences. Adverse side effects include headaches, insomnia, abnormal heartbeat, high blood pressure or psychosis (Storebø et al., 2015[31]; Volkow et al., 2009[32]; Winder-Rhodes et al., 2010[33]). Such negative effects might be more likely or more severe without medical oversight, e.g. due to overdosing, intranasal administration (which is related to increased risks of abuse), or when use is inadvisable because of other medical conditions (e.g. heart failure or an oversupply of thyroid hormones) (Weyandt et al., 2018[15]). While risking such side effects might be acceptable to treat a disease, the acceptability for PCE in otherwise healthy individuals has been questioned.

Moreover, PCE in children warrants special attention as their developing bodies and brains might be more vulnerable (d’Angelo, Savulich and Sahakian, 2017[34]). Exposure to side effects can impose costs on health systems that society has to shoulder. Due to these negative consequences, physicians’ obligation to refuse inquiries of inappropriate drug use has been highlighted, as have legal sanctions for untrained parents administering PCE drugs to children without supervision. Prevention and monitoring have been suggested (Gaucher, Payot and Racine, 2013[21]; Graf et al., 2013[18]; Maslen et al., 2014[35]).

In this debate, the potential for negative social consequences of individual PCE engagement has been emphasised, namely that other parents and children may experience diminished freedom of choice due to increasing competition (e.g. in schools) as well as indirect coercion and pressures to also engage in PCE in order not to fall behind (Graf et al., 2013[18]; Sattler and Singh, 2016[29]). Such pressures may rise with growing prevalence rates of PCE, and increasing pressure on parents and children to use medication to “keep up”. This can be especially problematic because children´s decision-making capacity is still developing and they are particularly vulnerable to direct and indirect coercion by both parents and peers. Additionally, young people´s assessment of the (health) consequences of PCE might be constrained (Gaucher, Payot and Racine, 2013[21]). Additionally, if everybody starts using enhancement to improve academic performance, no one will have a relative advantage, but everyone has to bear the negative consequences (Jane and Vincent, 2017[36]).

Researchers warn that the misuse and abuse of prescription drugs “is one of the fastest growing drug epidemics in the United States, particularly among adolescents” (Conn and Marks, 2014, p. 257[37]). While this warning did not specifically target PCE, scholars believe the prevalence of PCE in children to also be on the rise (O’Connor and Nagel, 2017[9]; Singh and Kelleher, 2010[38]). This section outlines some research examining the prevalence of PCE in children.

These trends are not limited to the United States, but it is difficult to compare prevalence rates across countries in part due to the lack of shared definitions and assessment approaches. In addition, different types of data can be used to estimate how common PCE is among children. These data include a) official data including prescription rates as rough indicators of PCE, b) information about parents (or other legal guardians) endorsing or actively giving prescription drugs to their children with the intention of performance enhancement without medical necessity, and c) self-reports of children who have been asked about their engagement in such behaviour. It has to be noted that not all studies explicitly refer to PCE as a motive for use (further motives are “getting high” for example).

The global manufacturing, trade, stocks, and consumption of methylphenidate (usually prescribed to treat ADHD) has been rising in the past ten years, according to the International Narcotics Control Board (2019[39]). High levels of consumption have been reported for northern Europe (e.g. Iceland), North America as well as other parts of Europe. The prevalence of ADHD diagnosis in Germany, for example, increased from 21 of 1 000 children in 2004 to 39 of 1 000 in 2013. The total amount of prescribed drugs and the number of daily doses per case has also risen in that time (Langner et al., 2019[40]). Reasons for this increase include a rise in the prevalence of ADHD and a higher awareness of parents and physicians about ADHD. However, over-diagnosis (Bruchmüller, Margraf and Schneider, 2012[41]) including with the purpose of PCE, cannot be ruled out as contributing to these trends (Gaucher, Payot and Racine, 2013[21]; Graf et al., 2013[18]). Even if unintentional, such surges in prescriptions make more drugs available for sharing, trading and exchanging, and thus for potential misuse.

The actual prevalence of parents administering prescription drugs to their children in order to enhance their cognitive performance is not well-researched. One survey in the US revealed that only 1% of parents of children aged 13-17 (who have no prescribed stimulants to treat ADHD), assumed that their children use “study aids”, while another 4% were not sure (C.S. Mott Children’s Hospital National Poll on Children’s Health, 2013[42]). However, parents might not be well informed about their children’s behaviour, particularly in the case of older adolescents. Another experimental study found an occasionally moderate but substantial willingness when parents were asked if they would medicate a healthy child for better school performance (Sattler et al., under review[43]).

Children´s self-reported PCE behaviour

An older meta-analysis estimated the 12-month prevalence rate of non-medical use of prescription drugs in the United States at 5-10% among grade-school students (Wilens et al., 2008[44]). A more recent study, again in the United States, shows that 1 196 000 (4.8%) adolescents between 12 and 17 years are estimated to have misused psychotherapeutics in 2018, of which 369 000 (1.5%) misused stimulants (Substance Abuse and Mental Health Services Administration, 2019[45]). When looking at the annual prevalence of the non-medical use of two important amphetamines used for PCE, Ritalin® use decreased from 2009 to 2018 in 8th-, 10th-, and 12th-grade students, while Adderall® use was more stable at higher levels in the same period (Johnston et al., 2019[46]). In 2012, when asked specifically about ever having taken medication to improve focus, memory, or concentration, 1% young people aged 14-18 surveyed in the United Kingdom reported they had (Clemence et al., 2013[47]). In a more recent Swiss study, 4.3% of surveyed upper secondary school students (18 or younger) reported prescription drug use for PCE (Liakoni et al., 2015[48]). When asked about the age of first use of methylphenidate for PCE, a small sample of 16 grammar school pupils (aged 18-21) in Germany retrospectively answered 16.58 years (Franke et al., 2011[49]). A frequent source of the prescription drugs are friends with prescriptions (e.g. (Garnier-Dykstra et al., 2012[50])).

To better understand PCE by children, the attitudes and reasoning that drive the choice of whether to use it or not must be explored. Although research in children is in its infancy, research on parents with children older than 18 or on college or university students suggests possible drivers and barriers of PCE use that might also apply to younger people. The following section reflects on factors driving and mitigating PCE in: a) parents (or other legal guardians) as well as b) children and adolescents (Table 8.2).

One important stakeholder group involved in direct and indirect decisions regarding PCE in children is parents (Arria and DuPont, 2010[51]). Parents can initiate PCE use because they want their children to reach performance goals inside or outside of school (Arria and DuPont, 2010[51]; Sattler et al., under review[43]).Motives for this can be, for example, a desire to optimise their children´s future, to financially benefit from better performance in the long run, to gain status for themselves or their children, or to remove or overcome stigmatisation of low performing children. Recent studies on parenting discuss a shift towards intensive parenting and competitive mind-sets of parents (Doepke, Sorrenti and Zilibotti, 2019[52]; Nadesan, 2002[53]; Wall, 2010[54]; Ulferts, 2020[55]). This shift might be also linked to increasing returns of education, the growing importance of cognitive abilities, and growing inequalities (Autor, 2014[56]). Intensive parenting has many faces, including increasing parent child-interactions to support educational success such as homework support or tutoring (Borra and Sevilla, 2019[57]; Gershuny and Harms, 2016[58]; Wells et al., 2016[59]). Engaging in cognitive enhancement might be another, less frequently occurring expression of this, as parents may view it as helpful to achieving these goals ( (Arria and DuPont, 2010[51]) cf. (Sattler et al., under review[43])). One recent study speaks to this by showing that parents in the US with a Machiavellian personality (i.e. individuals who tend to be selfish and extrinsically oriented towards money, success, etc.) tend to be more willing to instrumentalise prescription drugs to give their child an advantage compared to those with a non-Machiavellian personality (Sattler and Linden, under review[60]). The prospect of higher financial gains also increased willingness, especially for Machiavellians.

If some parents engage with this type of behaviour, it can have contagious or coercive effects (Maher, 2008[61]). About one third of respondents in an international but predominantly North American survey (without indication about parenthood) reported they would feel pressure to give prescription drugs to their children for enhancement purposes if classmates were also taking them. Such indirect coercion to engage in this behaviour due to feared disadvantage has been also observed in two qualitative studies in Canada with parents of children aged 3-9 (Ball and Wolbring, 2014[62]) and parents of students aged 25 and under (Forlini and Racine, 2009[63]). In addition, some parents report considering prescription drugs to be possible means to enhance children’s self-confidence, well-being or independence if these drugs were safe and effective (Ball and Wolbring, 2014[62]).

However, in a qualitative study with American college students (aged 18-26), few students said that their parents would accept if they themselves used prescription drugs in order to get better grades (Cutler, 2014[64]). A minority of parents in a German sample of parents (of children aged 5-18) report that they would only agree to give prescription drugs to children for enhancement under the supervision of a physician, while other parents would call for legal action against physicians if they were to engage in this (Hiltrop and Sattler, under review[65]). Several parents in a Canadian study, however, believed that prescription drug use for enhancement should be an individual choice, but also said that students using such drugs should be responsible for the possible consequences (Forlini and Racine, 2009[63]).

While parents can be promoters of PCE in children, they can also be obstacles because of risk aversion, moral qualms, or because they control resources and access to PCE such as money or making appointments with physicians. The few studies on this topic all indicate that the majority of parents consider PCE in a dismissive way (Ball and Wolbring, 2014[62]; Forlini and Racine, 2009[63]; Hiltrop and Sattler, under review[65]) due for example to the fear of adverse short- and long-term effects such as negative effects on the brain, and unfairness if only some children take such drugs (Forlini and Racine, 2009[63]; Hiltrop and Sattler, under review[65]). They compared it to cheating, doping in sports and a form of self-deception.

However, while a fair assessment of performance might become more difficult if some children take PCE, some parents also said that many factors already make such an assessment difficult, such as transmission of human capital from highly educated parents to their children (Hiltrop and Sattler, under review[65]). Parents were also worried that PCE may intensify the competition in educational settings, undermining free decisions about PCE use because of disadvantages for non-users (Ball and Wolbring, 2014[62]; Forlini and Racine, 2009[63]). In line with these dismissive views is the finding that over 85% of respondents favoured restrictions of PCE of healthy children under the age of 16 (Maher, 2008[61]). Besides teachers and doctors (who should intervene against PCE if it becomes more prevalent), parents also see the school system and politicians as being responsible for taking action and reconfiguring drivers of PCE use such as performance expectations (Hiltrop and Sattler, under review[65]). Next to such political demands, many parents negatively view other parents who give or force their children to take PCE (Ball and Wolbring, 2014[62]; Hiltrop and Sattler, under review[65]).

What do children think about PCE? What makes them more likely to engage in it? What holds them back? This has not been well studied, however research with older individuals (such as university students) offers relevant insights and shows the diversity of factors affecting the use of PCE. Here, only a sample of these factors can be described: For example, a study of college students in the United States found that (mis)using prescription drugs was most frequently done due to a desired enhancement of cognitive performance while studying. This motive became more prevalent after the first year in college ( (Garnier-Dykstra et al., 2012[50]) cf. a systematic review by (Faraone et al., 2020[66])). Motives for PCE use were not always to outperform, but also for “catching up” or being on par with others as reported by university students from England (United Kingdom) (Vargo and Petróczi, 2016[67]). This was also reflected in a sample of high school seniors in the United States where a higher grade-point average was more likely observed in non-users compared to users of prescription drugs using them for non-medically for study purposes (combined with other motives) ( (Teter et al., 2020[68]) cf. (Faraone et al., 2020[66])); interestingly this latter group, and those indicating a use for study purposes only, reported a higher percentage of more highly educated parents.

The use of drugs for PCE and the willingness of future use were particularly high if the relevant drugs were perceived or described as beneficial and less risky (Kinman, Armstrong and Hood, 2017[69]; Sattler et al., 2013[70]; Sattler and Wiegel, 2013[71]). Interestingly, 45% of young people (aged 14-18) surveyed in the United Kingdom expected the taking of such medications to be very or fairly effective for improving focus, memory or concentration (Clemence et al., 2013[47]), while German university students estimated potential side-effects to be very high (Sattler and Wiegel, 2013[71]). However, a study with college students in the United States offers no indication that non-medical use of prescription stimulants significantly increased their grade-point average compared to abstainers (Arria et al., 2017[72]). This might indicate that the drug effects are often overestimated and subjectively perceived rather than objectively observable. Students still seem to expect them to help them cope with stress as indicated by studies with (university) students in Germany ( (Sattler, 2019[73]) cf. (Wolff and Brand, 2013[74])). However, experiencing social support partially buffered the effects of stress, reducing likelihood of engaging in PCE. Thus, social support is an important resource and social relations matter. Nevertheless, suspected PCE use among peers and peer approval also seem to increase PCE as indicated by several European studies (Helmer et al., 2016[75]; Maier et al., 2013[76]; Ponnet et al., 2015[77]; Singh, Bard and Jackson, 2014[78]).

Research also indicates that personality and other personal characteristics play a role. For example, college and university students who self-identify as more risk prone, who have test anxiety, or who have a tendency towards procrastination have been found to be more likely to engage in PCE (Ponnet et al., 2015[77]; Sattler and Wiegel, 2013[71]). Moral objections towards PCE, however, hold a majority of them back (Sattler et al., 2013[79]). With regard to gender differences, several studies with university students (Champagne, Gardner and Dommett, 2019[80]; Singh, Bard and Jackson, 2014[78]) found male students to be more likely to use PCE than female students. There remain many candidate factors associated or causally linked with children´s decisions to use or abstain from PCE that need to be understood.

PCE is an important topic for the health, well-being, development and other facets of children´s lives. It is thus crucial to explore strategies that – depending on policy-makers’ goals –reduce the occurrence of this behaviour, or at least reduce risky uses. Targets of such strategies should be children and their parents, but also physicians and teachers. In the following sections, three potential strategies will be briefly presented.

If parents would like their children to perform better and/or if children have the same goal, they could be educated: a) about misperceptions regarding drug efficacy given the often limited positive effects of prescription drugs for healthy people and the possible detrimental health effects, b) about their potential overestimated prevalence, which might cause indirect coercion or contagion effects (Faraone et al., 2020[66]; Stock et al., 2013[81]; Weyandt et al., 2018[15]), and c) in applying less risky non-medical options for performance enhancement including sufficient sleep, nutrition, memory techniques, meditation, physical exercise or neurofeedback (a technique that gives real-time feedback of brain activity and thereby intends to help with regulating brain functions) (Dresler et al., 2013[7]; Gruzelier, 2009[82]). All these latter strategies may have multiple positive “collateral” effects on overall health and well-being. These educational strategies might be integrated in curricula thereby also targeting current non-users. In addition, students struggling academically or at-risk for drug misuse (e.g. because of test-anxiety or engagement in cheating behaviour) should receive resources, support and tailored messages (Sattler and Wiegel, 2013[71]; Weyandt et al., 2018[15]).

Two stakeholder groups that can professionally observe substance misuse and substance-related problems are teachers and physicians. Through teachers’ frequent interaction with students, they may find indications for non-medical uses of prescription drugs including accompanying side effects (e.g. irritability, feeling sad, reduced appetite) and as recourse, they can for example contact parents or school psychologists. Physicians are also important, because they are gate-keepers of the drugs and it has been observed that physicians not only frequently receive prescription requests for PCE, but that some of them also fill these requests (Hotze et al., 2011[83]).Thus, physicians should consider non-medical prescription drug use as a source of symptoms when understanding their medical history. They may inform and ask those who receive prescriptions for medical purposes (e.g. to treat ADHD) about potential pressures to and dangers of sharing their medication (including legal consequences for them and potential fatal consequences for users), inquire about their weekly dosage and left over drugs, ask for other risk factors of drug misuse (e.g. with a profile checklist), and conduct toxicology testing if a substance use disorder is suspected (DeSantis, Anthony and Cohen, 2013[84]; Faraone et al., 2020[66]; McCabe et al., 2019[85]; Weyandt et al., 2018[15]). As a response, physicians may consider changing prescribing practices (for example, by considering non-medical alternatives). Therefore, both teachers and physicians need to be enabled to do so (e.g. with training and resources or through establishing open lines of communication with one another in suspected cases of abuse).

As mentioned above, Duke University is one example of an institution that lists PCE as one form of academic dishonesty in their university policy. Policies forbidding the use of PCE in schools, colleges and universities may not only change an important determinant of PCE use, namely its moral acceptability, but also directly decrease student willingness to engage in PCE (Sattler et al., 2013[70]). General restrictions that make access to the drugs more difficult might also be effective. According to a survey of university students in Ireland and the United Kingdom, limited access is a frequently cited barrier to taking PCE, despite interest (Singh, Bard and Jackson, 2014[78]). Initiatives aimed at making prescription drugs available without prescription must also take this into account, but they should also acknowledge problems of trading such drugs on the black market, which also comes with its own set of risks.

In recent years research on the effects, prevalence, attitudes and reasons concerning the use of prescription drugs for cognitive enhancement has grown steadily. However, this is not the case for related research on children. To better understand this phenomenon, but also to inform the ethical debate about which concerns seem to be empirically substantiated, to tailor prevention strategies, and to advise policy-making, we need to know more about a) the functioning of these drugs in healthy individuals, b) exact prevalence estimates, c) attitudes (which also reflect public preferences) and decision-making of relevant stakeholders, as well as d) the effectiveness of prevention strategies and regulations. In the following, four key priorities for future research are set out.

PCE in children seems a fact but there is much that is still unknown. Although research on drug efficacy in healthy children is not possible due to ethical reasons, studies in older populations can be used to shed light on potential impacts on children (even if they are not directly transferable). These studies would benefit from larger samples, an acknowledgement of the variability of effects from person to person, a more systematic documentation of side effects and long-term effects, and further investigations into the functioning of the drugs (including the role of expectancy effects and motivational rather than direct cognitive improvements) (e.g. (d’Angelo, Savulich and Sahakian, 2017[34]; Weyandt et al., 2018[15])). Also, the question of how lab findings translate to improvements outside the lab would be useful. Moreover, prescription drugs might be compared to other enhancement means such as brain stimulation devices (Farah, 2015[86]).

Current data do not provide a clear picture of the prevalence of PCE in children across countries, although several scholars forecast prevalence increases in the future (O’Connor and Nagel, 2017[9]; Vargo and Petróczi, 2016[67]). Political regulation and prevention initiatives would not only provide insight about the current situation, they could also monitor macro changes (such as tensions in the educational system) with a) more representative large-scale studies that b) are longitudinal in nature, c) are sufficiently large (or oversample) to investigate vulnerable groups, d) cover different age-groups of children (with instruments tailored for age) as well as their parents, and e) specifically investigate cognitive enhancement as a motive for use (with a shared definition).

We need a deeper understanding of what children and parents believe about PCE, and why and how they make decisions about PCE use as this is essential to develop and adjust empirically informed intervention strategies and policies. This includes (mis-)perceptions about the functioning of the drugs and related risks (psychological, physiological, legal and social), personality traits (e.g. perfectionism or competitiveness), but also the role of the social context (e.g. peer approval or vicarious experience) (Faraone et al., 2020[66]; Hiltrop and Sattler, under review[65]; Schepis et al., 2020[87]). We know little about the role of physicians in PCE in children, but as already highlighted they are another important stakeholder group, such as when parents approach them and ask for prescriptions or advice. Therefore, the relationships within the child-parent-physician triad should also be investigated. Again, filling this research gap requires high quality data.

While gathering evidence for designing prevention strategies or revising regulations is one important step, well-designed empirical evaluations of effectiveness is a next logical step after their implementation. At the moment, such evaluations are limited (Faraone et al., 2020[66]). In particular, experimental designs with control groups, either as within- or between-subject designs, may test, for example, substance-related strategies (e.g. informing about dangers of substances), as well as interventions targeting general protective factors (such as improving learning strategies, self-efficacy and health literacy) in at-risk populations. To do so, they can utilise different methods such as social media campaigns, curriculum-based approaches or peer-based interventions.

Although PCE in children appears limited, aggregating global numbers suggests that several million children use such drugs for enhancement, voluntarily or not. They are therefore at risk of side effects and experiencing long-term consequences for their personality and brain development, while at the same time provoking other ethical and social problems (such as fairness issues when assessing grades).

The majority of experts have concluded that PCE in children is not advisable nor in the best interest of children (e.g. (Gaucher, Payot and Racine, 2013[21])). PCE may reduce children’s right to an open future to let them experiment, experience creativity, and develop a sound personal identity rather than enforcing conformity and productivity. This aligns with a recent claim that we need a debate about the value of perfection and the pursuit of perfection; should humans have the right to enhance, while on the other hand should there be a right to not enhance, which also begs the questions of what we value in childhood and adolescence (Nagel, 2019[8]).

These questions have to be answered also by listening to the voices of children. Interestingly, several studies with parents mirror the concerns ethicists have and only a few seem to be willing to use PCE on their children. Thereby, it is also an open question to understand how societal factors and trends may influence parents and children agreeing to PCE. Factors that may promote agreement can be the increasing returns of education, a growing relevance of cognitive abilities and growing inequalities. The answers to these questions will likely vary around the globe due to heterogeneous developments and cultural settings. To find answers to this question and to the many unknowns regarding PCE in children, we need interdisciplinary efforts by psychologists, sociologists, pharmacologists, paediatricians, teachers, ethicists, etc. and a multi-method approach (Nagel, 2019[8]). In educational settings, it should be considered a) that some children already take PCE (in addition to other forms of enhancement) which might make grading more difficult, b) that conditions in education (in particular performance pressure) contribute to such behaviour, c) that PCE itself can intensify the competition, and d) that teachers can play a key role in detecting and preventing risky substance uses by helping students find less risky alternatives or relevant support.

I would like to thank Francesca Gottschalk, Tracey Burns, Simona Petruzzella, and Kati Hiltrop for valuable feedback on a previous version of this manuscript. This research was supported by a grant [SA 2992/2-1] from the German Science Foundation. The views expressed do not necessarily reflect the policies of the funder. The authors did not receive any research support from public or private actors in the pharmaceutical sector.

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