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Gwu_psychotropicdrugsfact07.qxd

The Center for
Psychotropic Drugs and Children
Health and Health
Care in Schools

A 2007 Update
The School of Public
Health & Health Services
December 2007
THE GEORGE WASHINGTON UNIVERSITY
References
Background
The safe and effective use of medications for the treatment of certain medical conditions and 1 National Association of School Nurses.
Position statement: medication administration illnesses has enabled many children to attend school and achieve academic success.1 In in the school setting. Revised 2003. Available at medical practice, widespread acceptance of drug therapy for behavioral disorders has facilitated diagnosis and treatment of these conditions in ambulatory care.2 2 CDC. Attention Deficit Disorder and Learning Recent changes in the use of psychotropic medications by children and adolescents, and Disability: United States, 1997 – 1998. Centers concerns about adverse consequences, have prompted the US Food and Drug Administration (FDA) to revise their guidance for prescribers and patients. The need for up-to-date drug 2002.Vital and Health Statistics: Series 10, No.
206.
information, and for monitoring of students on medication, prompted the Center to updatethis fact sheet for those who may be called upon to administer medications to students during Emotional and Behavioral Health Problems in Children3 NIMH. Child and Adolescent Mental Health. NIH, National Institute of Mental Health, Emotional and Behavioral Health Problems in Children
March 2007. Available athttp://www.nimh.nih.gov/health • Studies show that at least one child in 5 has a mental, emotional, or behavioral disorder severe enough to cause some level of impairment. At least one child in ten has a mental 4 SAMHSA. Child and Adolescent Mental Health. illness severe enough to cause extreme functional impairment.3,4,5 Health Services Administration. November2003. Available at • A national survey of pediatricians showed that 19% of pediatric visits involved a psychosocial http://mentalhealth.samhsa.gov/publications/all problem requiring attention or intervention. Psychosocial problems are the most common chronic condition for pediatric visits, eclipsing asthma and heart disease.2 5 U.S. DHHS. Mental Health.A Report of the Surgeon General: Executive Summary and • In 2006, 4.7 million children (8%) were reported to have a learning disability; 10% of boys were identified as having a learning disability, compared with 6% of girls.6 http://www.surgeon general.gov/library/mentalhealth/toc.html#chapter3.
• Four and a half million children 3–17 years of age (7%) were reported to have Attention 6 Bloom B, Cohen RA. Summary Health Statistics for US Children: National Health Interview Survey, Deficit Hyperactivity Disorder (ADHD). Boys are more than twice as likely as girls to have 2006. CDC. National Center for Health Statistics;Vital and Health Statistics, Series 10,No. 234, September 2007. Available at: • Research indicates that depression is present in 1% of children and 5% of adolescents at any http://www.cdc.gov/nchs/data/series/sr_10/sr1 given time. Before puberty boys and girls are at equal risk for depression; after puberty onset the rate of depression is twice as high for girls.7 7 Brent DA, Birmaher B. Adolescent depression.
N Engl J Med. 2002; 347(9):667-668.
• Up to half of all children with ADHD—mostly boys—also have oppositional defiant disorder 8 Strock M. Attention Deficit Hyperactivity Disorder (ODD), which is characterized by defiance and outbursts of temper. About 20% to 40% of (ADHD). Bethesda, MD: NIH, NationalInstitute of Mental Health. Reviewed October ADHD children may eventually develop conduct disorder (CD), a more serious disorder characterized by behaviors such as lying, fighting, and other antisocial acts. These children http://www.nimh.nih.gov/health/topics/attentio tend to get into trouble in school, at home, and in their communities. Some children with n-deficit-hyperactivity-disorder-adhd/index.shtml.
ADHD (mostly younger children and boys) can also experience anxiety and depression.8 9 NIMH. Child and adolescent bipolar disorder: • Some evidence suggests an increasing prevalence of bipolar disorder in youth.9 Researchers an update from the National Institute ofMental Health. September 25, 2007. Available find that children and adolescents show more intense but somewhat different symptoms than adults,10 but others note that it is difficult to apply standard diagnostic criteria to them.11,12 health/publications/child-and-adolescent- Until studies identify specific treatments for pediatric bipolar disorder, adult medications are 10 NIMH. Largest study to date on pediatric prescribed off-label. Caution and close observation are warranted as some treatments for depression or co-occurring conditions—such as ADHD—can cause mania to develop in characteristics and short-term outcomes.
NIH, National Institute of Mental Health.
Science Update, February 6, 2006. Available at • In 2006, there were 9.6 million children in the US (13%) who had a health problem for which medication had been taken regularly for at least 3 months. Boys (15%) were more news/2006/largest-study-to-date-on-pediatric-bipolar-disorder-describes-disease- likely than girls (12%) to have been on regular medication for at least 3 months. Overall, 16% of youths aged 12–17 years were on regular medication compared with 14% of children aged 5–11 years, and 8% of children under 5 years of age.6 11 Brotman MA, Kassem L, Reising MM, et al.
Parental diagnoses in youth with narrowphenotype bipolar disorder or severe mooddysregulation [Abstract]. Am J Psychiatry. Definition: Psychotropic drugs are those that affect the function, behavior, or experience
of the mind.13 While their exact mechanism of action is not known, psychotropic drugs are 12 Simon GE.The antidepressant quandary— thought to act upon the biochemistry of the brain and positively affect thinking mechanisms, adolescent depression. N Engl J Med. 2006; emotional control, mood, and other behavioral processes. Included are neuroleptics (such as 13 Ayd F. Lexicon of Psychiatry, Neurology, and the Haldol), antipsychotics (such as Zyprexa), antidepressants (such as Prozac), stimulants (such Neurosciences. Baltimore:Williams & Wilkins; as Ritalin), and antianxiety agents (such as BuSpar).13 www.healthinschools.org
The Center for
Health and Health Care in Schools
Treatment: What we know
Psychotropic Drugs
• Stimulant and non-stimulant medications can be effective for the short-term treatment of ADHD.14 Some studies demonstrated that stimulants or stimulants in combination with and Children
behavioral treatments produce long-term improvements when the drug continues to be taken.15 • The use of selective serotonin reuptake inhibitor (SSRI) antidepressants to treat major depression in children and adolescents has been controversial. Many studies have shown SSRI 14 AACAP. Psychiatric Medication For Children And Adolescents: Part 2—Types Of Medications. agents to be only modestly effective in the treatment of major depression among adolescents.16 However, a large 2004 study by the National Institute of Mental Health (NIMH) concluded that the combination of fluoxetine [Prozac], approved for treatment of pediatric depression, http://www.aacap.org/page.ww?section=Facts+ with cognitive behavioral therapy (a form of talk therapy) was successful in helping 71% of the for+Families&name=Psychiatric+Medication++For+Children+And+Adolescents%3A+Part+ study’s teenagers overcome depression. The Treatment for Adolescents with Depression Study (TADS) also showed that fluoxetine alone was effective in 61% of subjects, while talk therapy alone worked with 43%. Thirty-five percent of those who received a placebo also improved.
treatments in child and adolescent psychiatry:An inventory. J Am Acad Child Adolesc Psychiatry. Patients became significantly less suicidal, no matter which treatment they were given.17 • Children and adolescents with major depressive disorder who are treated with 16 Delate T, Gelenberg AJ, Simmons VA, Motheral BR.Trends in the use of antidepressants in a antidepressants, may experience suicidal thinking and behavior.18 The FDA’s warning did not prohibit use of the medications in youth but called on physicians and parents to closely pediatric patients, 1998 to 2002. Psychiatric monitor children and adolescents taking antidepressants for any worsening in symptoms of Services. 2004;55(4):387-391.
17 Treatment for Adolescents with Depression depression or unusual changes in behavior.19 Study (TADS) Team. Fluoxetine, cognitive- • The long-term effects of antidepressants on a child’s developing nervous system have not been behavioral therapy, and their combination foradolescents with depression:Treatment for studied. Some physicians have expressed concern about the possibility of central nervous system problems after long duration therapy, or the development of additional disorders.20 randomized controlled trial. JAMA. 2004; Questions also have been raised about the longer-term use of antidepressants, whether they 18 Treatment for Adolescents with Depression would continue to be effective, and if effective, would produce more or different side effects.21 • The effectiveness of selective serotonin reuptake inhibitors (SSRIs) and clomipramine Adolescents with Depression Study (TADS):Long-term effectiveness and safety outcomes.
[Anafranil] for obsessive-compulsive disorder (OCD) has been indicated by a number of Arch Gen Psychiatry. 2007;64(10):1132-1144.
studies. The FDA approved the use of two SSRIs, fluvoxamine [Luvox] and sertraline [Zoloft], for use in pediatric OCD. Fluoxetine [Prozac] also is approved for use in pediatric OCD.22 American Academy of Child and AdolescentPsychiatry. Physicians’ MedGuide—The Use of • An NIMH-funded study to test the efficacy and safety of medications commonly used to treat Medication in Treating Childhood and Adolescent children and adolescents (in off-label applications), found that fluvoxamine, an SSRI antidepressant Depression: Information for Physicians. January2005. Available at http://www.parentsmed approved for treating OCD in children, was both safe and effective in treating social phobia, separation anxiety disorder, and generalized anxiety disorder in children 6–17 years of age.23 perspective on the controversy surrounding • In 2007, the FDA approved use of risperidone [Risperdal] for the treatment of schizophrenia the use of SSRIs to treat pediatric depression.
in adolescents ages 13–17, and for the short-term treatment of manic or mixed episodes of Am J Psychiatry. 2007;164(9):1302-1306.
bipolar 1 disorder in children and adolescents, ages 10–17.24 Risperdal was approved in 2006 antidepressants in children? N Engl J Med. for treatment of irritability associated with autistic disorder in children ages 5–16.25 • Data reported by a pharmacy benefits manager indicated that use of antidepressants slowed Medications in Children. N Engl J Med. considerably during 2005, in response to concerns about the risk of suicidality—especially during the first few months of therapy or when dosages are adjusted—but began to increase 23 Walkup JT, Labellarte MJ, Riddle MA, et al., for again in 2006. Approximately 7.8% of US schoolchildren (ages 4 to 17) have been diagnosed the Research Unit on PediatricPsychopharmacology. Fluvoxamine for the with ADHD, and about 4.3% of children currently receive medication for the condition.25 treatment of anxiety disorders in children andadolescents. N Engl J Med. 2001;344(17):1279- • Between 2000 and 2005, ADHD treatment rates increased an average of 9.5% per year for • Schools are often where students’ mental health needs are discovered and where support is provided.26 Fear and isolation can be harmful for students in treatment—but inclusion andcaring can really help. Children and adolescents recover sooner and better when theenvironment is made a safer place for recovery.27 FDA Advisories on Antidepressants, ADHD Medications
In May 2007, the FDA updated health advisories28,29 alerting prescribers to the increased risk of suicidal thinking and behavior
that may occur in children, adolescents, and young adults 18–24 when antidepressant medication is started. Patients should be
observed closely for signs of worsening illness, suicidality, or unusual changes in behavior. FDA also cautioned that depression
and certain other psychiatric disorders are themselves associated with increases in the risk of suicide.29 Patients will receive an
updated MedGuide30 with their prescription or renewal, informing them of the risks.
FDA cautioned in February 2007, that patients taking medications for ADHD should become aware of risks for possible
development of cardiovascular complications, and/or adverse psychiatric symptoms.31 This information has been added to the
MedGuides for ADHD medications.
In addition, patients taking SSRI or SNRI antidepressants should be cautioned that starting concurrent triptan medication for
migraine can result in serotonin syndrome, a life-threatening condition characterized by fast heartbeat, hallucinations,
restlessness, loss of coordination, nausea, vomiting, and diarrhea. Because these medications may be prescribed by different
physicians, patients are cautioned to tell their health care provider what medications they are taking.32
www.healthinschools.org
The Center for
Health and Health Care in Schools
Psychotropic Drugs Encountered in the Health Suite
Psychotropic Drugs
** Observed effects of medication (side effects), improper dosing, medication conflicts, missed doses, and Children
discontinued medication, or individual adverse reactions.
Symptoms *
What To Watch For **
Psychiatric Conditions in Children andAdolescents [press release]. Rockville, MD: US Drugs used for ADD and ADHD, including stimulants and non-stimulants
Food and Drug Administration, FDA News:August 22, 2007. Available at STIMULANTS
Signs of inattention include being easily
http://www.fda.gov/bbs/topics/NEWS/2007/NE 25 Medco Health Solutions, Inc. Drug Trend Report following directions, forgetting or losing things, failing to finish tasks, and skipping https://host1.medcohealth.com/medco/consu 26 Skalski AK, Smith MJ. Responding to the Signs of hyperactivity-impulsivity
are often where students’ mental health needs are discovered and where support is climbing, or leaving a seat at inappropriate provided. Principal Leadership. National times, blurting out answers, and difficulty http://www.nasponline.org/resources/principals agitation, tremors, muscle twitching,convulsions, euphoria, hallucinations, 27 SAMHSA. What a Difference a Friend Makes. Health Services Administration, 2005.
Available at http://download.ncadi.samhsa.
gov/ken/pdf/SMA07-4257/SMA07-4257.pdf.
NON-STIMULANT
Medications:28 FDA. FDA Proposes New Warnings about Suicidal Thinking, Behavior in Young Adults Who Take Andtidepressant Medications. FDA News, May 2, 2007. Available athttp://www.fda.gov/bbs/topics/NEWS/2007/NEW01624.html.
Antidepressants for depression, mood disorders, obsessive-compulsive disorder
Antidepressants—Revisions to ProductLabeling. FDA, May 2, 2007. Available at Depression Persistent sad, anxious, or
http://www.fda.gov/cder/drug/antidepressants/ “empty” mood; feelings of hopelessness, antidepressants_label_change_2007.pdf.
pessimism; feelings of guilt, worthlessness 30 FDA. FDA Public Health Advisory: Revisions pleasure in usual activities; slowed thinking Mental Illnesses, and Suicidal Thoughts or Actions. US FDA, May 2, 2007. Available athttp://www.fda.gov/ cder/drug/antidepressants/antidepressants_M Suicidality: Patients should be
February 21, 2007. Available athttp://www.fda.gov/bbs/topics/NEWS/2007/NEW01568.html.
Obsessive-compulsive disorder
32 FDA. Public Health Advisory—Combined Use (OCD) Recurrent unwanted ideas,
Serotonin Syndrome: Patients
thoughts, impulses, or images (obsessions) Inhibitors (SSRIs) or SelectiveSerotonin/Norepinephrine Reuptake threatening Serotonin Syndrome. US FDA.
medications prior to startingtreatment with triptans (such as http://www.fda.gov/cder/drug/advisory/SSRI_S Psychotropic Drugs Encountered in the HealthSuite Other anxiety disorders
33 Ritalin [package insert]. East Hanover, NJ: Panic disorder—sudden attacks of terror, Novartis Pharmaceuticals, Corp; April 2007.
34 Bezchlibnyk-Butler KZ,Virani AS (Eds.). Clinical pounding heart, sweating, faintness.
Handbook of Psychotropic Drugs for Children and Post-traumatic stress disorder (PTSD)—startled Adolescents. Cambridge, MA: Hogrefe & Huber response, irritability, aggression, violence.
35 Strattera [package insert]. Indianapolis, IN: Eli Social anxiety disorder (SAD)—extreme self- consciousness, fear of being watched, anxiety.
36 Prozac [package insert]. Indianapolis, IN: Eli Generalized anxiety disorder (GAD)— exaggerated worry or tension, insomnia;trembling, irritability.44 www.healthinschools.org
The Center for
Health and Health Care in Schools
Symptoms *
What To Watch For **
Psychotropic Drugs
Other psychotropic drugs used to manage ADD/ADHD, anxiety, or depression
and Children
Symptoms of anxiety: shakiness, jumpiness, trembling, tension, muscle aches, tiredness; inability to relax, twitching, fidgeting, 37 Fluvoxamine maleate [package insert].
Elizabeth, NJ; Purepac Pharmaceutical Co; 38 Anafranil [package insert]. Hazelwood, MO: 39 NIMH. Antidepressant Medications for Children breathing, fever, sore throat, swelling of and Adolescents: Information for Parents and Caregivers. NIMH, 2007. Available at Other anxiety disorders, as described above.
http://www.nimh.nih.gov/healthinformation/antidepressant_child.cfm.
Agitation, anxiety, insomnia; hypertension; possible hallucinations or delusions.Weight Adolescents. FDA News, Aug. 22, 2007.
Available at http://www.fda.gov/bbs/topics/NEWS/2007/NEW01686.html.
41 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM- IV-TR, Fourth Edition (Text Revision).
42 NIMH. Depression. Natl Institute of Mental Health, 2007. Available athttp://www.nimh.nih.gov/health/topics/depression/index.shtml.
Atypical Antipsychotics used in psychotic disorders and dementia
43 NIMH.When Unwanted Thoughts Take Over: Obsessive-Compulsive Disorder. NIMH, 2007.
respiratory infections; nausea, vomiting, http://www.nimh.nih.gov/health/publications/w hen-unwanted-thoughts-take-over-obsessive- 44 NIMH. Anxiety Disorders. National Institute of Mental Health, October 5, 2007. Available http://www.nimh.nih.gov/health/publications/an multiple conditions occurring together.
45 BuSpar [package insert]. Princeton, NJ: Bristol- 46 Wellbutrin [package insert]. Research Triangle 47 Inderal [package insert]. Philadelphia, PA: 48 Effexor [package insert]. Philadelphia, PA: Mood Stabilizers used for bipolar disorder and mania
49 NAMI. Effexor (venlafexine). National Alliance on Mental Illness Fact Sheet. 2007. Available at 50 Risperdal [package insert].Titusville, NJ: 51 Lithobid [package insert]. Marietta, GA: Solvay need for sleep; talkativeness, distractibility; 52 Depakote [package insert]. North Chicago, IL: 53 Yager J, Anderson AE. Anorexia Nervosa. N Engl J Med. 2005;353(14):1481-1488.
54 Spearing M. National Institute of Mental Health. Eating Disorders. Bethesda, MD: NIMH; Drugs used with eating disorders, specifically bulimia nervosa and binge-eating disorder; occasionally in
anorexia nervosa, after weight regain
Anorexia nervosa—Abnormal
restriction of eating due to intense fear of gaining weight or becoming fat; resistance to maintaining weight at or above aminimally normal weight for the age and Bulimia nervosa—Recurrent episodes
of binge eating, followed by forced purging
through self-induced vomiting, or use of
medications; fasting; excessive exercise.54 nervousness, insomnia; mania; agitation;decreased appetite; rash or hives;seizure; suicidality.28,29,30,36 Binge-eating disorder—Uncontrolled
eating (often rapidly and in great
quantities) without forced purging or
compensating behavior.54
www.healthinschools.org
The Center for
Health and Health Care in Schools
Mental Health Medications and the Risk of Suicide
Psychotropic Drugs
In May 2007, the FDA expanded the requirement for “black box” warningsto include all antidepressants.
and Children
• Antidepressants, which are often effective in treating depression and other mental disorders, carry a risk of harmful side effects and complications.
Mental Health Medications and the Risk of Some studies showed that antidepressants may cause suicidal thinking and Suicide55 Brent DA. Antidepressants and pediatric behavior in children and adolescents. In the studies, children taking depression—The risk of doing nothing. N Engl antidepressants had a 3.8% chance of developing suicidal thoughts or J Med. 2007;356(23):1598-1601.
behavior, compared with 2.1% of children taking placebos.55 56 FDA. Public Health Advisory: Suicidality in children and adolescents being treated with • These results prompted the FDA in 2004 to require that all antidepressants include a warning, printed in bold type, framed in a black border—the Drug Administration, October 15, 2004.
Available at http://fda.gov/cder/drug/ “black box”—at the top of the paper insert.56 57 Friedman RA, Leon AC. Expanding the black • Antidepressants also will come with a medication guide that advises parents box—depression, antidepressants, and the risk and caregivers about the risks and precautions.56 of suicide. N Engl J Med. 2007;356(23):2343-2345.
• Considering the warning, why use antidepressants? The FDA label itself 58 Gibbons RD, Hur K, Bhaumik DK, Mann JJ.
warns practitioners that the depression for which the medication is prescribed is the most important cause of suicidality.57 A 2006 study showed prescription rates and rate of early adolescentsuicide [Abstract]. Am J Psychiatry. that higher SSRI prescription rates were associated with lower suicide rates in children and adolescents.58 The greater risk may be in doing nothing.55 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17074941&ordinalpos=19 A child or adolescent taking antidepressant medication should be closely monitored for any &itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum.
changes in behavior, particularly when medication is initiated, or when dosing is changed or discontinued. Antidepressant therapy should not be stopped all at once but rather children and adolescents: information for discontinued gradually, on a tapering schedule, under the physician’s guidance.59 parents and caregivers. NIH, National Instituteof Mental Health. Available at Changes to watch for include worsening depression, emergence of suicidal thinking or http://www.nimh.nih.gov/healthinformation/ant behavior, or unusual behavior, such as sleeplessness, agitation, or withdrawal from normal 60 Gibbons RD, Brown H, Hur K, et al. Early Suicidal thinking, feeling, and behaviors are core symptoms of depression; consequently, there suicidality warnings on SSRI prescriptions and is no way to know whether suicidal symptoms that develop during treatment are due to the suicide in children and adolescents. Am JPsychiatry. 2007;164(9):1356-1363.
61 Libby AM, Brent DA, Morrato EH, et al.
An inverse relationship appears to exist between diagnoses of pediatric depression with Decline in treatment of pediatric depression prescriptions for SSRI antidepressants on one hand, and rates of suicide in children and after FDA advisory on risk of suicidality withSSRIs [Abstract]. Am J Psychiatry. adolescents on the other.60 Before SSRI antidepressants were introduced, the adolescent suicide rate tripled in two decades. When prescriptions for SSRI antidepressants increased for 62 Kurian BT, Ray WA, Arbogast PG, et al. Effect adolescent depression, suicide rates declined for a decade.55 In the two years following the of regulatory warnings on antidepressantprescribing for children and adolescents. Arch October 2004 FDA advisory, significant reductions in diagnosis of pediatric depression,61 and Pediatr Adolesc Med. 2007;161(7):690-696.
decreases in antidepressant prescriptions for children and adolescents were found,57,62 and 63 Bridge JA, Iyengar S, Salary CB, et al. Clinical these decreases were associated with increases in suicide rates in the same group.60 response and risk for reported suicidalideation and suicide attempts in pediatric Although depression and suicidal thinking are significant risk factors for suicide, depression in antidepressant treatment: a meta-analysis of patients in a 2004 fluoxetine study improved four times as often as suicidality developed.55 The benefits of antidepressants appear to be much greater than risks from suicidal thinking or behavior.63 Medication Administration in the School and
The Role of Schools
Medication Administration in the School
64 National Association of State Boards of • Forty-nine states have state-level school health policies. Of those, 36 states have mandatory or Education—State-Level School HealthPolicies: State-by-State Administration of recommended policies concerning administration of prescription medications at school. Ten states specifically address administration of psychotropic drugs.64 http://www.nasbe.org/HealthySchools/States/Topics.asp?Category=D&Topic=2.
• Control of prescription medications is particularly important in the school. Medications 65 US Drug Enforcement Administration.
administered at school should be taken in the presence of the school nurse or her designate.65 Stimulant Abuse by School Age Children:A Guidefor School Officials. US DOJ, DEA, Office of • Peers and family members are the leading sources of prescription drugs for illicit use by Diversion Control: June 2001. Available at http://www.deadiversion.usdoj.
gov/pubs/brochures/stimulant/stimulant_abuse.
• Students who use their prescription medications as prescribed are at a lower risk for probable drug abuse than individuals who have nonmedical use, or both medical and nonmedical useof prescription medications.66 • In 2003, the annual prevalence of illegal use of Ritalin was reported as 2.6% among 8th graders, 4.1% among 10th graders, and 4.0% among 12th graders.67 In 2006, the annualillegal use among 8th graders remained the same, in 10th graders use declined to 3.6%, andamong 12th graders illegal use increased to 4.4%.68 • One survey of more than 44,000 high school students found that nearly 7% reported having using methylphenidate (Ritalin) illicitly at least once and 2.5% reported using it monthly ormore often.65 www.healthinschools.org
The Center for
Health and Health Care in Schools
The Role of Schools: What to know, how to help64,66,69,70,71
Psychotropic Drugs
The FDA’s medication guidance does not prohibit the use of antidepressants in pediatricpopulations but urges caution in administration and vigilance in monitoring.
and Children
• Obtain from your state and local governments, and Board of Education the specific rules for medication storage and administration. (See box.) 66 McCabe SE, Boyd CJ,Young A. Medical and nonmedical use of prescription drugs among • Get to know the FDA resources on medications available on the FDA Web site, and be aware secondary school students. J Adol Health. of public health advisories issued by the agency.
67 Johnston LD, O’Malley PM, Bachman JG, • Be aware of the possible side effects of the drugs being administered; learn to recognize Schulenberg JE. Ecstasy use falls for second year symptoms of missed doses or overdosage. If you observe any of the behavioral warning in a row, overall teen drug use drops [pressrelease]. Ann Arbor: University of Michigan signs—worsening illness, or agitation, irritability, suicidality, and unusual changes in behavior—contact the physician or parent immediately.
19, 2003. Available athttp://www.monitoringthefuture.org.
• Ask parents to notify the school when dosing begins, any dosing changes are made, or 68 Johnston LD, O’Malley PM, Bachman JG, medication is replaced or discontinued. These are the times when the student is most likely to Schulenberg JE. Teen drug use continues down in experience changes or additional effects.
2006, particularly among older teens; but use ofprescription-type drugs remains high [press • Have an emergency plan for each student taking psychotropic medications, in case there is release]. University of Michigan News and ever a need to use one. Familiarize every relevant staff member with warning signs of Information Services: Ann Arbor, MI;December 21, 2006. Available at medication lapse, misuse, or abuse, and provide training on how to respond. http://www.monitoringthefuture.org/data/06data.html#2006data-drugs.
• Safeguard the privacy of students and protect them from any stigma that may be associated 69 AAP Policy Statement—Guidelines for the with their disorder or the administration of medications during school hours.
Administration of Medication in School.
Pediatrics. 2003;112(3):697-699.
70 U.S. Drug Enforcement Administration. Virginia Procedures for Medication Safety69,70,71
School Health Guidelines—General Guidelines forAdministering Medication in School. US DOJ, Prescription medications can be stored and distributed safely and securely at school.
DEA, Office of Diversion Control: June 2000.
Available at http://www.deadiversion.
Certain procedures will provide the surest handling: usdoj.gov/pubs/brochures/stimulant/vaschool_ • Obtain appropriate authorization forms from physicians and parents. 71 Maryland State Dept. of Education.
• Ask parents to bring the medication to the school, rather than sending it with the Administration of Medication in Schools: MD StateSchool Health Services Guideline. Baltimore, MD: MD State Department of Education; January • Ensure that medication is in the original container, bearing the name of the student, 2006. Available at http://www.marylandpublicschools.org/NR/rdonlyres/6561B955-9B4A- the name of the medication, dosage and timing, the name and phone number of the prescribing physician, with a copy of the package insert. • Review the MedGuide provided with some medications. • Store medications in a properly secured, controlled space. • Observe students taking medication, to ensure the dose is consumed.
• Keep accurate and complete records of all administration.
Resources
Government Resources

Non-Government Resources
Mental Health America
National Mental Health Association
National Institute of Mental Health
Bright Futures
National Alliance on Mental Illness
Children and Adults with Attention-
Supported by a grant from
US Food and Drug Administration
Deficit/Hyperactivity Disorder
the Robert Wood Johnson
Foundation
http://www.fda.gov/cder/drug/antidepressants/default.htm The Five Rights
The Center for
of medication administration
Health and Health Care in Schools
• The right patient
School of Public Health and Health ServicesThe George Washington University • Receives the right drug
• In the right dose
Washington, DC 20037202-466-3396 fax: 202-466-3467 • By the right route
• At the right time.
www.healthinschools.org

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