Case narrative

Kyle is a 4-year-old patient in your primary care practice. He is the third son born to Dara and Max, a couple you know well because you have been their family’s pediatrician for 12 years. Dara and Max are both highly educated professionals who consistently emphasize dedication to school work and scholastic achievement in their parenting. Kyle’s parents raise no concerns about Kyle’s physical health but they express frustration about his behavior. As compared with their other sons, Dara and Max feel that Kyle is less able to focus on “educational activities” such as puzzles and books; he seems to favor more active play and prefers activities where he can run and climb. He can be “very oppositional” when they try to redirect him towards “educational activities.” Dara and Max worry that Kyle’s behavior may indicate attention-deficit/hyperactivity disorder (ADHD). Although his preschool teachers do not suspect ADHD and express no concerns about Kyle’s behavior at school, Kyle’s parents request a trial of Ritalin. Dara says “Kyle is so unlike our other sons. I just want to see if the medicine can help him focus and behave differently.” You respond by asking what she means by “differently,” to which Max replies “We would like him to behave … better.”

The quest for “better”: defining enhancement

The desires of Dara and Max may resonate with many parents. Many large and small decisions of parenthood are usually guided by the parents’ desire to help their children live better lives. Parents are expected to maximize their children’s opportunities for success by making thoughtful choices for their children in the home, in the classroom, in the pediatrician’s office, and in all domains of life.