ADHD Assessment of Children by School Nurse

Attention Deficit Hyperactivity Disorder presents itself in many different ways for many different people. It is further complicated by the fact that there are three types of ADHD recognized by the DSM-IV and even further evidence that females and males manifest the disorder in different ways. ADHD has been a challenge to school administrators for many years. The symptoms of the disorder not only interfere with the educational process of the affected child but they also can be disruptive and interfere with the education of students who learn with and interact with the affected child. ADHD impacts many aspects of the school day including the learning process, socialization and maturity. Its impact cannot be underscored enough as it has the potential to create self-esteem issues which can lead to inappropriate behavior, serving to further interfere with the learning process. Schools are often the first entities to notice the symptoms of ADHD. When a child gets into the structured setting of a classroom and is expected to maintain focus and perform task that require sustained concentration the symptoms often become more evident than they may have been in the past. Many times the child's parents are unaware of the problem or they are suspicious there may be a problem but are not sure how to address its possibility. In addition, teachers have varying teaching styles and there are varied classroom dynamics in each setting which can further complicate the suspicion of ADHD. This project designed an assessment that can be used by school nurses at all grade school levels. The assessment will be useful in the decision to approach parents to allow an ADHD diagnostic battery in a suspected child. It will also be useful to assess the level of success any one child's treatment is currently providing, which can lead to earlier needed treatment adjustments and stop the cycle of problems that are often seen with ADHD that is uncontrolled.

FLOW OF INFORMATION

Table of Contents

Introduction

Statement of Problem

Literature Review

Methodology Discussion

Assessment Tool

Conclusion

INTRODUCTION

There is no denying ADHD exists and it impacts education across the nation. ADHD manifests itself in many different ways however, the outcome is often the same, a problem effectively educating the affected child.

"Attention Deficit Disorder is the most commonly diagnosed psychiatric disorder of childhood (National Institutes of Health [NIH] Consensus Statement, 1998). According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), ADHD affects approximately 3% to 5% of school-age children (Busch, 2003). Children with ADHD are unable to stay focused on a task, cannot sit still, act without thinking, and rarely finish projects they begin at home or school. Children who have been diagnosed with ADHD are frequently treated with psychostimulant medications, most commonly methylphenidate (e.g., Ritalin; Frankenberger, Lozar, & Dallas, 1990; Kwasman, Tinsley, & Lepper, 1995; Reeve, 1990; Runnheim, Frankenberger, & Hazelkorn, 1996). According to data provided by the U.S. Drug Enforcement Agency (2002), there was a 900% increase in methylphenidate production from 1990 to 2001. Ninety percent of the methylphenidate was consumed in the United States for the treatment of ADHD. Production of other drugs used to treat ADHD has also increased. From 1993 to 2001, the production of amphetamines (Dexedrine and, later, Adderall) increased by 5,767%. By 2001, amphetamine production accounted for 44% of the stimulants produced in the United States, the vast majority of which are used to treat ADHD (Busch, 2003)."

"The behaviors associated with ADHD may be first observed or most troublesome in a classroom setting. Snider, Frankenberger, and Aspensen (2000) found that teachers were involved in making the initial referral nearly 40% of the time. This suggests that teachers play an important role in the initial screening for ADHD. In light of current concerns about treatment of ADHD with stimulant medication, it is critical that teachers are knowledgeable and objective if they are to play a role in the diagnosis of ADHD (Busch, 2003). "

There have been a small number of studies to examine the true ability of teachers to notice and recognize possible symptoms of ADHD (Busch, 2003).

" They found that teachers with more training and experience had more confidence than inexperienced teachers but that all identified important barriers to effective instruction, including lack of time to administer specialized interventions, lack of training, large class size, and severity of students' problems. Jerome, Gordon, and Hustler (1994) evaluated Canadian and U.S. teachers' knowledge of concepts related to ADHD and found that although teachers had little training regarding ADHD, they did well on knowledge-based questions regarding etiology and educational implications (Busch, 2003). "

According to experts, ADHD is among the most common of all diagnosed childhood disorders. Unfortunately it is often not recognized until the negative impact has already occurred on the child's school experience and learning abilities (Hart, 2002).

'Because of the highly familial nature of the disorder (Epstein et al., 2000), it is quite likely that parents with ADHD will have at least one child who displays clinically significant ADHD symptoms themselves (Hart, 2002). Rutter et al. (1999) report that the first-degree relatives of those with ADHD are 68% more likely to present with ADHD themselves than are controls. Faraone and Biederman (1997) have suggested that up to 25% of children presenting with ADHD will have a parent with ADHD. Even in the absence of a formal diagnosis of ADHD, children of parents with ADHD are more likely to be impulsive, inattentive, and overactive than their peers (Hart, 2002)."

This statistic further complicates the ability for early assessment of an ADHD student as the ADHD parent may fail to recognize important signals of the disorder. In addition it can be difficult to determine whether the parent's ADHD impacted parenting style is at the root of the student's difficulty or if the student has the actual disorder.

In one study more than 80 children from preschool were evaluated for effectiveness of parental ability to recognize the symptoms in their own child.

"These children were selected at the time of their 3-year developmental check from two cohorts (1992-93 and 1995-96, respectively) (Hart, 2002). Children came from families living in the New Forest and Southampton regions of Southern England (N = 7,068). These areas comprise a mix of urban, suburban, and rural settings that include areas of prosperity and significant pockets of relative deprivation (Hart, 2002). The children selected from cohort 1 (n = 30) constituted the PT arm of a randomized controlled trial previously reported in this journal (Sonuga-Barke et al., 2001). The 59 children in cohort 2 participated in a second trial of the same PT package. In both trials, children were randomly assigned to either PT (total n = 89), an alternative treatment (n = 28), or a waiting list group (n = 30). Children from non-PT groups were not included in the current analysis. A three-stage screening procedure previously described by Sonuga-Bar ke et al. (2001) was used in both cohorts (Hart, 2002)."

The results indicated that maternal ADHD served as a strong barrier to an effective use of parental diagnostic screening tools. Because of the high genetic influence of ADHD there is a significant chance that parents will not recognize the disorder in their children because they are dealing with it in their own life. These studies further point to a need for a school nurse assessment tool that will allow early identification of possible ADHD.

LITERATURE REVIEW

Over the years there have been many studies performed to address the issue of ADHD. Studies have looked into the symptoms, the causes, the impact and the outcome of having the disorder, both in and outside of the educational process. Literature tracking the way the disorder affects learning indicate that it can have a negative impact on the process of learning, particularly in the area of reading (Busch, 2003). Literature about ADHD has included studies about understanding the difference between true learning disabilities and what appears to be learning disabilities that are rooted in an underlying problem such as ADHD. These studies further underscore the importance of a development of an assessment tool for the purpose of school nurse screening for ADHD students.

One study found that educators and those who work in administrative positions with students have limited knowledge about how to recognize the symptoms of the disorder.

"A random sample of 200 general educators and 200 special educators from Wisconsin were surveyed. Results revealed that teachers had limited knowledge about ADHD and the use of psychostimulant medication (Busch, 2003). Teachers' opinions about the effect of stimulant medication on school-related behaviors were generally positive, although special education teachers were more positive than general educators (Busch, 2003). The survey confirmed previous research indicating that teachers were the school personnel who most frequently recommended an assessment for ADHD. The results are discussed in terms of their educational significance and implications for teacher preparation and continuing education (Busch, 2003)."

There have been studies about the impact stimulant meds have on academic performance as well.

'Scientists' understanding of the nature of ADHD is incomplete, and implications for diagnosis and treatment are emerging continually (Busch, 2003). Because teachers are often the first ones to recognize the symptoms of ADHD, it is essential for them to draw upon a current and accurate knowledge base as they interact with parents, physicians, and other professionals (Busch, 2003)."

"Teachers play their most crucial role before any diagnosis is actually made by the family physician, psychiatrist, or pediatrician (Busch, 2003). According to Weber et al. (1992), children who are suspected of having ADHD are initially identified because of their behavioral and academic performance in the classroom. Studies conducted in schools repeatedly report the same sequence of events for many children referred for suspected ADHD. Teachers become aware of the students' difficulty in meeting the behavioral, attentional, and academic norms for the class and suggest the possibility of ADHD to parents (Pearcy, Clopton, & Pope, 1993; Runnheim et al., 1996; Weber, et al., 1992). Parents are concerned about their child's academic performance and behavior in the classroom and follow through with a referral to a physician (Busch, 2003). Referred students are frequently diagnosed as having ADHD by the physician based on reports from the teachers and parents. Kwasman et al. (1995) reported that 39% of physicians telephoned the schools of children who had been referred for ADHD and 77% attempted to obtain a written report from the school (Busch, 2003). In the absence of independently valid tests for ADHD (NIH Consensus Statement, 1998), teacher referrals have become a significant factor in determining whether a child will be diagnosed with the disorder. If a teacher informs parents that the child should be evaluated for ADHD, that teacher is also likely to rate the child high on characteristics associated with the disorder. As a result of this circular procedure, children diagnosed with ADHD are viewed as having a medical disorder that must be treated by a physician (Busch, 2003). "

School nurse assessment tools can assist in the reduction of any circular diagnosis that may be caused by the teacher's feelings about the student by the time he or she is asked to complete an assessment form.

'Because teachers play such a pivotal role in the identification and treatment of ADHD, they need to be knowledgeable. However, past studies have revealed that special education teachers received little or no training on ADHD or issues related to stimulant drug therapy (Kasten, Coury, & Heron, 1992; Reid et al., 1994), and more recent studies suggest that this is still the case (Busch, 2003)."

This study strengthens the need for the development of a tool for assessing possible ADHD in students that can be used by school nurses .

One study examined teacher ability to recognize potential ADHD in the classroom. The study used a four part survey that was developed to explore not only the teacher knowledge about ADHD but also their opinion about the disorder.

"However, it was uniquely designed around the specific research questions to reflect current knowledge about the nature of ADHD and treatment with stimulant medications (Busch, 2003). The survey began with eight demographic questions. The remaining three parts of the survey consisted of statements to which teachers were asked to respond using the 5-point Likert-type scale. Part A of the survey consisted of 13 items to assess factual knowledge about ADHD and the use of stimulant medication (Busch, 2003). Although Part A assessed factual information, a Likert-type scale was used rather than a true / false format for two reasons: (a) to provide consistency in format throughout the survey and (b) to increase the probability that responses reflected knowledge (or lack of knowledge) rather than guessing. Part B consisted of 23 items that asked participants to indicate their views about the effects of stimulant medication on classroom behavior (Busch, 2003)."

Four hundred surveys were sent with a return rate that was 36%.

"The teachers had a mean of 16.5 years of experience (SD = 9.46) and a range of 1 to 36 years as a teacher. Fifty-two respondents had more than 20 years of classroom experience (Busch, 2003). There were no significant correlations between years of experience and answers to items. All respondents indicated that they had experience with students who had been diagnosed with ADHD (Busch, 2003)."

" Responses were determined to be correct on the basis of the NIH Consensus Statement (1998). Only 5 out of 13 items were answered correctly by more than half of the responding teachers. To determine whether the mean differences were significant between general and special educators, an analysis of variance (ANOVA) comparing means was completed (Busch, 2003). There were no statistically significant differences between general and special educators (Busch, 2003). "

The results of this study indicate that teachers have less knowledge about ADHD then was previously thought. In addition this study flies in the face of another study concluding teachers had a solid knowledge of the topic. It is important to provide an standard and universally applicable tool for the assessment of ADHD students.

The hallmark symptoms of ADHD are different for each subtype. What can further complicate the matter is that the symptoms are also common to appropriate stages of childhood development.

The above chart underscores the problem with identifying potential ADHD students when one factors in the subjective ness of the symptom list.

The importance of designing an assessment tool for school nurses in the search for ADHD students is strengthened by the known negative impact that the disorder can have on the student's self-esteem and consequent behavior patterns (Reason, 1999).

"Children's happiness and success depend on their constructive response to the expectations of family, friends, and school. These expectations, to a greater or lesser extent, derive from the goals held in common by a community. In setting these goals, a community imposes significant demands on children's psychological resources (Reason, 1999). Given their cultural origin, it is no surprise that many of these demands, and the expectations from which they derive, vary from community to community. Children growing up in a postindustrial society are faced with a host of demands, some of which are shared by other communities, while others are specific to that society (Reason, 1999). For instance, formalized education imposes a whole range of requirements, including compliance, focused concentration, and the willingness to listen and reflect. The hurdles set by the education system are partially a function of modern society's emphasis on competition and achievement (Reason, 1999)."

Difficulties meeting the demands can have a range of negative impacts on the child's educational path.

There are a large number of children currently diagnosed with ADHD. It does not discriminate against age, race or economic standing as it impacts schools nationwide.

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Statistically children from poverty stricken families and intercity areas are more likely to be diagnosed than children of affluence and upper middle America. This knowledge should also serve as a prompt to assess as early as possible and to be especially aware of children displaying possible symptoms who also fit the demographic profile of the disorder.

"The results of a study on Attention Deficit Hyperactivity Disorder (ADHD) suggest it is not practical to administer a wide range of neuropsychological tests in order to evaluate ADHD (Rosselli, 1999). Tests assessing attention, memory, visuoconstructional abilities and executive function may be included. It is also suggested that tests assessing primary cognitive functions and other complementary tests may also be added (Rosselli, 1999)."

Certain portions of IQ testing have proven to be lower in the ADHD population than in the control groups. "Some results deserve further investigation. Despite a normal score on the WISC-R Vocabulary subtest, and higher scores on the Similarities and Comprehension subtests, children with ADHD significantly under-performed on the Token Test, another language comprehension test. The Token Test, however, assesses more than language understanding alone. Attention may be important, as well as verbal span memory and the ability to follow verbal commands. Therefore, we propose that the low scores of children with ADHD observed in this test may have not been due to a deficit in language understanding, but rather to an attentional deficit and an inability to follow verbal commands. It is well-known that the inability to follow verbal commands represents a significant defect in ADHD (American Psychiatric Association, 1994)."

The memory test results have intrigued experts in the field in particular. Tests show that they can store and retrieve information as well as no ADHD students, however more attempts to retain the information, both verbal and non-verbal.

IMPORTANCE OF ASSESSMENT TOOL

The importance of a nursing assessment tool can be easily defined. A nursing assessment tool for the assessment of ADHD will provide a standard of assessment that can be followed nationwide. Teachers interact with the students on a daily basis. They have the potential to develop preconceived ideas about the children in their classrooms. If the child is ADHD and disruptive the teacher may develop a dislike for that student. In addition the teacher may view all disruptive kids as ADHD and treat them as such without having an official assessment completed.

School nurses interact with the students in a different manner than teachers do. They often see the students when the students become ill or they become injured. Students with ADHD are proven to be more accident prone than students without ADHD so it is possible that the nurse at school will be the first to suspect that something is amiss. The nurse will see the student outside of the classroom setting. The nurse will have a record of injuries that occur as well as any medications that the student may be taking.