When children with ADHD don’t take their medication, the symptoms—difficulty sustaining attention, impulsiveness, and sometimes physical restlessness and hyperactivity—re-emerge, particularly in younger children.
New research, led by the Murdoch Children’s Research Institute in Australia and published in Archives of Disease in Childhood, shows that children with ADHD were going without treatment 40 percent of the time—which could make it difficult for them to focus in class and work with their teachers and classmates.
In the Australia-based study, associate professor Daryl Efron, the study’s lead author, said medication use was relatively high in the first few months, then progressively decreased, only increasing again after five or six years of treatment. Previously published studies from other countries, including the United States, have found generally similar results.
“This does make it more difficult for caregivers and teachers to work with these children, but more importantly makes it difficult for the children to engage well in the school work and other activities, and to get along calmly and happily with their friends,” Efron wrote in an email to Education Week.
In the United States, the federal Individuals with Disabilities Education Act forbids school personnel from requiring students to take prescribed medication or establish it as a condition for eligibility for special education services. And for families with school-age children, there are many potential barriers to consistent medication use—including access to transportation and scheduling of medical appointments, school nurses and school nurse supervisors told Education Week.
“There’s still a stigma around ADHD,” said Clayton Wetzel III, the 2017 Vermont school nurse of the year. “But pretending your child doesn’t have it or saying, ‘Yeah, they might have it, but I don’t want them to take medication,’” is not the best approach, he said.
In Australia, school nurses are not very involved in the management of children with ADHD, Efron said, because many children on ADHD medication take once-daily doses given in the mornings, so the nurses do not need to administer another dose at lunchtime or midday.
Laurie G. Combe, the president of the National Association of School Nurses has observed a similar trend in U.S. schools, but said that nurses here still play a role, along with teachers and administrators in evaluating whether students are receiving the appropriate medication.
“There are times when medication is not right and you can [address ADHD] through other means,” said Wetzel, the school nurse at Waitsfield Elementary School in the Harwood Unified schools in Vermont. “But in some cases, medication really is the thing.”
Wetzel has seen firsthand children who become more focused students after taking medication, he said.
“Kids become lost in class and disinterested and then they take even the lowest dose and all of a sudden they can focus,” Wetzel said. “It can help them not just in class, but overall socially and emotionally.”
The Australia study of more than 3,500 children looked at all redeemed ADHD prescriptions of the three medicines—methylphenidate (commonly known as Ritalin), dexamphetamine, and atomoxetine—by participants in the Longitudinal Study of Australian Children. The results revealed that boys were four times more likely to be prescribed ADHD medication than girls.
For families with school-age children, there are many potential barriers to consistent medication use—including access to transportation and scheduling of medical appointments, said Kate King, the director of health, family, and community services for the Columbus, Ohio, school system and a former school nurse.
The Australia study also found that children from socially disadvantaged families who were prescribed ADHD medication were less likely to consistently take it because it can be more difficult to attend medical appointments, pay for appointments to get prescription refills, and miss work to attend appointments.
“People start [the medication], but because it’s a controlled substance, parents actually have to go get a prescription in their hand and take it to the pharmacy every month,” said Kate King, the director of health, family, and community services for the Columbus, Ohio, school system and a former school nurse. “Well, that’s hard. It’s really hard.”
The Columbus, Ohio, schools use 11 school-based health centers to help families get their children’s medication on a regular basis. With the health centers, parents can stop in to get their child’s prescription when they drop off or pick up their children, King said.
During her time as a school nurse, King said that rather than focusing solely on whether children were taking the medication, she partnered with families to ensure the medication worked for their children.
“So often people just stop taking it and they don’t feel [comfortable] to back to their physician and say, ‘Hey, this isn’t working,’” King said. “Some meds work for some kids and other meds work for other kids.”
King encourages the school nurses under her charge to do the same and, if granted approval by families, to connect directly with health-care providers.
“If we have a release, we can say, ‘The parents aren’t seeing it work and we’re not seeing it work. So, can we try something else,’” King said.
In some cases, that something else may not even be medication. The study found that almost 4 percent of families never redeemed their prescription for ADHD medication.
“I don’t preach that medication is the best thing, but if medication is, let the school nurse be a part of that solution,” Wetzel said. “Even parents that have been hedging on whether or not they want to do medication, they’re sometimes more willing to listen to the school nurse than their doctor because they have a personal relationship with that school nurse.”
Wetzel works with teachers to collect information that may be helpful for doctors prescribing the medication or in determining whether students should be evaluated for ADHD, such as: Are students consistently making careless mistakes on their schoolwork? Are they listening when spoken to directly? Are they completing assignments?
“We see them much more often than their providers do. It’s about making sure the doctors are in touch with what the parents are seeing, what the students are seeing, and the what the teacher sees,” Wetzel said. “The students are important too. If they have no appetite, or if they’re feeling [unusual], or it’s under-stimulating to the point where they just don’t have energy, they need a different medication.”