By Megan Flaherty
Illustration by Malcolm Garris/PhotoDisc
February 8, 1999

Although 3 to 5 percent of school-aged children are believed to suffer from attention deficit hyperactivity disorder, the condition remains largely a mystery. Experts have studied ADHD—the most frequently diagnosed children’s behavioral disorder—for more than 50 years, but they still aren’t certain what causes it, how to recognize it and how best to treat it.

This knowledge gap means parents, teachers, and health professionals—including school nurses—have their work cut out for them when a child is suspected of having ADHD. School nurses are part of the multidisciplinary teams that evaluate such children. And if the child is diagnosed with the disorder and is prescribed Ritalin (methylphenidate) or other drugs, school nurses supervise the treatments.

Does he wiggle?

A common time for a child to be diagnosed with ADHD is when he or she starts school and teachers or parents notice disruptive, fidgety, disorganized, or inattentive behavior, experts say. "I often hear from teachers: ‘He seems lost,’ " said Anne Fallon, RN, who works in the Round Rock Independent School District north of Austin in Texas.

Because there are many possible causes for these behaviors, the school nurse should try to keep teachers and parents from immediately concluding that it’s ADHD, Fallon said. In fact, such behaviors could be due to illness, bad nutrition, poor vision or hearing, or a stressful or dysfunctional home environment, experts say.

If those causes are ruled out, school nurses often spearhead efforts to investigate the problem further. Retta Knox, RN, who works at Hart Elementary School near Amarillo, distributes an extensive questionnaire to teachers and parents. It includes a basic health history and questions like "How long can he sit and watch TV?" and "Does he wiggle?"

If the signs and symptoms of ADHD persist in more than one setting, the child may have the disorder, said Judith Vessey, PhD, RN, FAAN, a developmental pediatric nurse practitioner and professor at Johns Hopkins University School of Nursing in Baltimore, Maryland.

"No one professional should be diagnosing ADHD," Vessey said. "Kids need a more thorough work-up than just a 15-minute visit to the pediatrician." A proper ADHD diagnosis would be the result of psychological and medical testing, educational reports, and a family profile, Vessey said. "It’s a very time-consuming process to do a good evaluation. You can’t do it overnight," Knox added.

Medication at school

An estimated 1 million children diagnosed with ADHD take the stimulant Ritalin to improve their attention span and control hyperactivity. Many must take a dose during the school day, following strict protocols for medication administration established by school districts.

Encouraging compliance with medication regimens is an important part of a school nurse’s job, Fallon said. "We try to make the child understand why they’re taking it," she said. "I cringe when I hear ‘I can’t behave unless I take a pill,’ " Fallon said. "It’s important to reinforce that [Ritalin] helps you, but you still must decide how you’re going to behave."

Because school nurses usually work for more than one school, they are not always able to directly administer medication. In some cases, a nurse must train a school employee, like the office secretary, to administer a drug and must educate the employee on possible drug interactions and side effects. Ideally, the worker in charge of medication is diligent about records and makes sure the child swallows the pill, said Beverly Bradley, PhD, RN, president of the American School Health Association.

Report on Ritalin

The use of Ritalin to treat ADHD has increased 700 percent in this decade, experts say, but the drug remains controversial. Ritalin critics say it is overprescribed and given to children who simply misbehave. There are no studies examining the long-term effects of the drug, critics say, which is verified in a report issued by a panel of the National Institutes of Health in November 1998.

But supporters say Ritalin has a proven record of getting children with ADHD back on track. The results of a clinical trial—concluded in 1998—by the National Institute of Mental Health (the largest trial ever conducted by the agency) showed Ritalin and other medications were effective treatment for ADHD. The results actually concluded that Ritalin should at times be prescribed in higher doses and showed closely monitored treatments work well enough to erase the diagnosis for 82 to 85 percent of children who take it.

School nurses say they’ve witnessed cases in which Ritalin has helped and cases in which it hasn’t made much difference. The drug works best in coordination with behavior modification or counseling plans, Bradley said. "In the best of all worlds, medication alone is not considered the cure," she said.

"It’s not a quick fix," Vessey added. "It will work in combination with consistent, quality parenting and good education."

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