SHOULD WE USE COGNITIVE ENHANCERS TO RAISE STUDENT ACHIEVEMENT? A CONTROVERSIAL PROPOSAL
Associate Professor John A Clark
School of Educational Studies, Massey University, Palmerston North – j.a.clark@massey.ac.nz
According to the American Academy of Child and fix this vexing problem. To be taken with a free school breakfast Adolescent Psychiatry, “There is evidence that the use of and a glass of milk . . . or a grain of salt . . . pharmacologic cognitive enhancers is growing among the ‘cognitively healthy . . . Pharmacological cognitive enhancers The concern about the inequality of school achievement, (PCEs) are medications which improve cognitive functions captured by the expression ‘the long tail of underachievement’ such as attention, working memory, learning, and executive in talk about the results of NCEA, PIRLS, PISA and TIMSS as function; as a result, they lead to better performance in the well as national standards, is often accompanied by suggested classroom as well as in social settings.’ In a 2005 survey by the solutions which generally fall into one of two categories: U.S. National Institute on Drug Abuse, within school and beyond school. 2.5 per cent of 13–14 year olds, 3.4 per Now that National Within school possibilities include cent of 15–16 year olds, and 5.1 per cent such things as: changes to management of 17–18 year olds used methylphenidate Standards have given us and organisation, curriculum and (Ritalin) illicitly. Although some of assessment, teaching and learning, the robust data required this use can be termed recreational, a personal relationships and classroom substantial majority use PCE’s to help to identify those interactions, and the like. Beyond them in the classroom. Nearly 90 per cent school factors range over a multitude of modafinil (a drug used to treat sleep students within New of things, including reform of social, apnea and narcolepsy) use is by healthy, political and economic structures such Zealand’s long tail of non-sleep deprived individuals, such as as government policies on employment, physicians, academics, and students. It underachievement . . . to family circumstances such as literacy is clear, therefore, that the use of PCE’s and poverty, to individual characteristics by the healthy is becoming a societal issue that demands the where motivation and personal responsibility loom large. There attention of public officials and the neuroscience community.” is no denying that many of these, if enacted, might have a David R. Meyer, DO and Vishal Madaan, MD 2012. positive effect in reducing the inequality of school achievement Now that National Standards have given us the robust data whereby differences in school achievement are not governed by required to identify those students within New Zealand’s long tail underlying differences in, for example, family wealth and income. of underachievement, Professor John Clark of Massey University So far, so good – there is, however, a ‘but’, and it is this. None suggests that rather than attempting to address the complex of the changes mooted, whether they are within or beyond the issues of child poverty or learning disorders, the Minister may school, will have much causal effect on reducing the inequality of find that cognitive enhancers are just what the doctor ordered to school achievement if these are not accompanied by significant
changes in what goes on in children’s heads. For it is in the brain where learning takes place and it is the brain which holds the content for the generation of the learning outputs (what we say, write and do in everyday contexts and in more formal tests and examinations) used to construct the national and international measures of school achievement. Whatever might happen outside of the brain (the conditions of learning), unless it impacts on the brain in particular ways then there can be no change to learning outputs and so no change in the inequality of school achievement. Now, it probably is the case that some of these changes will have some cognitive effect, and that is all to the good. Suppose that a particular change (teaching method) or even a raft of changes (school breakfasts, parents reading to their children or earning a living wage) lead to neural changes which in turn produce learning outputs that demonstrate enhanced learning, is this all we can do or is there more? There is, and it involves the use of cognitive enhancers which can be used to boost learning and learning outcomes just that little bit more, above and beyond what the within and beyond school factors can do. Cognitive enhancers are, in the main, prescription medicines which have the potential to have some positive effect on learning. Donepezil is one such drug which is in current use as a cognitive enhancer. The Medsafe (2012) datasheet on Donepezil provides some basic information about the medication. Donepezil is administered to those suffering Alzheimer’s disease. Alzheimer’s disease is associated with relative decreases in cholinergic system activity in the cerebral cortex and other areas of the brain. Donepezil is understood to exert its therapeutic influence in the central nervous system by enhancing cholinergic functioning.
Significant correlations have been found between the use of Donepezil with Alzheimer’s disease and change in ADAS-cog which is a sensitive and well validated scale which examines cognitive performances such as attention, language, memory and reason. If Donepezil slows down or stabilises the loss of memory and cognitive impairment in Alzheimer patients it is plausible to then ask whether Donepezil will increase the memory and cognitive performance of those who are not sufferers of the disease. Studies of the use of Donepezil by university students in the USA taking high stakes examinations for competitive entry into certain professional schools certainly indicate that it has the effect of increasing memory and raising the cognitive performance of those taking the examinations. While Donepezil does have effects beyond those sought, it would appear that these are not likely to be of a seriously adverse kind. Donepezil can only be prescribed by a registered medical practitioner such as a GP but there are no further restrictions on its prescription. Whether a doctor would be prepared to prescribe Donepezil to healthy young people remains an open question. The cost of Donepezil is minimal since a recent decision to subsidise it: 5mg tablets cost $8.47 for a 3 month supply of 90 tablets and $15.47 for a 3 month supply of 10mg tablets. The cost of Donepezil does not appear to be a barrier to purchasing Donepezil with a prescription. Given that Donepezil is available, prescribable and purchasable then we need to ask, what next? We have three options: If no child is to be prescribed Donepezil then we are forgoing a means of helping children to raise their school achievement, so the inequality remains. ■■ If all children are prescribed Donepezil then most will have raised school achievement but this too will maintain the inequality of school achievement and worse, is likely to increase it. ■■ If only some children are to be prescribed Donepezil then it is possible, even likely, that the inequality in school achievement could be reduced if, and only if, the supply of the drug is restricted to those children with the lowest levels of school achievement. ■■
Which option should we choose? The first option could be adopted if it could be shown that the harm to health of the other effects of taking Donepezil outweigh the good which might be brought about by the use of the drug for educational ends. Such empirical studies that exist tend to focus either on Alzheimer patients, university students preparing for high stakes examinations and children with autism and various neurological difficulties, with most reporting positive rather than negative effects on memory, learning and the like: none appear to have been conducted with ‘normal’ school-aged children. While some children may experience some medical effects, particularly if they have cardiovascular, gastrointestinal, neurological or pulmonary conditions, with Alzheimer patients there is no evidence of increased risk of mortality (in a pooled review of studies (n=4146) the mortality rate of the placebo group numerically exceeded that in the Donepezil experimental group). So the mortality risk with children is likely to be very low or non-existent. Whether there are likely to be health risks such as addiction or neural damage remains unclear but available evidence suggests a low risk. Therefore I conclude that there is
no compelling reason to accept option one. This leaves us with either option two of all children or option three of some children. The second option, covering all children, requires some unpacking. ALL means without exception and here we run into some difficulties. There is a very practical problem of actually being able to scoop up every last child and ensure that they receive Donepezilon on a daily basis. Who is going to round up every child, who is going to provide it and who is going to ensure that each and every child takes their medicine? This would require massive state intervention and I believe would ultimately turn out to be impractical. It would also require a government willing to mandate universal administration of the medication by using exceptional and draconian powers. Then there is the sheer cost of free provision for all. There are also some good reasons for the provision of Donepezil not to be made universal. One is that some children may well have medical conditions of the kind identified earlier which would rule out their being given it. Another is that there will be parents who have objections of one sort or another, such as religious conviction or opposition to the state intruding in their lives to the extent that the universal supply of Donepezil would require. It seems reasonable to uphold their genuine resistance against their children being compelled to take the drug. There is, finally, a real worry about equality itself. To be sure, there is equality of access as no child is denied access to Donepezil nor is any child prevented from acquiring it through cost. There may also need to be a regulatory change to ensure doctors prescribed it. There would also be equality of treatment since all children would receive the drug in equal amount. But it
is with equality of outcome that problems begin. If all children, or all children bar the exceptions noted above, take Donepezil then the consequence will be that the initial inequality will not only very likely remain but could be increased further. Taking Donepezil would mean all children or at least a good many of them will raise their school achievement in equal amounts with the gap between top and bottom achievers being maintained. It would be deeply ironic if the very measure taken to reduce the inequality of school achievement had the very opposite effect of increasing it. Therefore, I conclude that the second option should not to be adopted either. This leaves us with the third and final option, that Donepezil only be provided to some children, namely, those low achieving students who need it the most. If the inequality of school achievement is to be reduced, even if it cannot be completely eliminated, then the distribution of Donepezil must only be given to those who require it the most. Boosting their learning and memory capacity to a significant extent will lead to a closing of the gap between high and low achievers for it should raise the level at the bottom without lifting further the level at the top. No doubt there will be parents of high achieving children who will demand that their children also be provided with Donepezil on the grounds of equal access and equal treatment. Such demands ought to be resisted since the aim of making the medication available to some children and not to others is to reduce the inequality of outcome and this will not be achieved if equality of access and equality of treatment are pursued as social policies. If decisions are to be made about which children are to participate in the scheme and who are to be excluded then
there must be a mechanism for doing this. Here is one possible approach, although there could be others: It is implemented over time with an initial trial and if successful then progressively rolled out on a national scale. ■■ Decisions about who to include and exclude should be based on the empirical evidence of learning and its assessment over a long rather than a short period of time, making use of informal classroom assessment and more formal assessment results where appropriate. ■■ Decisions to be made by a panel consisting of, for example, a doctor to cover medical risk, a psychologist to advise on psychological concerns, a school nurse to provide regular oversight, teachers to brief on educational matters as well as individual parents to protect the interests of their child, including the giving or withholding of informed consent. ■■ The medication could initially be made available to children in decile 1–3 schools and administered as part of the breakfast in schools project, which would have the advantage of ensuring that most children actually took their medicine (if left to the child to take or the parent to provide to the child, it is possible that there would be a lower level of usage). The proposed scheme to have nurses in decile 1–3 schools would allow for medical oversight and the regular monitoring of any health problems. ■■
Finally, there would need to be very thorough assessment to demonstrate that this intervention was working as intended. That is, there would need to be a demonstrable reduction in the inequality of school achievement over a reasonably long term which could be attributed, in part, to the effects of Donepezil on school achievement. This could be difficult to measure with any
accuracy since this intervention should be part and parcel of a wider raft of social and educational measures which collectively could lead to improved school achievement and even if it were the only measure introduced there is still the ethical objection to setting up the experimental conditions to test the efficacy of Donepezil between experimental and control groups in classroom settings. However, despite these concerns, it seems reasonable to conclude that in pursuit of reducing the inequality of school achievement we should be prepared to make Donepezil available to those students whose achievement falls at the lower end in order to raise their performance and therefore help close the inequality gap. There is a caveat. The use of Donepezil is not a ‘magic bullet’ to be regarded as a substitute for other within and beyond school remedies. At the very most it is an ‘add on’ to these, giving an additional boost to what they bring to the brain. The inequality of school achievement does not exist in isolation but is intimately connected to other inequalities (health, employment, longevity, and so on), a point made all too well in the recent book Whither Opportunity (Duncan & Murname, 2011) which charts out how the inequality of school achievement sits alongside, for example, the growing inequality in family wealth and income between the rich and the poor, something which is as much evident in New Zealand as it is in the USA where the study was undertaken. If any of the interventions, including this one using cognitive enhancers, are to have any significant effect then it can only be when a concerted ‘across the board’ attack is made on reducing the many inequalities that progress will be made on reducing the educational one.
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Finally, the proposal to use cognitive enhancers in an effort to reduce the inequality of school achievement will no doubt generate objections (an earlier version of this paper was presented to a research seminar at the Institute of Education at Massey University and generated robust debate: it is likely to do the same among those who read this article). One will focus on the cost. Yes, there will be a cost involved to cover the state subsidy, the amount is currently unknown but could be calculated with reasonable accuracy. This, however, must be weighed against the longer term social and economic benefits which are likely to accrue from a reduction in the inequality of school achievement, which might be more difficult to quantify. ■■ Another will focus on the medical risks involved but the evidence to date, such as it is, appears not to be significant ■■ Then there is likely to be a concern about the overmedicalisation of young people –they take enough prescription drugs as it is without adding more to the mix. It may well be the case that our young are on more medications than we would wish, being given them as a quick fix for conditions which might well be addressed in other ways. But the use of Donepezil for selected students would be for a more compelling social reason, to help reduce the inequality of school achievement (and possibly other inequalities besides). If it could do this then the social merits of using such a medication would outweigh any worries about selected children taking a daily pill. ■■ It might also be said that the proposal is founded on a deficit theory but this is no argument against it. Insofar as the proposal is based on an empirical account of the way the world is then there is a deficit – certainly something is absent. ■■
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There is a lack, but not every lack turns into a need (we lack many things but this does imply that we need them). In the case of the inequality of school achievement there is such a large lack and it is one which is in need of addressing with appropriate measures. But those who level a charge of deficit theory go beyond this empirical claim because they want to introduce a moral dimension by claiming that a deficit theory carries with it a degree of blame; that is, blame is heaped on the individuals and their families for their misfortune. But a causal account of what is absent contains no moral component let alone one of blame. It is hard to understand why those who criticise the validity of an empirical theory do so by importing a moral concept which falls completely outside of any causal explanation.
In the end, the onus is on those who object to school children taking Donepezil to raise their school achievement and so reduce the inequality of school achievement, to show in a very convincing and compelling way why these children should have something withheld from them and denied an opportunity to improve their lives over their lifetime. References 1 Duncan, G. & Murname, R. (eds) (2011) Rising Inequality, Schools, and Children’s Life Chances. New York: Russell Sage Foundation & Chicago: Spencer Foundation. 2 Medsafe (2012) New Zealand Datasheet: Donepezil. Wellington.
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