Ridiculous things. This is a new one one me.

ADHDMom · Feb 25, 2016

I am an LPN and the mother of an ADHD child. In order for me to ensure that my son ate a good breakfast before school I sent his med to school. I took the bottle to school every month and the school nurse would administer it per M.D. order. Granted, that order was QD, not TID at school. I am not an irresponsible parent. I did this because of the problem with keeping weight on my son. The med is a stimulant, which also acts as an appetite suppressant. This being said I'm also very much aware of how easy it can be for some parents to just pass the buck when it comes to medicating their child. I just can't be too hasty when it comes to making a judgement call because I might not know the full set of circumstances.

ixchel · Feb 25, 2016

Oh, boy, I got to hear some stories tonight. My son and husband bonded over injuries. My husband has had ADHD and his parents were against medical intervention. They instead filled every second of his time with extracurricular activities. This was not... helpful.

His first injuries were massive lacerations covering his back and butt. The ones in his back were so big and deep, his repairs were done in an OR in case any organs were damaged. He was 8, and he'd fallen from a tree.

At 10, he managed to collide with another child in such a way that he broke his femur. A few years after that, his toes, fibia and tibia. He's torn his rotator cuff and pulled countless muscles. At 29, he gave himself what looked like gills on the lateral side of his wrist with a pole saw. His most recent injury, at 30-something, he fell out of another tree and got a ton of little tiny splinter fractures in his arm.

(You'd think he'd stay away from trees by now.)

He is absolutely the poster child for the studies that show those with ADHD are highly more likely to suffer more injuries. [emoji23]

Forgive the further anecdote, but I couldn't resist sharing! You school nurses get to triage these wildlings when they come streaming in bleeding from really bone headed escapades. [emoji23] I can't imagine how many "oh shizz" moments my husband gave his poor school nurses!

Farawyn · Feb 25, 2016

Yes, between that^ and the Food Challenges, the boys give us quite the shizzworthy moments.

ConverseAngel · Feb 25, 2016

...Medication is the only successful therapy, as one can witness on the very first day of administration; facilitating a happier, emotionally healthier, successful child in not just education but all aspects of social development...

As a lifelong member of Team ADHD, thank you!

As some have mentioned not every individual with ADHD responds to an extended release the same way they respond to an immediate release med. Even now as an adult, I take both an extended release qd and an immediate release dose bid with the option of a third prn if I need it.

My parents -even though they are providers as well- were reluctant to medicate me in the first place, but when we finally found the first med that "matched" it seemed like I was an entirely different person. I've been asked my opinion by friends and coworkers for my opinion on ADHD meds and it's been the same for years now:

Don't be afraid to use medication to treat it. For some people behavioral therapy can be enough to help them learn to cope, but for some (most) the medication is needed.

SnowyJ, RN · Feb 25, 2016

I don't think it has even been in question here that ADHD med can be very helpful. The question was the timing of the meds. I have a lot of students with ADHD, and none of them take 3 doses in just over 6 hours.

The issue in the OT was whether this was the best option for the CHILD rather than convenience for the adult.

I can't imagine anyone who is a school nurse not seeing the value of medication for ADHD. We have seen it work.

JenTheSchoolRN, BSN, RN · Feb 25, 2016

The reason I asked about insulin aspart (obviously a much different medication) but also a medication with little stigma and a lot of potential side effects if dosed incorrectly and has a similar duration of action as methylphenidate. Again, just to provoke thought.

Little stigma, perhaps, but not a medication I don't ever question. Puberty can be hell for blood glucose and insulin dosing and I am in constant communication with parents about a child's blood glucose levels, especially when they trend hi and/or low and I am communicating that information to their providers. It has led to many adjustments. And I am always wary of bolusing twice with less than 3 hours apart, despite an order and will clarify (I've seen kids drop into the 50s/even 40s from it.)

The beauty of the school nurse role is that we get to truly see if some treatments are working close-up, in real time, and over extended periods of time - in a way that providers cannot always do.

And school nurses always think about what is happening at home. It can keep me up at night sometimes - especially when I can do nothing about it despite really trying and know is it interfering with a child's life and ability to learn. Because unlike other situations, I get to see its effects every day.

Boston, I love your insight and appreciate it can get the wheels turning, but I swear I learn new things about this specialty every day. Things I could never learn by not being a school nurse. It helps me approach preventive and treatment care differently. I wish every pediatric nurse could spend a day or a week being a school nurse.

SnowyJ, RN · Feb 25, 2016

This article is helpful. It is always important to keep in mind that the lowest possible therapeutic dose should be used.

The What, When, And How Of Taking Ritalin | PBS - Medicating Kids | FRONTLINE | PBS

allnurses Guide · Feb 25, 2016

Boston, I love your insight and appreciate it can get the wheels turning, but I swear I learn new things about this specialty every day. Things I could never learn by not being a school nurse. It helps me approach preventive and treatment care differently. I wish every pediatric nurse could spend a day or a week being a school nurse.

I will try to learn a bit about the school nurse specialty as we go and during that time I was also give some information from a prescriber perspective, as many of you may not think along those lines. The caveat is that I really only deal with adults, but he principle is the same. I think I understand you SNs are advocates for your patient and I am sure you deal with some difficult situations with parentals.

The first thing I look at is the patient: is the patient therapeutic and safe on the dose they are currently on? If the patient is safe but not at goal, then my consideration turns to why: is the dose wearing off too soon (patient has breakthrough symptoms at the tail, final 25%, of the duration of action) or is the patient having breakthrough symptoms at the peak dosing? If the former, there are two options: increase the dosing at the current interval (which increases the risk of dose-dependent side effects at peak) or adjust the dosing interval (which essentially spreads out the area under the curve) and does not significantly impact dose-dependent side effects at peak. In fact if a patient is taking 15mg twice a day (q6h) and having breakthrough symptoms then often you could dose them 10mg three times a day (q4h) and improve their symptoms and reduce their risk. That is basic pharmacology. Obviously the patient would need to be monitored for ADRs later in the day (sleep, dinner).

I would check to make sure the research supported the dosing regimen, which it does.

I would also have to consider the patient in regards to compliance. If the patient is having gaps in his medication because of the home situation then I might want to change the dosing so a nurse could administer it rather than leaving it to chance at home.

I also wouldn't hesitate to make a new plan if a nurse called with concerns about witnessed ADRs.

Cattz, ADN · Feb 25, 2016

I was a school nurse for awhile. The kids took a dose before coming to school. Then we gave the noon dose, parents gave the third dose. Sounds like the parents aren't coping well. Maybe the kids need something physical to do after school rather than be expected to be calm?

I totally agree. Mom and I talked about this as well.

Cattz, ADN · Feb 25, 2016

Cattz, as a mom of an ADHD boy, thank you for advocating for this child. By your description, you do a great job.

Thank you so much. I appreciate that ix.

Farawyn · Feb 25, 2016

Thanks for taking an interest, Boston. As the only health personnel in the building, we need to bounce ideas off of each other. It's why this forum is so strong and tight knit. We are truly each others' co-workers. Any of your input is appreciated.

NanaPoo · Feb 25, 2016

I am trying to understand the mindset, it's not my are of expertise. At the same time, as I think is reasonable to do every once in awhile, I am also challenging it slightly. For example, I could imagine it is easy in the school nurse mindset to forget about life once that child leaves school.

I think you're mistaken here. Like any other area of nursing I've worked in, I'm still a nurse when I'm school nursing, just as when I was hospice nursing.

In hospice for 12 years, I took thoughts of patients home with me at night and wondered if they were okay and couldn't get them off my mind.

Now as a school nurse, I think about my kids in the evenings, too. I worry about the kid I sent out for an x-ray or concussion assessment. Last night I thought all evening about a kid who's changing ADHD meds and his parents are really struggling with behavioral issues, grades, and general middle school garbage. I worry about my kids. They're always on my mind...my littles and my bigs.

The actions we take as school nurses aren't because we don't want to be inconvenienced and park our feet on our desks. It's because we're looking out for the best interest of our students. Our job is primarily to keep our students as healthy as possible, preventing illness so that classroom time is maximized.