Evaluation of Access to Care and Medical and Behavioral Outcomes in a School-Based Intervention Program for Attention-Deficit Hyperactivity Disorder
Williams, Richard A., Horn, Susie, Daley, Sandra P., Nader, Philip R., Journal of School Health
Attention-Deficit Hyperactivity Disorder (ADHD) is the most common chronic behavioral disorder in childhood. Prevalence estimates of ADHD in U. S. children range from 1% to 20%. Children with ADHD have problems with attention, distractibility, impulsivity, and hyperactivity. These problems and their consequences often endure into adolescence and adulthood, placing children with ADHD at significant long-term risk for academic, psychological, and social morbidity.[1,3-6] The Project for Attention-Related Disorders (PARD) was designed to improve access to care and, therefore, to increase treatment for children with attentional problems in the San Diego (Calif.) Unified School District. PARD sought to improve collaboration among teachers, school nurses, physicians, and parents caring for children with ADHD by developing a school-based intervention program for ADHD.[7,8]
Between March 1990 and June 1992, 110 children in the San Diego (Calif.) Unified School District were identified by teachers as having attention-related problems and were enrolled in PARD. Because of funding limitations, participation and follow-up in PARD is limited to children covered by MediCal or whose parents meet income eligibility for the Child Health and Disability Prevention Program (CHDPP). Eligible parents in CHDPP have an annual income of < $27,900 for a family of four. A system for identifying children with attention problems was instituted throughout the school district, as were teacher and nurse educational inservices. However, children who did not meet the criteria could not be followed with funding from PARD and were not included in the data except where specifically mentioned.
Once identified by the teacher, each child was seen by the school nurse for an initial history and physical. This evaluation included a parental (or guardian) questionnaire regarding health and social histories of the child. The evaluation also included a Conners checklist that rates various behaviors of the child on a scale of 0 to 3, such as "restless in a |squirmy' sense" and "distractibility or attention span problem," with 0 being "not at all" and 3 being "very much." Behavior scores found in ADHD are summed, and a score of 15 or greater suggests increased likelihood the child has ADHD.
After the initial evaluation was completed by the nurse, teacher, and parent(s), the child was referred to a local physician for further evaluation. After evaluation of the physical exam as well as the child's health history based on parent and school reports, the physician prescribed medical therapy, if indicated, and initiated other treatment modalities, as necessary, including referral for counseling. The child also could be referred for counseling by the school. Counselors included school psychologists, private psychologists and counselors, and private psychiatrists.
Periodically, nurses relayed information on the type of intervention employed to PARD coordinators. At the end of each school year, the teacher reevaluated each child using the Conners checklist, and comments from the teacher and school nurse became part of the evaluation for a more qualitative measure of progress.
School nurses also completed a questionnaire rating their own ability to evaluate and refer children with ADHD. The questionnaire addressed factors in caring for children with ADHD. Nurses estimated confidence in their abilities in each of the areas before and after inservices dealing with ADHD.
Of 110 participants, 95 were male and 15 were female. Ethnic breakdown of children included 34 Caucasian, 32 African-American, 34 Hispanic, two Asian, and eight were unspecified. Data were incomplete or missing for some children; 32 children (29%) were missing or had incomplete initial history forms, 21 children were missing the initial parent Conners score, 10 children were missing the initial teacher Conners score, 47 were missing the second teacher Conners score, and 48 children were missing teacher or nurse evaluation comments. …