Neuroethics

, Volume 10, Issue 3, pp 419–430 | Cite as

Personal Autonomy and Authenticity: Adolescents’ Discretionary Use of Methylphenidate

Original Paper

Abstract

Minors with attention-deficit-hyperactivity disorders (ADHD) are liable to use pharmacological treatment against their will and may find their authentic “I” modified. Thus, their use is widely criticized. In this study, the effect of ADHD drugs on adolescents’ personal experience is examined. The goal is to understand how psychological changes that young people experience when they take these medications interrelate with their attitude toward being medicated. Methylphenidate is the most common pharmacological treatment for ADHD. We look into the change that Israeli adolescents undergo when they use it; their experience in controlling the change, and their assessment of the meaning of the change for their lives. Thirty-eight adolescents participated in semi-structured interviews. The findings, analyzed using grounded theory, show that methylphenidate affects the participants’ demeanor, mood, and even preferences. The participants, aware of these effects, apply discretion in taking methylphenidate and thus influence their traits and their willingness to engage in various activities. When needing to prepare for a matriculation exam, for example, they take methylphenidate; when they need to be creative or sociable, they avoid it and enjoy what they consider the advantages of ADHD, such as creativity and spontaneity. As discretionary users, they shape their life stories in a way that makes them more meaningful and diverse, better tailored to their social surroundings, and more useful in maintaining personal autonomy in the course of pharmacological treatment of ADHD.

Keywords

methylphenidate (Ritalin) ADHD discretion personal autonomy authenticity psychopharmacology 

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder that begins in childhood and lasts into adulthood [1]. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), defines ADHD as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, presents in two or more settings (e.g., at home, school, or work; with friends or relatives; and/or in other activities), and directly degrades social, academic, or occupational functioning [1]. ADHD is treated in educational, psychological, nutritional and/or pharmacological ways, of which the last-mentioned is the most common [2]. Such treatment, however, is debated due to concern that it may change the user’s very essence [3, 4, 5].

As studies on the effect of ADHD medications on users’ experience differ in their findings, this experience is not clear, necessitating further discussion [6]. Researchers also dispute the extent of the impact of ADHD medications on users’ authenticity. Adolescents’ perception of the extent of their control over the use of these medications remains a ‘black box’ in research. Such control of treatment for ADHD is critical in understanding the ethicity of recommending these kinds of medications. Therefore, in our decisions to subject children and adolescents to pharmacotherapy, we should be careful to preserve their personal autonomy and authenticity [7].

Methylphenidate, best known by its trade name, Ritalin, is the most common pharmacological treatment for ADHD. Its enhancing effects on the functioning of adolescents with ADHD are well documented [8]. This study tracks the importance of the experiencing of methylphenidate use for the way Israeli adolescents choose to take it and their sense of control over its use. Thus, the study may influence our understanding of the ethics of “putting kids on Ritalin.”

Effect of Medications on Adolescents with ADHD

ADHD impairs one’s ability to concentrate and pay attention, possibly causing impulsiveness and hyperactivity and often accompanied by learning and emotional disorders. Unsurprisingly, then, ADHD marches in tandem with behavioral and learning difficulties. In adolescence, these hardships may combine with ordinary adolescent vicissitudes to diminish functioning in and away from school [8, 9].

Most studies on what adolescents with ADHD think about the disorder show that many perceive it negatively, believing that it impairs their functioning and fearing its stigma [10, 11]. Stimulants, including methylphenidate, improve these adolescents’ functioning immensely by attenuating impulsiveness and hyperactivity and enhancing attention [8, 9], thereby bettering academic comportment and behavior in and away from school [12]. Those who take methylphenidate, for example, become somewhat subdued and, consequently, cause little harm to others and exhibit improved social capacity [8, 9].

Qualitative studies on methylphenidate use among young people with ADHD as they themselves experience it reach similar conclusions. Most youngsters who participate in such research credit the drug for improving their scholastic, behavioral, and social conduct [5, 11, 13, 14, 15]. Some, however, attest that methylphenidate does not help them and impairs their social conduct [11]. Additionally, methylphenidate, as a stimulant, has side-effects including abdominal pain, headache, delayed growth, eating disorders, and diverse psychological disorders such as depression, psychosis, nervousness, oversubdued personality, and changes in behavioral characteristics that determine authenticity [8, 9, 11, 17]. Their severity as well as their very presentation depend on the type of medication, its dose, and personal sensitivity. These effects, particularly the psychological ones, may change users’ essence and, thus, encourage adolescents to desist from using the drug [6]. Thus, methylphenidate must be matched with its users very cautiously [16].

Effect of Methylphenidate on Users’ Authenticity

The lexeme “authenticity” denotes the true essence of a person, action, or object [18, 19]. The word “authentic” is fraught with power, suggesting something’s being “of undisputed origin or authorship” or, less emphatically, “faithful to an original” or a “reliable, accurate representation” [19]. People consider authenticity a moral virtue because their having it means they are true to themselves and their nature as people [20]. Accordingly, many studies discuss effects of medications, specifically those for ADHD, on authenticity [15, 20, 21, 22, 23].

To determine whether personal authenticity is safeguarded during medical intervention, Newson and Ashcroft believe that philosophers’ definitions of authenticity should be combed for helpful insights. Philosophers’ outlooks on the essence of authenticity, however, are not uniform (18, 19). For many existentialists, an authentic person is one who can and does actualize h/her autonomy and assumes responsibility for h/her decisions. Sartre, for one, stresses the authentic individual’s freedom and awareness of it [7, 18]. From this perspective, one may invoke self-aware personal freedom as a test of the ethicity of pharmacological treatment of ADHD [7]. Antipodally, contemporary philosophers such as Guignon [24] and Varga [25] also trace true authenticity to individuals’ interaction with society, meaning that it also expresses their commitment to values transcending the personal [19]. Guignon, for example, suggests, “Authenticity then involves reflectively discerning what is really worth pursuing in the social context in which the agent is situated” [24: 155]. Therefore, devotees of his approach may add the effect of pharmaceuticals on commitment to social values when assessing of the impact of medications on an individual.

Another gauge of the authenticity and, in turn, the ethicity of medical treatment is the extent of happiness and meaning that the treatment imparts to one’s life [7]. Relying on Nietzsche and Foucault, Newson and Ashcroft [7: 254] define authentic individuals as authors of their own lives considered as narratives and evaluated through an aesthetics of the self. In this line of thought, third parties concerned with enhancement technologies should be concerned in two ways: first, to the extent that such technologies objectively enhance individuals’ abilities to live full and well integrated lives, and second, to the extent that how this is achieved matters to the individual.

Singh [15] examines the meaning of treatment with psychiatric drugs for users’ authenticity on the basis of outlooks of current thinkers, foremost Neil Levy [26], who proposes testing authenticity via two competing but complementary apprehensions: “self-discovery” and “self-creation.” In the former, authenticity is an inner truth wholly unrelated to the individual’s actions and wishes; it entails self-revelation of the inner essence. Self-creation proposes choice and will to change as a litmus test of authenticity. Erler and Hope, relying on DeGrazia [27], add a third approach: the will to change does not suffice to effect change; true self-creational authenticity also requires the user of a pharmaceutical to reflect on the essence of the change [20].

One may also test the effect of medications on authenticity by combining elements of the foregoing approaches, thereby regarding authenticity as the product of “self-discovery” and of “self-creation” together [15, 20].

The Self-Perceived Effect of Psychiatric Medications on Authenticity

Even if the use of a medication does nothing to impair the user’s authenticity, it remains a moral and practical imperative to respect, as far as possible, the authenticity of a person who uses medications to preserve h/her self-defined authentic essence [20, 21]. To achieve this respect, we need to identify users’ attitudes toward the effects of medications on their authenticity.

Some users of psychiatric medications [20], including those indicated for ADHD [23], believe that they help them maintain authenticity by revealing their true healthy essence. Others accuse the drugs of impairing authenticity because they see their disorder as their true essence or an inseparable part of it [20, 23]. Yet other patients fault the medication itself for compromising their authenticity. Finally, some think it pointless to discuss the question because it has nothing to do with their decision to take the medication [20].

Methylphenidate and Personal Autonomy

The research debate about the effect of medications on the personal autonomy of individuals with ADHD strongly resembles that concerning the impact of pharmaceuticals on authenticity.

A review of researchers’ views on the effect of ADHD medications yields conflicting results. Some claim that absent medicinal treatment, individuals with ADHD may lack the emotional and cognitive ability, or the self-control, that is needed to exercise personal autonomy [5, 15, 28, 29]. A medication such as methylphenidate, which acts on the brain, may enhance behavioral control. If so, a decision to medicate for ADHD may enhance patients’ ability to exercise their autonomy [29]. The same may be so if users are aware of its effects, act in view of their understanding of the treatment, and are satisfied with the outcome [30]. Various studies agree that most users do find an improvement in functioning due to pharmacotherapy, crediting it for letting them act in ways that surmount the limits that their ADHD would otherwise impose [14, 15].

Conversely, the very decision to medicate may be the product of an aggressive system [22, 31, 32] that aims, as Foucault contends in reference to psychiatry, “to discipline and control patients” [32: 278]. Comstock, following Foucault, claims that the educational-medical establishment pressures children with ADHD and their parents to medicate in order to regiment and control children more easily by stripping them of their initial authenticity [3]. Studies about the feelings of young people who take methylphenidate report that they do feel pressure to medicate and forgo some of their original authenticity under its influence. Some even stop taking methylphenidate for this reason [13, 17].

In this study, we examine the effect of methylphenidate on adolescents’ personal experience in order to understand how the psychological changes that these youngsters undergo as they use the medication combine with their attitude toward using it. Thus, we ask what changes these young people go through; how they experience the extent of their control over the change; and how they assess the meaning of this change, and their decision to medicate, for their lives.

Method

Sampling

This study uses purposive sampling [33]. To do so, we employed seven research assistants with personal experience in teaching students with ADHD and recruited interviewees who were also acquainted with such students. All seven assistants had more than a year of experience in school, received training in qualitative research from the principal researcher, and took thorough training in conducting semi-structured interviews. To increase diversity and, in turn, credibility [33], they selected participants whom they personally knew but who lived in various parts of Israel.

Participating were adolescents aged 15–19 who were diagnosed with ADHD, were taking methylphenidate regularly or intermittently, or took it previously for a period of more than a year. The interviews were held in May 2014–July 2015.

The sample thus recruited comprised twenty girls and eighteen boys who were seventeen years old on average. All were Jewish; for technical reasons related to drawbacks in the authors’ fluency in Arabic and access to the Arab population, Arabs were not selected. The participants were parsed by the schools that they attended: State-secular, State-religious, and haredi (ultra-Orthodox—five participants). We stopped interviewing after feeling that saturation had been achieved.

Procedures and Tools

After the participants and their parents completed consent forms, the interviewers asked them to provide personal demographic information. The interviews were devised by the interviewers under instructions from the authors as to the main topics. First, the participants’ attitude toward methylphenidate and toward the environment of its use (peers, teachers, family) was examined. Each interviewer was asked to draft twenty items for the principal researcher’s approval. In constructing the items, s/he was to focus on the following:
  1. 1.

    Perception of the short-term effect of methylphenidate, effects on feelings and emotions, ability to perform tasks, creativity, sociability, and authenticity.

     
  2. 2.

    Perception of the long-term effect of methylphenidate.

     
  3. 3.

    Attitudes of others (family, friends, teachers) toward the participant and toward methylphenidate use.

     
  4. 4.

    How the participant perceives the meaning of ADHD.

     
  5. 5.

    Strategies by which the participant chooses to medicate and how these strategies changed over the years.

     

As the interviews were semi-structured, the items thus produced served the interview merely as initial foundations; various items changed during the interview and usually more items were asked.

Data Analysis

Once recorded and transcribed, the interviews were examined on the basis of grounded theory [34]. In Stage 1, open coding analysis yielded subject headings that were assigned to phrases that exposed the participants’ perceptions.

Next, axial coding allowed the authors to identify key categories and compare participants’ perspectives in order to establish similarities and dissimilarities among the participants. The resulting categorization captured each participant’s perceptions of the implications of the long- and short-term effects of methylphenidate use, as well as processes that resulted in costs and benefits of methylphenidate use.

In Stage 3, selective coding demonstrated that the solidification of an attitude toward methylphenidate use emerged as the leading category. This category elicited a theory: the participants adopted a mixed approach to their original personality and toward ADHD. Under certain circumstances, they found it advantageous to use methylphenidate; under others, they considered it a drawback. Either way, they viewed the medication as a tool that defeats both the advantages and the disadvantages of ADHD. Therefore, they chose to use it selectivity, enjoying the advantages of ADHD under circumstances that made this desirable and avoiding its drawbacks when circumstances were different. Thus, knowingly and deliberately, they broadened their options in life.

Rigor

Both researchers are well versed in qualitative analysis and in the research topic. One has immense experience in qualitative and psychiatric research, including research on ADHD (Author 1, 2012, 2013). The other is a teacher who has done practical field experience with pupils with ADHD.

In all three stages of the analysis (described above), the researchers treated all interviews separately (“analyst triangulation” [35]), compared their findings, and resolved nearly all of their disagreements by consensus. The remaining few points at issue were resolved by a third senior researcher who has experience in qualitative research on coping with ADHD among teachers, among other strengths. Our triangulation of data sources also included re-examining attitudes toward the interviewees’ perceptions at a time lag [35]. In these complementary interviews, fifteen participants displayed consistency in their attitudes when asked to re-explain the psychological changes that they experienced. To make the participants’ reportage more credible, diversity among them in terms of gender, types of schools (secular, religious, ultra-Orthodox), and parts of the country was assured [35]. The use of multiple participants and interviewers also made the information gathered more reliable [33, 35].

Ethicity

The college’s Institutional Review Board approved the performance of the study. All participants and (for those under age eighteen) their parents signed a form indicating willing consent to participate. They were assured that all their particulars would be kept in confidence and that the study would be used for teaching and research only, as in fact was done.

Findings

Perceived Effect of Methylphenidate on Participants’ Capabilities

Most participants indicated that methylphenidate enhanced their ability to focus on one topic but left them less able to skip among multiple topics. For this reason, it affected behaviors associated with learning, sociability, and creativity. For example, it helped them to focus on material taught in class and thus to learn better. Examples follow: “Uh … first of all, just in the clearest way you’re much more focused and less distracted by other things. Uh … like it just enables you to listen and learn in class” (A.K.).

It’s a kind of freedom. Because when I’m with Ritalin it’s much easier to concentrate. I tried to do homework without it and I found myself doing three different subjects, totally different, say, chemistry, history, and arithmetic together. Book after book after book and I’m writing answers. I, like, do five questions in math, close [the book] and move on to chemistry, close [the book] and move on to history and back to math. I didn’t manage to sit with one material, finish it, and continue. It was really frustrating, switching all the time…. The materials were so different, one had absolutely nothing to do with the other and the other (M.).

A few participants claimed that they had been given a class assignment that required them to hop from topic to topic and avoid fixating on only one. Here, they thought methylphenidate might be harmful.

According to most participants, excessive focus impaired capabilities that they needed for successful social interaction. Two examples follow: “[Methylphenidate] makes it much easier for me to concentrate and I don’t want to concentrate with girlfriends; I want to talk about all the nonsense that we have to talk about” (M.) “There are things. Without Ritalin, I can concentrate on 15,000 things at once (because I’ve got ADHD) but not on one thing, and when I’m on Ritalin I can focus on one thing and not on 15,000. Then I’m with lots of girlfriends and I’m like, wait a second, wait a second, what … like … I don’t know how to behave that way” (S.).

Only a few participants absolved methylphenidate of any effect on their social capabilities. T., for example, said that he had heard from friends that methylphenidate hurt their social behavior; however, it did not harm him even as it helped him to study. Several participants believed that methylphenidate might even help their social activity by preventing pernicious impulsive behavior. N., for example, explained that not taking methylphenidate leaves her “without brakes” and liable to offend those around her. Methylphenidate, she added, makes her much more “thoughtful and cautious” and keeps her from offending her friends.

According to most participants, focusing on one topic under the influence of methylphenidate disrupts the natural creativity that they have as individuals with ADHD. Examples follow:

I think my creativity is dead […] because [with methylphenidate] I’m so focused on what we have to do, with things that I can’t think about another way to do something with them. Like, if they ask me to think about something I’ll think about something but it really focuses me on what I have to do, I shouldn’t swerve away from anything; they told me to read the book and I’ll read the book. I won’t start flipping through the pages, I won’t skip over the abstract, I won’t mess around with little things on the pages [M.].

[Methylphenidate] doesn’t make you too creative. Say if I had something in the afternoon (a youth-movement activity) on a day when I also have math, I wouldn’t agree to take it because you have to … Some activity or something at the [movement] branch as a counselor, if I take it then I say I can’t plan it all day because my head won’t be in it and I won’t manage to think […] (without methylphenidate). It’s all one big salad and within this salad the ideas come and you don’t have …. It’s a salad that flies around in your head and it’s not in your head when you’re at a concert and there’s nothing flying in your head (O.).

Choice and Personal Autonomy

Change in preferences

Most participants opined that methylphenidate changed their preferences. They felt that it diminished their desire to engage in physical activity, social interaction in particular, and amplified their wish to sit still and learn. Examples follow:

“[Methylphenidate] helps me set priorities. With and without Ritalin, I want the same things. But without it, I’ll put the wrong thing first (friends before studies). Then my schedule gets messed up (because I don’t do my school assignments)” (M.). “Sometimes it [methylphenidate] cuts me off socially. [With methylphenidate] I don’t want to be with friends, don’t like people” (S.).

On a day when I take Ritalin I’m happy all of a sudden that I can shush kids who talk in class. Usually it’s not pleasant for me because I talk all through class. Suddenly when I take Ritalin I shut people up. So it really changes me; all of a sudden I concentrate on anything; it even makes me want to study (R.).

You don’t have to connect under Ritalin. I just … < laughs>. Even if I sit with a group of friends, I just sit there. I remember it, I’m just sitting there and staring at them, what do you want out of life? […] Sometimes I feel I don’t want to do things even though I’d want to do them [without methylphenidate] [...]. It changes your regular desire [O.].

Evidently, then, the participants believe that methylphenidate affects not only their behavior and capabilities (see previous section) but also their will.

Effects on personal autonomy

Many participants reported loss of personal autonomy, as in the following examples: “If I take the pill now, it doesn’t matter how much I want to do something [when not under the influence of methylphenidate]. It’s like, ‘Hey, why are you, the whole gang, going out for pizza now?’” (L.). “Very concentrated and very focused and I’ve got no spare time, no spare time to take a little broader look and calm down. I don’t feel like it. I just have to do what I have to do—study or whatever I have to do, and I’m not free to breathe” (Y). “I felt it hypnotized me, hypnotized me. .. as though I know, try to get out of it but can’t” (N.). “I did things I didn’t want to do [under the influence of methylphenidate]. I’d sit all day and study and I’d sit on the bed or at the computer or on the cellphone all day instead of going out. Suddenly the effect wears off at midnight; tomorrow there’s school, who feels like going out? You go out for five minutes. I had no escape” (M.A.). “After you take it, it’s like the brain slips into a slow mode. It wants to sit on the sidelines. It puts quiet into the surroundings. You don’t want to walk; you want to sit [and study]. It, like, grabs you. You know what, this pill, like, knocks on your head, as they say, rams your head against the wall” (H.). “But say you had a big field in front of you and suddenly everything contracts into a little path and you have to walk down it. You can’t choose to turn anywhere, there’s one way, finish it and you can go on […]” (M.).

Most participants were aware of the change that took place in their personal autonomy when they were medicated. Therefore, when asked if it amazed them, they replied: I was amazed at first but then I realized that that’s how it works. If I push myself, I can overcome these effects. I managed to overcome the don’t-want-to feeling when I had to” (A.). “The first few times it happened [methylphenidate diminished my desire for social interaction], I was really amazed but it went away fast. Because I understood that with Ritalin I’m really different from what I am without it” (Y.).

Totally [amazed]. The moment I’m with Ritalin and all my friends go out, I stay home. Because I don’t feel like doing anything. And even though I know inside that I want to go out with my friends, because of the Ritalin I won’t go because I haven’t got the strength for it. It’s not fatigue, you’re out of it. It’s not that you don’t have strength; you’re not tired but you don’t have strength. I don’t want to do anything. It’s what I want. And I’m totally amazed about myself, really (L.).

Several participants who reported a change in personal autonomy claimed that they sense the change and its effects on their preferences only when the effect of the medication wears off.

It [the effect of methylphenidate] is surprising because I get excited about going out with friends, never mind what time it is. And it’s embarrassing [to not feel like going out with friends]. And I’m amazed about myself. The moment you don’t know what’s happening to you, it’s like you’re drugged. Only after Ritalin do you become aware of it (M.A.).

Sensations and Emotions

Most participants stated that methylphenidate sometimes detracts from their joie de vivre. They seemed to find enthusiasm hard to marshal. Some reported feeling morose. Examples follow: “It’s not … Look, [without methylphenidate] I was a happy-go-lucky girl. I’d wake up and go crazy. Once I took Ritalin, it was like I suddenly plunged” (Y.). “I felt … like they drained my energies, drained my … this happiness that I used to have. It’s not that I was sad but this, like, happiness went away. Sometimes you can’t express emotion” [N.]. “When I take [methylphenidate] I’m all by myself. There’s nothing. I know in advance that the day I take [it] I’ll spend the whole day sitting on the sidelines. I prepare myself so if someone asks me I’ll say that I didn’t sleep well last night, that I’m tired, that I don’t feel good” (H.). “Sometimes in recess, say, I just can’t […]. I sit there; I don’t know how to have breakfast without something to get excited about …. I just listen and don’t respond, a kind of apathy, less, uh … enthused about things” (A.G.). “I’m much more indifferent to things, like nothing moves me in particular. Uh, like apathetic. I don’t show any … like a poker face. You don’t show any sadness, happiness, anger” (O.). “When I’m on Ritalin I’m, like, apathetic, and it’s not depression; it’s like less-happy” (G.). “It would ruin the … as if … the experience because it also affected me in the afternoon, it affected me all day long, I wouldn’t have stayed alive these two years if I took it every day” (O.). “[Under the influence of methylphenidate] you cry over nothing and you’re sullen, passive; you see the world as something black, things like that” (R.). “When I take the pill I suffer; I feel a sense of depression, less happy, not having fun with friends. When I take the pill, [my friends] laugh at me that I’m sad and tired all the time and don’t behave the same” (D.).

Several participants reported experiencing no mood change under the influence of methylphenidate. “Others say this, like, embarrassment makes you really down … I don’t feel it. I feel I’m a living, happy person with or without. Even on days when I’m not alive and happy it has nothing to do with Ritalin” (N.).

Change in Authenticity

Due to the methylphenidate-influenced changes described above, most participants felt that the medication transforms their persona. Examples follow: “Yes, I still have energies but [with methylphenidate] I’m less bouncy and happy. Yes, it’s not me” (H.). “I’m not the same G. When you’re with Ritalin, I’m, like, apathetic; it’s not depression, it’s a kind of less-happiness” (G.). “I don’t talk with people as well. Because it’s less myself. It extinguishes parts of me. It makes me concentrate more, but looking at it altogether, it’s harmful” (O.E.). “Because I’m hyperactive, it creates a situation where I’m on it and I’m not on it. I’m a totally different person” (O.) “There’s before Ritalin, there’s after Ritalin, but there’s with Ritalin. It’s kind of different” (S.H.).

Because with Ritalin it’s not who I am. Period. There’s nothing more to say. With Ritalin, it’s not who I am. … Ritalin changes you; Ritalin doesn’t make you who you are, it … takes your personality and says—now you’re a serious person, you’re concentrating, and that’s last kind of guy I am. I’m not serious at all…. But, uh, it changes your personality on you (M.A.).

“It gets me off of Valium; it’s like someone turns my dial; it’s what I feel. Look, it’s like I said before: I feel other; sure I’m me but not really me. It’s hard for me to explain; I behave differently when I take [it] from when I’m without the pill” [A.]

Several participants felt that their authenticity had not changed or that their true authenticity is the one enabled by methylphenidate. N., For example, once believed that methylphenidate changes her identity but appears to have reasoned, at the time of the interview, that even though she changes under the influence of the medication, her real identity has not been impaired.

Yes, I wanted to experience; I wanted; I felt Ritalin wasn’t letting me [experience] or the person who gave me Ritalin didn’t want; didn’t want the real me [description of the onset of adolescence]: I felt the real me [being harmed] and I objected to taking these pills because of it. There were times when I didn’t want to, but when I grew up [at age seventeen] and got to know myself, I realized that right now this is what is helping me, it’s not the only thing, but it’s helping me. Again, I don’t know how to say [that I have a different identity when I take methylphenidate] because I’ve been taking Ritalin from a very early age. But I don’t think I’m somebody else; I think I’m me without the impulsiveness.

S.N., a methylphenidate user since early childhood, explained that she is “the right S.N.” precisely when she is on the medication. “In the evening, when the Ritalin wears off, I go crazy; I start to be disturbed [and in my real nature I’m not disturbed].”

Discretionary Use of Methylphenidate

By the time they reached adolescence, almost all the participants had developed autonomous approaches toward the use of methylphenidate. Most took it for study purposes and desisted when study was either undemanding or unimportant. The following examples demonstrate how this discretionary self-medication came about.

Switching from Steady Use to Selective and Controlled Use

M. has been taking methylphenidate since her early primary-school years. When she reached adolescence, she felt that it was impairing her authenticity and for this reason stopped taking it when she finished seventh grade. Then noticing that her moratorium was causing her grades to fall, she went back to methylphenidate: “I was a stupid kid. I can’t take risks when it comes to my matriculation. Least of all that way.”

M. celebrated both manifestations of her authenticity. She thought well of her adult version of authenticity, which she put on like a piece of clothing by taking methylphenidate. Nevertheless, she also considered ADHD part of her authenticity and therefore wished to preserve it:

Interviewer. “If you could ask for a wish to be granted—not to be ADHD—would you make this wish or not, and why?”

M.: “I wouldn’t ask because ADHD is very special for me. I don’t know if it’s… It’s a kind of worldview. I can’t give it up, the way I really think. I enjoyed the whole mess that sits in my thinking. It’s fun when things fly away fast. It’s an other-worldly way of thinking, a very special way of thinking, and I don’t want to let it go. Yeah, in class it makes things very hard. It puts lots of other things into my head and it lowers my concentration on the teacher at that moment, but I can't give up the way that I think.”

Interviewer: “So doesn’t it bother you that Ritalin comes along and neutralizes this, it’s not you?”

M.: “It neutralizes it for limited time when necessary [M. uses methylphenidate for study purposes only.] This doesn’t bother me.”

Interviewer: “Do you gain more from ADHD than you lose?”

M.: “It’s part of my personality. I can’t just walk away from it all of a sudden.”

Thus, M. enjoys being able to control both identities—the identity influenced by the medication, which gives her, in her own words, “maturity, seriousness, and studiousness,” and her flippant unmedicated identity, which, as she previously described (see above) gives her superior social interaction.

L. took methylphenidate continuously from fourth to eighth grade on his mother’s instructions. His achievements and behavior improved. In adolescence, he assumed responsibility for his medication. If he had been asked about methylphenidate when he was a boy, he claims, he would have sung its praises. After reaching adolescence, however, he realized that he loved his ADHD because this “gift” (as he put it) made him creative and energetic. He also felt that the medication diminished his social advantages and abilities as a person with ADHD; therefore, he avoided the medication wherever possible but made exceptions ahead of important exams.

When asked, “Why do you take Ritalin?” L. replied,

I reached the conclusion that, hey, I can’t stand the matriculation exams, I don’t have the strength for matriculation exams, but it’s important, and yes, I have to start doing something about it, and I had a hard time last year [when I hardly used the medication]. So let’s try it. And it really did help me with my studies.

Thus, N. recognizes the personal utility of Ritalin and exercises personal autonomy in taking or not taking it even though he would rather feel like a person with ADHD.

Beginning to Take Methylphenidate Only at the Onset of Adolescence

S.H. is a gifted student who initially found high grades easy to come by. In high school, however, she realized that due to difficulty in remaining seated and attending to her studies she had become a mediocre student. After seeking an evaluation (with her parents’ consent) and emerging with an ADHD diagnosis, she learned by trial and error to tailor her use of methylphenidate to her needs. She explained that she enjoys the flightiness that her ADHD gives her. “I love my life [as a person with ADHD] without Ritalin because [having ADHD] means pleasant surprises, surprises like that.” Like most participants, she sees ADHD as an advantage as well as a disorder: “It’s totally, it’s the best gift I could ever get. I feel that it’s what makes me me.” S.H., however, is also driven to achieve. Appreciating the utility she gains by instrumentalizing the medication, she touts her discretionary approach toward its use:

[Methylphenidate] added to my sense of confidence. I know that I can concentrate on everything and I can also be creative if I feel like [going off the medication]. I can get into something in many different ways. With Ritalin, I know that I can explore it in depth and know what it says, and without Ritalin I know that I can also approach everything around me and be creative.

If so, in S.H.’s judgment, methylphenidate enriched her life.

O. was diagnosed with ADHD in tenth grade but long refused to take methylphenidate. In eleventh grade, however, realizing that her unrestrained behavior was causing her difficulties and that methylphenidate would improve her scholastic abilities, she yielded and began to use the medication. She explains:

This organized [use of methylphenidate when it’s needed for study purposes] is convenient even though it always makes me feel a little not-you. I tell you … don’t be too problematic about this. It’s good for you [because as an ADHD kid you study better on medication and don’t get entangled with the teachers]. On the other hand, it’s not really me. You get it?

O. says that she stops taking methylphenidate whenever an important social activity looms, e.g., something involving her youth movement, in which she serves as a counselor. In this manner she uses the drug intelligently “to attain both scholastic and social goals.”

Diagnosis against Families’ Will

Some participants had been evaluated against their families’ will. N., for example, was not evaluated in childhood due to parental opposition. When she reached tenth grade, however, she stood up for herself and demanded an evaluation, in the aftermath of which she went on methylphenidate. The medication improved her scholastic success dramatically:

With Ritalin, I function great in class. I’m totally into the study material and don’t busy myself walking out of class to get some air. I feel fully focused; the teacher explains something and I feel that I absorb everything and work it through and even remember the material for tests.

However, the medication impaired her previous cheerful behavior. “My brothers sometimes gripe that I’m not as fun as I used to be and my parents are always aware of my mood shifts and tell me that I don’t have to take [methylphenidate] and that they’d rather I be happy with grades of 70 and not all withdrawn into myself with grades of 95–100.”

Despite her family’s opposition, N. continued to self-medicate. She explains:

When I think about my ultimate purpose, to pass the matriculation exams and finally get a good matriculation certificate, it gives me the strength to continue taking that pill every morning. Every test where I get a good score, mostly 95 to 100, gives me encouragement and proves the positive effects of the medicine and [reminds me] why I take it.

N. also makes sure to skip her dose of methylphenidate on weekends and school vacations. This, she reports, allows her to maintain her social relations and “enjoy both worlds, school and the social thing.”

Thus, most participants subject their use of methylphenidate to discretion and personal autonomy in order to profit from both the spontaneity and joie de vivre that they find in ADHD and the seriousness and scholastic success that methylphenidate gives them.

Quitting Methylphenidate

A few participants stopped using methylphenidate altogether. M.A., For example, chose this route because, he says, he really enjoys having ADHD. Methylphenidate, to his mind, severely impaired his authenticity. The following exchange demonstrates his approach:

Interviewer: “If you could ask for a wish to be granted—not to be ADHD—would you make this wish or not, and why?”

M.A: “I wouldn’t make it.”

Interviewer: “Why not?”

M.A. “It’s me, I’m M.A. and I’ve got ADHD. Be real with yourself.”

Interviewer: “Has ADHD caused you any harm?”

M.A. “Yes, but that’s M.A. Whatever you call it, I’m M.A.”

Interviewer: “What do you like about [ADHD]?”

M.A. “No ... I don’t know. It’s M.A. I’m goofy. I do whatever strikes me. When I was a little kid, my parents tell me stories that I’d go to the bathroom and just pee in the bushes. Just so. An attention and concentration disorder, me sitting in class on your lap, on the desk. It’s very, that’s what I am, perverse. Maybe when I was little you’d tell me you’re not attentive and focused, I’d say OK, but now? No. This is M.A. I want to be who I am.”

Discussion

Authenticity Changes

Medical convention sees ADHD as a problem that should be solved in order to control the individual’s challenging behavior and correct his or her functioning. To this end, pharmacology may be used despite its unfortunate undesired effects. It stands to reason, then, that if we mitigate the adverse effects of methylphenidate, its users’ adherence will improve [6]. The participants in this study accept this reasoning only in part, if at all. Most see ADHD not as a disorder but as a trait that has advantages and drawbacks. Similarly, they perceive most effects of methylphenidate not as side effects but as the essence of what the medicine does, helping under certain circumstances and hindering under others. For example, methylphenidate attenuates advantages of ADHD such as spontaneity and disadvantages of the disorder such as study-subverting difficulties in focusing. Thus, by instrumentalizing methylphenidate, the participants manipulate their traits as required and find ways to attain their goals and enhance the self-defined meaning of their lives.

This study reveals far-reaching changes in participants’ behavior, capabilities, moods, and perception of personal autonomy under the influence of methylphenidate. Previous studies indicate similarly triggered behavioral changes [6]. Sometimes, however, these descriptions are slightly different. Some studies, for example, report an improvement in social capacity, of all things [6]. The differences between some of these studies and the findings reported above, which show impairment to social capabilities and personal autonomy under the influence of methylphenidate, may have been found because we examined elements of the feelings of adolescents and not of children. Another possible source of the differences is that several previous studies focus on goings-on in school and not on interviewees whose social world is situated mainly away from school, a place that demands less concentration and more spontaneity and effervescence.

Very few ADHD studies yield evidence of changes in preferences and personal autonomy, let alone awareness of these changes [17]. This study fills the gap by illuminating changes in the preferences of the personality when methylphenidate is used. At first glance, the reported far-reaching changes in participants’ traits, particularly the impairment of personal autonomy, subvert the underlying ethics of pharmacotherapy [7]. The findings, however, show that the participants are aware of the effects of methylphenidate and submit to them voluntarily. Therefore, the changes that occur in their autonomy because they take the medication may be seen as an expression of previous exercise of their personal autonomy. By making intelligent use of methylphenidate, they construct their image and equip it with a narrative that allows them to live more meaningful and varied lives. Their remarks, in most cases, make it clear that they value scholastic success immensely and invest thought in ways of achieving it. Therefore, in accordance with the view put forward there, of acceptance of pharmacological treatment as an act of authenticity that highlights authentic moral characteristics, the participants’ use of methylphenidate should not be deemed inauthentic [7].

The attitude of most participants, however, should be viewed not solely as one built on self-creation but rather as a hybrid that retains indicators of self-discovery. They found in their personalities aspects to which they adhered, returning to them and refraining from self-medication when they find medication unsuitable to their autonomous wishes.

An authentic life, modern philosophers say, is one that is both meaningful to the individual and anchored in the society in which s/he acts [19]. Accordingly, intelligent use of methylphenidate allows most of the young people interviewed in our study to realize their abilities and lead lives that are both socially and scholastically correct in their eyes.

Golomb [18], summarizing his book on authenticity, likens the authentic individual to an orchestral musician who performs without a conductor. If we accept Golomb’s simile, we find that the participants’ control of their medication allows them to become better players. Methylphenidate lets them align their playing with that of different orchestras—different milieux—while being the true conductors of their musicianship.

Conclusion

The young participants understand the effect of methylphenidate on their traits. Even if we reject the importance of safeguarding the authenticity of medication users, we should be mindful of the users’ wish to preserve their authenticity. The findings show that the changes the participants underwent satisfied their wishes.

If we wish to keep our intervention ethical, we should leave responsibility for taking ADHD medication in the hands of those who have the disorder—but only after ascertaining that they understand the implications both of ADHD and of forgoing this treatment.

Notes

Compliance with ethical standards

Conflict of interest

There are no conflicts of interest in relation to the submitted manuscript.

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Copyright information

© Springer Science+Business Media B.V. 2017

Authors and Affiliations

  1. 1.School for Advance Degrees, Achva Academic CollegeBeer-Tuvia, Arugot , MP ShikmimIsrael
  2. 2.Hemdat Hadarom College of EducationKiryat Hinuch, Sdot NegevIsrael

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