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Back Straight Talk About Responsible Treatment
For School Personnel

A Reference Guide For
School Personnel
About ADHD and Stimulant Medications

The S.T.A.R.T. Now program was developed in consultation with the following organizations*:

  • The Drug Enforcement Administration (DEA)
  • The National Association of School Nurses (NASN)
  • The National Council for Patient Information and Education (NCPIE)
  • The National Institute on Drug Abuse (NIDA)
  • The National Institute of Mental Health (NIMH)

Novartis would like to thank each of these organizations for lending their valuable time to this project.

*These organizations do not endorse any particular products or companies.

Introduction
Teachers, school administrators and school nurses play a critical role in the lives and well-being of all children. In addition to nurturing academic and intellectual development, school personnel are responsible for the safety and welfare of children while they are away from their parents during the school day.

According to the Drug Enforcement Administration (DEA), most schools are doing a commendable job teaching their students about the dangers associated with illicit drug use.1 Because many children take prescription medications during the school day, school officials also need to know about the medications with which children may come in contact while at school. Medications when taken as prescribed by a physician are safe and effective, but when misused/abused by those for whom they are not prescribed can have serious consequences.2,3

Attention Deficit Hyperactivity Disorder (ADHD) is one of the chronic conditions for which children are sometimes prescribed medication to be taken during school hours. ADHD is one of the most common disorders in children; in fact, it is the most studied childhood psychiatric disorder. Its symptoms have been described in the medical literature since 1902.

This program is designed to help you ensure that the children under your care for whom medications have been prescribed use them responsibly and safely, and that prescription medications for ADHD are only taken by those for whom they are intended. According to the DEA, well-informed school personnel can better recognize that a child has symptoms of drug-related problems and help prevent the diversion and subsequent misuse of prescription medications by other students in their schools.4

First, let's talk about ADHD treatment and proper use of medication; then, we'll review some facts about ADHD.

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I. Straight Talk About Responsible Treatment

How is ADHD Treated?
The overall treatment plan for ADHD usually includes more than one type of help. According to a recent study, a combination of medicine, behavior therapy and emotional support leads to the greatest improvement in people with ADHD.5

  • The first treatment step focuses on behavior: parents, teachers and healthcare professionals teach patients how to control some of their inappropriate actions.
  • When a doctor believes it is necessary, the next step involves the use of stimulants. Stimulants are believed to work by blocking the reuptake of the neurotransmitters dopamine and norepinephrine, thereby making enough available in the brain.6
  • When taken orally as prescribed, these medications help control the symptoms of ADHD that would otherwise interfere with a child's daily functioning. They help calm children who are hyperactive and help children who have trouble concentrating. These medications have been used safely and effectively in the treatment of ADHD for over 40 years. Research shows that they can improve symptoms in up to 90% of children with ADHD.7
  • A government-sponsored, 14-month study involving more than 500 children showed that school-aged children diagnosed with ADHD had a marked reduction in core ADHD symptoms when treated with a combination of medication and behavioral treatment.8
  • Some children with ADHD take medication in the morning before school with a duration that lasts throughout the school day. Others may need to take a mid-day dose, in most cases under your supervision.

Misuse and Abuse of Stimulant Medications
Children need to understand that as helpful as stimulant medications can be, like all prescription medications, they should only be taken as directed by a doctor and they are only safe for people for whom they have been prescribed. Children also need to know that if they give or sell their medication to others, not only are they participating in conduct that could cause serious harm to another individual, they are also engaging in illegal activity.9

Patterns of misuse and abuse include:

  • Taking higher than prescribed doses.
  • Frequent episodes of binge use followed by severe depression.
  • An overpowering desire to continue inappropriate use of the medication despite serious adverse medical and social consequences.10

Stimulant medications are classified as Schedule II by the DEA. Schedule II drugs are medications of accepted medical value that, if misused or abused, can lead to tolerance and dependence. Codeine is an example of another Schedule II drug. Codeine is found in Tylenol® with Codeine, Robitussin® A-C and other medications commonly given to children. When used as indicated, these drugs are safe, effective and non-addictive.11

As the DEA explains, this does not mean that a child or young adult who is properly diagnosed with ADHD and prescribed a stimulant medication as part of his or her treatment will become "addicted." These medications should only be taken by mouth as prescribed by a doctor. Inappropriate use of these medications can be highly dangerous. Generally, oral ADHD medications taken as prescribed are not associated with misuse or addiction.12

Dispensing Medications at School
Policies for dispensing stimulant medications at school vary and may affect the likelihood of diversion. To help children take their ADHD medications safely and responsibly, and to help you track and manage medications that need to be administered at school, the DEA recommends that:

  • Schools consider prohibiting students from carrying ADHD medication to or from the school. This would necessitate having a parent, guardian or other responsible adult deliver to and remove these medications from the school.
  • ADHD medication be provided to the school in the original pharmacy bottle that is properly labeled with the student's name, the name and strength of the medication, the dosage to be administered and the frequency of the administration.
  • One person (preferably the school nurse) maintain primary control of the medication supply. Additionally, the DEA and the National Association of School Nurses (NASN) recommend that a log be maintained indicating:

  1. On the front:
    1. The name and grade/homeroom of the student.
    2. The name and strength of the medication.
    3. The amount of medication to be dispensed.
    4. The time the medication is to be dispensed.
    5. Duration of order.
    6. A running log of the day, time and the initials of the person who dispensed the medication.
  2. On the back:
    1. The signature and initials of each person who dispenses the medication.
    2. An accounting of the amount of medication received by or removed from the school signed by the deliverer and the receiver. A physical count of the medication would be conducted in the presence of the parent or guardian. This same adult would initial and date the medication log.
    3. A register of behavioral inventories completed by the staff to be sent to the physician.
  3. Attached to the Individual Student Log:
    1. The signed parental permission for the school staff to administer the medication during school hours and a written signed medication order from the doctor whose name appears on the prescription bottle.

Additionally, the DEA recommends:

  • Schools consider not permitting a student to self-administer ADHD medication outside the presence of school staff so that verification can be made that the medication has, in fact, been consumed.
  • The drug supply be secured by means such as a locked room, drawer or cabinet within a locked room. Non-duplicative keys to the locked drug storage area should be limited, and an inventory and accountability system for these keys should be maintained.
  • Unused medication not removed from the school by a parent or other responsible adult be destroyed by the school nurse. It is advisable that the destruction of the medication be witnessed by at least one other person and documented.13

Following these storage and safety guidelines are ways to help reduce the likelihood of stimulant abuse and diversion. Nevertheless, it is important to be able to spot warning signs. Here are some signs of drug abuse in general:

  • Withdrawn, depressed, or tired behavior.
  • Hostile or uncooperative attitude.
  • Strained or changed relationships with family members.14
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II. ADHD Information

What is ADHD?

  • ADHD is a medical disorder associated with the balance of chemicals (neurotransmitters) in the brain.
  • While researchers continue to investigate the exact cause of ADHD, scientific studies suggest that it is related to disturbances in the transmission of dopamine and, to a lesser extent, norepinephrine.
  • Because there is no one test that identifies ADHD, doctors must uncover the disorder by looking at certain patterns of behavior. While clinical studies using brain imaging technologies have shown differences in the brains of people with ADHD, such technology is not a common diagnostic tool.
  • Although there is no genetic test and no genetic marker for ADHD, the disorder's tendency to run in families has led researchers to believe that genetics may also play a role.15
  • Studies show that between 4%-12% of U.S. school-aged children have ADHD,16 which is about 4 million kids in all.

ADHD Symptoms
Primary symptoms of ADHD are hyperactivity, inattention and impulsivity. Children with ADHD may demonstrate one, two or all three of the core symptoms. Examples include:

Hyperactivity Inattention Impulsivity
 
  • Roaming around a room

  • Talking incessantly

  • Inability to sit through
  • Difficulty in filtering out unncessary distractions
  • Getting sidetracked by movements of people or objects.
  • Acting before thinking

  • Demonstrating a very short temper

  • Yelling or hitting
 

While children without ADHD can occasionally demonstrate some of these symptoms, children with ADHD exhibit them on an ongoing basis and in more than one setting (such as at school AND at home). Also, when the symptoms stem from ADHD they interfere with the child's ability to function academically or socially on a daily basis.

If you notice a child continues to exhibit these symptoms, it is appropriate to discuss your observations with his or her parents. But remember, only a doctor can diagnose ADHD or recommend a medication.

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Other Resources

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References
S.T.A.R.T Now School Personnel Brochure

  1. A Message from the Drug Enforcement Administration, Laura M. Nagel, Deputy Asst. Administrator, Office of Diversion Control; http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#a

  2. ibid.

  3. What are the dangers in abusing stimulant medications? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#e

  4. A Message from the Drug Enforcement Administration; http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#a

  5. MTA Cooperative Group. A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry. Dec. 1999; 56:1073-1086.

  6. Wilens, Timothy. Straight Talk About Psychiatric Medications for Kids. The Guilford Press. New York, NY. 1999. p. 192.

  7. Goldman, L.S. et al. Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. JAMA. April 8, 1998; 279 (14): p. 1106.

  8. MTA Cooperative Group. A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry. Dec. 1999; 56:1073-1086.

  9. What are the dangers in abusing stimulant medications? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#e

  10. How is it being abused? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#d

  11. What are the dangers in abusing stimulant medications? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_iabuse.htm#e

  12. ibid.

  13. What precautions can schools take to ensure the safe handling of these medications? http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm#h

  14. http://www.kidshealth.org/parent/emotions/behavior/using_drugs_p2.html

  15. Elia, J. M.D. et al. Treatment of Attention - Deficit - Hyperactivity Disorder. New England Journal of Medicine. March 11, 1999; 340(10): 787.

  16. AAP Subcommittee on Attention-Deficit/Hyperactivity Disorder. Clinical Practice Guideline: Treatment of the School-Aged Child with Attention-Deficit/ Hyperactivity Disorder. Pediatrics Vol. 108. October 2001.