Globalization and Cognitive Enhancement: Emerging Social and Ethical Challenges for ADHD Clinicians


Globalization of ADHD and the rise of cognitive enhancement have raised fresh concerns about the validity of ADHD diagnosis and the ethics of stimulant drug treatment. We review the literature on these two emerging phenomena, with a focus on the corresponding social, scientific and ethical debates over the universality of ADHD and the use of stimulant drug treatments in a global population of children and adolescents. Drawing on this literature, we reflect on the importance of ethically informed, ecologically sensitive clinical practices in relation to ADHD diagnosis and treatment.

This is a preview of subscription content, access via your institution.


Recently published papers of particular interest have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Conrad P. Identifying hyperactive children: The medicalization of deviant behaviour. Lexington, MA: Lexington Books; 1976.

    Google Scholar 

  2. 2.

    Conrad P. The medicalization of society: On the transformation of human conditions into treatable disorders. Baltimore, Johns Hopkins UP;2007.

  3. 3.

    Shrag P, Divoky D. The myth of the hyperactive child and other means of child control. New York: Pantheon;1975.

  4. 4.

    Barkley R. Issues in the diagnosis of attention-deficit/hyperactivity disorder in children. Brain Dev. 2003;25:77–83.

    PubMed  Article  Google Scholar 

  5. 5.

    Malacrida C. Medicalization, Ambivalence and Social Control: Mothers’ Descriptions of Educators and ADD/ADHD. Health (London). 2004;8(1):61–80.

    Article  Google Scholar 

  6. 6.

    Horwitz A. Creating mental illness. Chicago: Chicago UP; 2002.

    Google Scholar 

  7. 7.

    Sonuga-Barke EJ, Schlotz W, Kreppner J. Differentiating developmental trajectories for conduct, emotion and peer problems following early deprivation. Monographs of the Society for Research in Child Development. 2010;75:102–24.

    PubMed  Article  Google Scholar 

  8. 8.

    Parens E, Johnson J. Facts, values and Attention Deficit Hyperactivity Disorder (ADHD): an update on the controversies. Child Adolesc Psychiatry Ment Health. 2009;3:1. doi:10.1186/1753-2000-3-1.

    PubMed  Article  Google Scholar 

  9. 9.

    Mayes R, Bagwell C, Erkulwater J. ADHD and the Rise in Stimulant Use Among Children. Harv Rev Psychiatry. 2008;16:151–66.

    PubMed  Article  Google Scholar 

  10. 10.

    Singh I. Beyond Polemics: Science and ethics of ADHD. Nat Rev Neurosci. 2008;9(12):957–64.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    • Parens E. On good and bad forms of medicalization. Bioethics. 2013;27(1):28–35. An important development in the medicalization debates that moves the concept on from older versions into interesting and useful new territory.

    PubMed  Article  Google Scholar 

  12. 12.

    Singh I. Human development, nature and nurture: Working beyond the divide. BioSocieties. 2012. doi:10.1057/biosoc.2012.20.

    Google Scholar 

  13. 13.

    Worthman CM, Protsky PM, Schechter DS, Cummings CA. Formative experiences: The interaction of caregiving, culture and developmental biology. Cambridge, UK: CUP; 2010.

    Book  Google Scholar 

  14. 14.

    Layard R, Dunn J. A Good Childhood. London: Penguin; 2009.

    Google Scholar 

  15. 15.

    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM) – 5. Virginia, USA: American Psychiatric Publishing; 2013.

    Google Scholar 

  16. 16.

    Centres for Disease Control and Prevention (CDC). Mental health surveillance among children- United States, 2005–2011. Atlanta, GA: US Dept of Health and Human Services; 2013.

  17. 17.

    Schwarz A, Cohen S. A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise. The New York Times March. 2013(31).

  18. 18.

    Scheffler RM, Hinshaw SP, Modrek S, Levine P. The global market for ADHD medications. Health Aff. 2007;26:450–7.

    Article  Google Scholar 

  19. 19.

    Cornejo JW, Osio O, Sanchez Y, et al. Prevalence of attention deficit hyperactivity disorder in Columbian children and teenagers. Rev Neurol. 2005;40(12):716–22 [in Spanish].

    PubMed  CAS  Google Scholar 

  20. 20.

    Pineda D, Ardila A, Rosselli M, et al. Prevalence of attention—deficit/hyperactivity disorder symptoms in 4–17 year old children in the general population. J Abnorm Child Psychol. 1999;27(6):455–62.

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Pino P, Mojarro-Praxedes M. Hyperkinetic D disorders: double-phase epidemiological study of a population from Sevilla. An Psiquiatria. 2001;17(6):265–70 [in Spanish].

    Google Scholar 

  22. 22.

    Catalá-López F, Peiró S, Ridao M, Sanfélix-Gimeno G, Gènova-Maleras R, Catalá MA. Prevalence of attention deficit hyperactivity disorder among children and adolescents in Spain: a systematic review and meta-analysis of epidemiological studies. BMC Psychiatry. 2012; doi: 10.1186/1471-244X-12-168

  23. 23.

    Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164:942–8.

    PubMed  Article  Google Scholar 

  24. 24.

    Polanczyk G, Jensen P. Epidemiological considerations in Attention Deficit Hyperactivity Disorder: A review and update. Child Adolesc Psychiatric Clin N Am. 2008;17:245–60.

    Article  Google Scholar 

  25. 25.

    Gomez R, Harvey J, Quick C, et al. DSM-IV AD/HD: confirmatory factor models, prevalence, and gender and age differences based on parent and teacher ratings of Australian primary school children. J Child Psychol Psychiatry. 1999;40(2):265–74.

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Levy F, Hay DC, McStephen M, et al. Attention deficit hyperactivity disorder: a category or a continuum? Genetic analysis of a large-scale twin study. J Am Child Adolesc Psychiatry. 1997;36(6):737–44.

    Article  CAS  Google Scholar 

  27. 27.

    Hinshaw SP, Scheffler RM, Fulton BD, Aase H, Banaschewski T, Cheng W, Mattos P, Holte A, Levy F, Sadeh A, Sergeant JA, Taylor E, Weiss MD. International Variation in Treatment Procedures for ADHD: Social Context and Recent Trends. Psychiatr Serv. 2011:62(5).

  28. 28.

    INCB. Psychotropic Substances: Statistics for 2011. International Narcotics Control Board Report. 2012. Accessed 30 May 2013.

  29. 29.

    • Zuvekas S, Vitiello B. Stimulant medication use among US children: A twelve-year perspective. Am J Psychiatry. 2012;169(2):160–66. A careful longitudinal study showing a slowing in overall rates of stimulant medication use among US children over the twelve year period, but a worrying increase in use among adolescents.

    PubMed  Article  Google Scholar 

  30. 30.

    INCB. International Narcotics Control Board. Report of the International Narcotics Control Board for 2007. 2007.

  31. 31.

    Timimi S, Taylor E. ADHD is best understood as a cultural construct. Br J Psychiatry. 2004;184:8–9.

    PubMed  Article  Google Scholar 

  32. 32.

    Moffitt TE, Melchior M. Why does the worldwide prevalence of childhood attention deficit hyperactivity disorder matter? Am J Psychiatry. 2007;164(6):856–8.

    PubMed  Article  Google Scholar 

  33. 33.

    Amaral OB. Psychiatric disorders as social constructs: ADHD as a case in point. Am J Psychiatry. 2007;164:1612–3.

    PubMed  Article  Google Scholar 

  34. 34.

    Bass JK, Bolton PA, Murray LK. Do not forget culture when studying mental health. The Lancet. 2007;370(9591):918–9.

    Article  Google Scholar 

  35. 35.

    Watters E. Crazy like us: The globalization of the American psyche. New York: Free Press; 2010.

    Google Scholar 

  36. 36.

    Kirmayer L. Beyond the ‘new cross-cultural psychiatry’: Cultural biology, discursive psychology and the ironies of globalization. Transcult Psychiatry. 2006;43(1):126.

    PubMed  Article  Google Scholar 

  37. 37.

    Moynihan R, Doran E, Henry D. Disease mongering is now part of the global health debate. PloS Medicine. 2008;5(5):e106.

    PubMed  Article  Google Scholar 

  38. 38.

    Dumit J. Drugs for Life: How Pharmaceutical Companies Define Our Health. Durham and London: Duke University Press; 2012.

    Google Scholar 

  39. 39.

    Grand Challenges in Global Mental Health Initiative.

  40. 40.

    •• The Lancet. Global Mental Heath. 2011. The series is the second of two Lancet special issues that outlines key challenges in global mental health. The series helped mobilize the NIH, WHO and UN to regard mental health in the context of global public health trajectories and goals.

  41. 41.

    The Lancet. Global Mental Heath. 2007.

  42. 42.

    Summerfield D. Afterword: Against “global mental health”. Transcut Psychiatry. 2012;49(3):1–12. doi:10.1177/1363461512454701.

    Google Scholar 

  43. 43.

    Bemme D, D’Souza N. Global Mental Health and its Discontents. 2012.

  44. 44.

    Farmer P. An Anthropology of Structural Violence. Curr Anthropol. 2004;45(3).

  45. 45.

    Canino G, Alegria M. Psychiatric diagnosis- is it universal or relative to culture? J Child Psychol Psychiatry. 2008;49(3):237–50.

    PubMed  Article  Google Scholar 

  46. 46.

    Wakefield JC, Pottick KJ, Kirk SA. Should the DSM-IV criteria for conduct disorder consider social context? Am J Psychiatry. 2002;159:380–6.

    PubMed  Article  Google Scholar 

  47. 47.

    Rohde LA, Szobot C, Polanczyk G, Schmitz M, Martins S, Tramontina S. Attention-Deficit/Hyperactivity Disorder in a Diverse Culture: Do Research and Clinical Findings Support the Notion of a Cultural Construct for the Disorder? Biol Psychiatry. 2005;57:1436–41.

    PubMed  Article  Google Scholar 

  48. 48.

    Bronfenbrenner U. The ecology of human development. Camridge, MA: Harvard UP; 1979.

    Google Scholar 

  49. 49.

    Merrill RM, Lyon JL, Baker RK, Gren LH. Attention deficit hyperactivity disorder and increased risk of injury. Advanced Medical Science. 2009;54:20–6.

    CAS  Google Scholar 

  50. 50.

    Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602.

    PubMed  Article  Google Scholar 

  51. 51.

    World Health Organization. Constitution. 1946/2006.

  52. 52.

    Fulton BD, Scheffler RM, Hinshaw SP, Levine P, Stone S, Brown TT, Modrek S. National Variation of ADHD Diagnostic Prevalence and Medication Use: Health Care Providers and Education Policies. Psychiatr Serv. 2009;60(80).

  53. 53.

    Getahun G, Jacobsen SJ, Fassett MJ, Chen W, Demissie K, Rhoads GG. Recent Trends in Childhood Attention-Deficit/Hyperactivity Disorder. JAMA Pediatr. 2013;167(3):282–8.

    PubMed  Article  Google Scholar 

  54. 54.

    Froehlich TE, Lamphear BP, Epstein JN, Barbesi WJ, Katusic SK, Kahn RS. Prevalence, recognition, and treatment of Attention-Deficit/Hyperactivity Disorder in a national sample of US children. Arch Pediatr Adolesc Med. 2007;161(9):857–64.

    PubMed  Article  Google Scholar 

  55. 55.

    Zima BT, Bussing R, Tang L, Zhang L, Ettner S, Belin TR, et al. Quality of care for childhood attention-deficit/hyperactivity disorder in a managed care Medicaid program. J Am Acad Child Adolesc Psychiatry. 2010;49(12):1225–37.

    PubMed  Google Scholar 

  56. 56.

    Zito JM, Safer DJ, Devadatta S, Gardner JF, Thomas D, Coombes P, et al. Pediatrics. 2008;121(1):e157–163.

    PubMed  Article  Google Scholar 

  57. 57.

    Morgan PL, Staff J, Hillemeier MM, Farkas G, Maczuga S. Racial and Ethnic Disparities in ADHD Diagnosis From Kindergarten to Eighth Grade. Pediatr. 2013; doi: 10.1542/peds.2012-2390

  58. 58.

    Frazier TW, Shattuck PT, Narendorf SC, Cooper BP, Wagner M, Spiznagel EL. Prevalence and correcolates of psychotropic medication use in adolescents with an autism spectrum disorder with and without caregiver-reported attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2011;21:571–9.

    PubMed  Article  Google Scholar 

  59. 59.

    DosReis S, Barksdale CL, Sherman A, Maloney K, Charach A. Stigmatizing experiences of parents of children with a new diagnosis of ADHD. Psychiatr Serv. 2010;61(8):811–6. doi:10.1176/

    PubMed  Article  Google Scholar 

  60. 60.

    Hinshaw SP, Stier A. Stigma as Related to Mental Disorders. Annu Rev Clin Psychol. 2008;4:367–93. doi:10.1146/annurev.clinpsy.4.022007.141245.

    PubMed  Article  Google Scholar 

  61. 61.

    • Mueller AK, Fuermaier ABM, Koerts J, and Tucha L. Stigma in attention deficit hyperactivity disorder. Atten Defic Hyperact Disord. 2012;4(3):101–114. doi:10.1007/s12402-012-0085-3 DOI:10.1007%2Fs12402-012-0085-3. A key, comprehensive meta-analysis of the stigma literature in ADHD.

  62. 62.

    Singh I. Doing their jobs: Mothering with Ritalin in a culture of mother-blame. Soc Sci Med. 2004;59(6):1193–205.

    PubMed  Article  Google Scholar 

  63. 63.

    Koro-Ljungberg M, Bussing R. The management of courtesy stigma in the lives of families with teenagers with ADHD. J Fam Issues. 2009;30:1175–200.

    Article  Google Scholar 

  64. 64.

    Frazzetto G, Keenan S, Singh I. Bambini e le droghe: The case of ADHD and Ritalin in Italy. BioSocieties. 2008;2(4):393–412.

    Article  Google Scholar 

  65. 65.

    O'Driscoll C, Heary C, Hennessy E, McKeague L. Explicit and implicit stigma towards peers with mental health problems in childhood and adolescence. J Child Psychol Psychiatry. 2012;53(10):1054–62. doi:10.1111/j.1469-7610.2012.02580.x.

    PubMed  Article  Google Scholar 

  66. 66.

    Singh I. A disorder of anger and aggression: Children's perspectives on Attention Deficit/Hyperactivity Disorder in the UK. Soc Sci Med. 2011;73:889–96.

    PubMed  Article  Google Scholar 

  67. 67.

    Bröer C, Heerings M. Neurobiology in public and private discourse: the case of adults with ADHD. Sociol Health & Ill. 2013;35(1):49–65.

    Article  Google Scholar 

  68. 68.

    Filipe AM. Through the looking-glass: a critical review of sociology and medicine towards the diagnosis of ADHD. Configurações. 2011;8:73–86.

    Article  Google Scholar 

  69. 69.

    Edwards C, Howlett E. Putting knowledge to trial: ‘ADHD parents’ and the evaluation of alternative therapeutic regimes. Soc Sci Med. 2013;81:34–41.

    PubMed  Article  Google Scholar 

  70. 70.

    Edwards C, Howlett E, Akrich M, Rabeharisoa V. Attention deficit hyperactivity disorder in France and Ireland: parents' groups' scientific and political framing of an unsettled condition. 2012. Accessed 30 May 2013.

  71. 71.

    Ortega F. The Cerebral Subject and the Challenge of Neurodiversity. BioSocieties. 2009;4:425–45.

    Article  Google Scholar 

  72. 72.

    Behague D. Psychiatry and Politics in Pelotas, Brazil: The Equivocal Quality of Conduct Disorder and Related Diagnoses. Med Anthropol Q. 2009;23(4):455–82.

    PubMed  Article  Google Scholar 

  73. 73.

    Wilcox CE, Washburn R, Patel V. Seeking help for attention deficit hyperactivity disorder in developing countries: a study of parental explanatory models in Goa. India Soc Sci Med. 2007;64(8):1600–10.

    Article  Google Scholar 

  74. 74.

    Bruckner TA, Hodgson A, Mahoney CB, Fulton BD, Levine P, Scheffler RM. Health care supply and county-level variation in attention-deficit hyperactivity disorder prescription medications. Pharmacoepidemiol Drug Saf. 2012;21(4):442–9. doi:10.1002/pds.2264.

    PubMed  Article  Google Scholar 

  75. 75.

    Wang PS, Berglund P, Olfson M, Pincus HA. Wells, Kessler RC. Failure and Delay in Initial Treatment Contact After First Onset of Mental Disorders in the National Comorbidity Survey Replication Arch Gen Psychiatry. 2005;62(6):603–13.

    Google Scholar 

  76. 76.

    Schwarz A. Attention Disorder or Not, Pills to Help in School. The New York Times. 9 October 2012.

  77. 77.

    Singh I. Not Robots: Children's perspectives on authenticity, moral agency and stimulant drug treatments. J Med Ethics. 2012. doi:10.1136/medethics-2011-100224.

    PubMed  Google Scholar 

  78. 78.

    Singh I. VOICES Study: Final Report video clip ‘Doctors’:

  79. 79.

    Froehlich T. Strive to diagnose better, not to prescribe less. NY Times; 2012.

  80. 80.

    Green JG, Gruber MJ, Kessler RC, Lin JY, McLaughlin MA, Sampson NA, et al. Diagnostic validity across racial and ethnic groups in the assssment of adolescent DSM-IV disorders. Int J Methods Psychiatr Res. 2012;21(14):311–20.

    PubMed  Article  Google Scholar 

  81. 81.

    • Nigg J. Future directions in ADHD etiology research. J Clin Child Adolesc Psychol. 2012;41(4):524–33. Key overview of the importance of specifying environmental and historical contributions to ADHD etiology.

    PubMed  Article  Google Scholar 

  82. 82.

    Frank A. The Wounded Storyteller: Body, Illness, and Ethics. Chicago: University of Chicago Press; 2010.

    Google Scholar 

  83. 83.

    Kleinman A. Rethinking Psychiatry: from cultural category to personal experience. New York: The Free Press; 1988.

    Google Scholar 

  84. 84.

    Good B. Medicine, Rationality, and Experience: An Anthropological Perspective. Cambridge: Cambridge UP; 1994.

    Google Scholar 

  85. 85.

    Singh I, Kelleher KJ. Brain enhancement in children. In: Farah M, Chatterjee A, editors. Neuroethics in Practice. Oxford, UK: Oxford University Press; 2013.

    Google Scholar 

  86. 86.

    Advokat C. What are the cognitive effects of stimulant medications? Emphasis on adults with attention-deficit/hyperactivity disorder (ADHD). Neuroscience & Biobehav Rev. 2010;34(8):1256–66.

    Article  CAS  Google Scholar 

  87. 87.

    Hall WD, Lucke JC. The enhancement use of neuropharmaceuticals: more scepticism and caution needed. Addiction. 2010;105(12):2041–3.

    PubMed  Article  Google Scholar 

  88. 88.

    Repantis D, Schlattmann P, Laisney O, Heuser I. Modafinil and methylphenidate for neuroenhancement in healthy individuals: a systematic review. Pharmacol Res. 2010;62:187–206.

    PubMed  Article  CAS  Google Scholar 

  89. 89.

    •• Smith MF, Farah MJ. Are prescription stimulants “smart pills”? The epidemiology and cognitive neuroscience of prescription stimulant use by normal healthy individuals. Psychol Bull. 2011;137(5):717–41. The most authoritative overview to date of the scientific literature on cognitive enhancement, and a meta-analysis of US prevalence estimates.

    PubMed  Article  Google Scholar 

  90. 90.

    Rabiner DL, Anastopoulos AD, Costello EJ, Hoyle RH, McCabe SE, Swartzwelder HS. Motives and perceived consequences of nonmedical ADHD medication use by college students are students treating themselves for attention problems? J Atten Disord. 2009;13(3):259–70.

    PubMed  Article  Google Scholar 

  91. 91.

    • Ilieva I, Boland J, Farah MJ. Objective and subjective cognitive enhancing effects of mixed amphetamine salts in healthy people. Neuropharmacology. 2012;64(1):496–505. The first systematic investigation of the important question of how perceptions of cognitive enhancement correlate with objectively measurable outcomes.

    PubMed  Google Scholar 

  92. 92.

    Vrecko S. Just how cognitive is “cognitive enhancement”? On the significance of emotions in university students’ experiences with study drugs. AJOB Neuroscience. 2013;4(1):4–12.

    PubMed  Article  Google Scholar 

  93. 93.

    •• Ragan CI, Bard I, Singh I. What should we do about student use of cognitive enhancers? An analysis of current evidence. Neuropharmacology. 2013;64:588–95. doi:10.1016/j.neuropharm.2012.06.016. Authoritative overview of cross-national prevalence estimates in cognitive enhancement; and an assessment of need for policy intervention.

    PubMed  Article  CAS  Google Scholar 

  94. 94.

    Franke AG, Bonertz C, Christmann M, Huss M, Fellgiebel A, Hildt A, et al. Non-medical use of prescription stimulants and illicit use of stimulants for cognitive enhancement in pupils and students in Germany. Pharmacopsychiatry. 2010;43:1–7.

    Article  Google Scholar 

  95. 95.

    Humle T, Friislund M. ‘Study drugs’ vinder frem på universiteter. In: Information Online. 2010.

  96. 96.

    Hansard. HC Deb 4 June 2013, cc1072W-1073W.

  97. 97.

    Italian National Committee for Bioethics (CNB), Presidency of the Council of Ministers. Neuroscience and Pharmacological Cognitive Enhancement: Bioethical Aspects. 2013.

  98. 98.

    Swanson JM, Wigal T, Volkow ND. Contrast of medical and non-medical use of stimulant drugs: Basis for the distinction, and risk of addicition: Comment on Smith and Farah. Psychol Bull. 2011;137(5):742–8.

    PubMed  Article  Google Scholar 

  99. 99.

    Rimsza ME, Moses KS. Substance abuse on the college campus. Pediatr Clin North Am. 2005;52(1):307–19.

    PubMed  Article  Google Scholar 

  100. 100.

    Friedman RA. The Changing Face of Teenage Drug Abuse - The Trend toward Prescription Drugs. N Engl J Med. 2006;354(14):1448–50.

    PubMed  Article  CAS  Google Scholar 

  101. 101.

    Schwarz A. Attention-Deficit Drugs Face New Campus Rules. The New York Times. 30 April 2013.

  102. 102.

    Kaye S, Darke S. The diversion and misuse of pharmaceutical stimulants: what do we know and why should we care? Addiction. 2012;107(3):467–77.

    PubMed  Article  Google Scholar 

  103. 103.

    Rabiner DL. Stimulant Prescription Cautions: Addressing Misuse. Diversion and Malingering Curr Psychiatry Rep. 2013;15(7):1–8.

    Google Scholar 

  104. 104.

    Talbot M. Can a daily pill really boost your brain power? The Guardian Online. 2009.

  105. 105.

    Poulin C. Medical and nonmedical stimulant use among adolescents: from sanctioned to unsanctioned use. Can Med Assoc J. 2001;1658:1039–44.

    Google Scholar 

  106. 106.

    Garnier-Dykstra LM, Caldeira KM, Vincent KB, O’Grady KE, Arria AM. Nonmedical use of prescription stimulants during college: Four-year trends in exposure opportunity, use, motives, and sources. J Am Coll Health. 2012;60(3):226–34.

    PubMed  Article  Google Scholar 

  107. 107.

    McCabe SE, Teter CJ, Boyd CJ. Medical use, illicit use, and diversion of abusable prescription drugs. J Am Coll Health. 2006;54(5):269–78.

    PubMed  Article  Google Scholar 

  108. 108.

    Peterkin AL, Crone CC, Sheridan MJ, Wise TN. Cognitive performance enhancement: Misuse of self-treatment. J Atten Disord. 2010; doi:10.1177/1087054710365980

  109. 109.

    Bostrom N, Sandberg A. Cognitive enhancement: methods, ethics, regulatory challenges. Sci Eng Ethics. 2009;15(3):311–41.

    PubMed  Article  Google Scholar 

  110. 110.

    Harris J. Enhancing Evolution: The Ethical Case for Making Better People. Princeton University Press; 2007

  111. 111.

    Greely H, Sahakian B, Harris J, Kessler RC, Gazzaniga M, Campbell P, et al. Towards responsible use of cognitive-enhancing drugs by the healthy. Nature. 2008;456(7223):702–5.

    PubMed  Article  CAS  Google Scholar 

  112. 112.

    Larriviere D, Williams MA, Rizzo M, Bonnie RJ. Responding to requests from adult patients for neuroenhancements Guidance of the Ethics. Law and Humanities Committee Neurology. 2009;73(17):1406–12.

    Google Scholar 

  113. 113.

    British Medical Association (BMA). Boosting your Brainpower: Ethical Aspects of Cognitive Enhancement. Report, Nov 2007.

  114. 114.

    CEST. Psychiatric Drugs and Expanded Uses: an Ethical Perspective. 2009.

  115. 115.

    Singh I, Kelleher KJ. Neuroenhancement in young people: proposal for research, policy and clinical management. Am J Bioeth Neurosci. 2010;1(1):3–16.

    Google Scholar 

  116. 116.

    •• Graf WD, Nagel SK, Epstein LG, Miller G, Nass R, Larriviere D. Pediatric neuroenhancement Ethical, legal, social, and neurodevelopmental implications. Neurology. 2013;80(13):1251–60. First public statement by a professional group (American Academy of Neurology) on pediatric cognitive enhancement.

    PubMed  Article  Google Scholar 

  117. 117.

    Sonuga-Barke EJ, Koerting J, Smith E, McCann DS, Thompson M. Early detection and intervention for attention deficit hyperactivity disorder. Expert Review of Neurotherapeutics. 2011;11(4):557–63.

    PubMed  Article  Google Scholar 

  118. 118.

    Singh I, Sinnott-Armstrong W, Savulescu J. (in press). Bioprediction, Biomarkers, and Bad Behavior: Scientific, Legal, and Ethical Challenges. Oxford UP.

  119. 119.

    Singh I, Rose N. Biomarkers in psychiatry: Promises and perils in the real world. Nature. 2009;460(7252):202–7.

    PubMed  Article  CAS  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Ilina Singh, Angela M. Filipe, Imre Bard, Meredith Bergey, and Lauren Baker declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information



Corresponding author

Correspondence to Ilina Singh.

Additional information

This article is part of the Topical Collection on Attention-Deficit Disorder

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Singh, I., Filipe, A.M., Bard, I. et al. Globalization and Cognitive Enhancement: Emerging Social and Ethical Challenges for ADHD Clinicians. Curr Psychiatry Rep 15, 385 (2013).

Download citation


  • Attention deficit hyperactivity disorder
  • ADHD
  • Stimulants
  • Ritalin
  • Adderall
  • Globalization
  • Diagnosis
  • Treatment
  • Medicalization
  • Prevalence
  • Global mental health
  • Cognitive enhancement
  • Culture
  • Ecology
  • Hyperactivity
  • International
  • Addiction
  • Diversion
  • Diagnostic criteria
  • Clinical practice
  • Ethics
  • Psychiatry