The Medicated Child

The number of students who take medication at school continues to grow

By Kathleen Vail

Every year, the Los Angeles Unified School District doles out about 450,000 doses of medication to its students. Children are taking a variety of medicines -- anything from short-term antibiotics to insulin, psychotropic drugs, and medications to treat asthma, says Karen Maiorca, director of nursing services for L.A. Unified. In the district, the nation's second largest, 70,000 children have asthma and 1,600 have diabetes.

L.A. Unified is hardly alone among school districts in the heavy responsibilities it bears in handing out medicine to students. Schools all over the country -- in rural, suburban, and urban districts of all sizes -- are helping their students manage chronic and acute illnesses, both physical and mental.

About 13 million children in kindergarten through 12th grade take medication in any two-week time period, according to a study by Ann Marie McCarthy, an associate professor at the University of Iowa. Most common are AD/HD medications, followed by over-the-counter and asthma medications, respectively. In another study, looking at changes in medication in schools, McCarthy found that students were taking about 200 different kinds of medications in 2003, up from the 58 found in a late 1980s study.

Pharmaceuticals and pediatrics

Not only is there an increase in the variety of medicines being dispensed, but more children than in past decades are taking behavioral and mood-regulating medication. And doctors are prescribing more medicines for childhood illness that must be taken during the school day.

According to a study by Medco Health Solutions, spending on drugs to treat behavioral problems in children increased 77 percent from 2000 to 2003. Spending on all other pediatric drugs increased by 23 percent in that same period.

Many of these powerful drugs have serious side effects and must be taken at precise times in exact doses. For example:

• Ritalin and some other attention-deficit drugs may need to be taken in small doses throughout the day.

• Diabetic children must monitor their blood sugar all day and receive insulin shots based on those readings.

• Children with severe food allergies must have epinephrine nearby in case of anaphylactic shock.

• Asthmatic children need their inhalers close at hand when they become short of breath.

All of these factors make prescription drug use by children during the school day more common than ever before.

"People need to understand that kids get their health care from a system where the role of drugs has increased, because we know how to tinker with how the body works, and drugs are the vehicle," says Julia Graham Lear, executive director of the Washington, D.C.-based Center for Health and Health Care in Schools, which provides resources on school-based health.

Despite a growing chorus of parents and others who question what they consider a rush to medicate children, the number of children who take medication at school continues to grow. "Just as pharmaceuticals are playing a role in adults' health care," says Lear, "they are playing an increasing role in pediatrics."

At the same time, the number of school nurses is falling. According to the National Association of School Nurses, the recommended ratio of school nurses to students is one school nurse to every 750 students. In reality, the national ratio is just one to 1,350 children. This means many children are getting their daily doses of medication from people without a medical background, most often a health aide, secretary, teacher, or counselor.

Under these conditions, it's especially important that schools redouble their efforts to make sure they have a safe and secure process in place for dispensing medicine. The issue of medication management, says Lear, "is not going to go away."

The law and drugs

Many states and school districts regulate how schools handle prescription and nonprescription drug use among students. Commonly, these laws and policies, written during the zero-tolerance era, emphasize concern over illegal use and abuse of drugs. We hear, for example, of students being suspended for having Tylenol in their pockets or backpacks.

However, state lawmakers, educators, and others have begun to recognize the need to revise zero-tolerance policies to allow students to carry their own prescription medications when necessary.

Stark cases point up the need for change. For example, in 1999, a California mother was awarded $9.9 million (later reduced to $2.23 million) in a lawsuit against the Hanford Elementary School District. Her son, a fifth-grader, died from an asthma attack in the school office while staff members tried to put together his nebulizer.

The boy's mother sued the district, saying school officials never told her that her son could have carried his inhaler with him if she'd gotten a doctor's note saying it was necessary.

In September 2004, the California legislature passed two laws, one allowing children to carry asthma inhalers, the other allowing them to carry and administer auto-injectable epinephrine for severe, potentially fatal allergic reactions. While many districts in California and elsewhere were spurred by the Hanford tragedy to allow students to bring their asthma medication to school and keep it close by, some have not changed their policies.

California Assemblywoman Sarah Reyes, D-Fresno, who introduced the legislation, told the Modesto Bee, "I had heard from many parents of asthmatics that their kids were not able to get their asthma medication because it was stored in the [school nurse's] office, and they could not understand why their children could not carry their asthma medication with them."

Just days after Gov. Arnold Schwarzenegger signed the California legislation, Congress approved a bill that encourages states to pass similar laws that allow asthmatic students to carry and administer their own medication. Under the federal law, the U.S. Department of Health and Human Services gives preference to states with inhaler laws when awarding grants for asthma-related programs.

While the federal law doesn't have a lot of teeth, it does underscore the growing concerns about the way schools handle student medication issues.

The role of the school nurse

In LA Unified, lunch is a busy time. That's when 1,100 diabetic children need their insulin shots. "We're scrambling to deploy nurses," says Maiorca.

Most school and state policies spell out what nonmedical staff can and cannot do -- at L.A. Unified, nonmedical staff cannot give insulin injections, which must be administered by a school nurse. The district provides training for the thousands of nonmedical personnel who are responsible for giving out medication in other forms, however, and has developed a training video as well.

Clearly, such training is necessary. In a survey of school nurses by the University of Iowa's McCarthy, about half of the respondents reported medication errors -- most frequently allowing a child to miss a dose. According to the survey, 76 percent of the school nurses said they use various nonmedical school staff to help dispense medication -- including secretaries, health aides, and teachers.

Staff members who dispense medicine need to be sure they have the right child, the right medication, and the right time, says Janice Hootman, president of the National Association of School Nurses and nursing supervisor for the Multnomah Education Service District in Portland, Ore.

It's a matter of safety. If different people are assigned to the job, Hootman says, there's a potential for confusion among the children -- as well as a potential for students to miss doses and for adults to miss symptoms and side effects. Schools are vulnerable to liability in this area.

"If you don't do things by the standard of practice," she says, "you can be held accountable for poor performance."

How can you make it safer?

Schools are not doctors' offices; their mission is to educate, not diagnose and treat. Still, it's abundantly clear that the physical and mental well-being of children influences how well they learn, and their medical conditions are the schools' concern during the school day. And that means -- among other things -- responsible management of children's medication.

School officials need not shoulder this burden alone, however. The Center for Health and Health Care in Schools, with funding from the Robert Wood Johnson Foundation, is seeking information and consensus among educators and health workers about medication management in schools.

The center has produced a paper titled "A Systems Approach to Reducing Risk and Strengthening Quality in School Medication Management," which recommends ways districts can systemically make sure that children are getting their medication safely.

The paper includes these recommendations:

• Policy. Districts should have a concise, written policy on medication and make that policy available to everyone -- staff, students, and parents. The policy should spell out the responsibility of the school and the district in medication management, including which school staff members will be dispensing the medications. Parents' responsibilities should be listed as well, including making sure they provide medicine in original containers. Regulations about over-the-counter drugs and whether students are allowed to self-medicate (in the case of asthma inhalers) should also be included.

• Delegation. If your state law allows you to delegate the dispensing of medication to nonmedical staff at school, make sure that these staff members are trained and that everyone in the school knows who they are. One way to do this is to ask your school nurse, or the agency responsible for school health in your district, to register the names and responsibilities of all employees who provide medication, making sure they all understand their duties.

• Documentation. It's important to have a systematic way of recording -- in a handwritten log or on a computer spreadsheet -- each time a child takes a dose of medication. This documentation, with the child's name, medication, and the date and time of taking it, will provide a record for parents, and it could protect the school district from liability.

• Process. Find out if your medication management program is safe by having your school nurse and the nonmedical staff members who dispense medication review the processes and procedures they follow. To ensure safety, they should ask students their names and compare the names with the medication labels before dispensing each dose. Even better, they can attach the students' photos to their medication bottles.

Another way to prevent errors is to make sure students receive their medication in a physical environment that is not chaotic. For example, if a large number of students arrive at the same time, is there a lot of noise and confusion in the front office or the nurse's office? If the school secretary dispenses medication, is he or she also required to answer telephones and perform other duties at the same time?

• Security. Take steps to ensure that drugs are locked away to prevent theft, but also make sure that whoever has access to the keys is readily available.

• Standards. Schools should contact local medical professionals to learn the standards for managing medical conditions and then be scrupulous in following them. If they cannot document that they followed the standards in their medication management program, they could be vulnerable to lawsuits.

• Communication with medical professionals. It can be difficult for educators to get a handle on these complex issues. After all, schools are not medical centers. It's important, then, for schools to ask for help from medical professionals in their communities. Likewise, local medical professionals need to see schools as partners, as well.

The aim, of course, is healthy students who are ready and able to learn. As Hootman, who worked on these recommendations, put it, "Schools want to attain ultimate safety for children."