issues in monitoring medication effects in the classroom

Psychology in the Schools, Vol. 46(9), 2009 C© 2009 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/pits.20422

ISSUES IN MONITORING MEDICATION EFFECTS IN THE CLASSROOM

LAURA ANDERSON AND CHRISTY M. WALCOTT

East Carolina University

SARAH G. RECK AND STEVEN LANDAU

Illinois State University

The task of medication monitoring in the schools has increased for school psychologists, yetthere is little research specific to pediatric psychoactive medication. The current article reviewsissues pertinent to school-based medication monitoring. Feasibility, acceptability, and perceptionof effectiveness are reviewed as fundamental considerations before implementing a medication-monitoring plan in the schools. The importance of individualization, ecological implementation,and development of socially valid objectives is stressed along with the need for additional research,tools, and measures in this area. Practical considerations for school psychologists include discussionof parental consent and confidentiality, multilevel assessment and monitoring, data recording, anddetermining clinical significance. C© 2009 Wiley Periodicals, Inc.

Increasing numbers of children are prescribed psychoactive medications, and presenting symp-toms typically permeate multiple ecologies. The school environment is one critical context formedication monitoring. Guidelines from the American Academy of Pediatrics (AAP) have em-phasized the importance of school-based data in medication-monitoring protocols (AAP, 2001).Likewise, researchers have long advocated for school psychologist involvement in medication mon-itoring due to specialized training and access to school data (e.g., Pelham, 1993; Power, Atkins,Osborne, & Blum, 1994; Wodrich & Landau, 1999). As pediatric psychopharmacology is an emer-gent field, responsible prescribing physicians typically seek feedback from both parents and schoolpersonnel regarding a child’s response to medication. Even a well-researched medication, proveneffective across various populations and settings and delivered with high treatment integrity, mayfail to produce a positive response for a particular child. Furthermore, given referral concerns andtreatment objectives, assessment should be a continuous feedback loop, with medication monitor-ing and cross-ecological symptom evaluation driving decision making (Anderson & Phelps, 2009).School-based practitioners are well-suited to facilitate this process.

Medication monitoring, implemented with fidelity, epitomizes the response to intervention(RTI) model. Recent research suggests that careful, individualized monitoring is a necessity—especially for those students presenting with particularly problematic externalizing behavioral pro-files (Molina et al., 2009). The National Institute of Mental Health Collaborative Multisite Multi-modal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA) recentlyreleased the results of an 8-year follow-up study. These data revealed little in terms of systematicpositive results for interventions and suggested the demand for (a) early intervention and monitoring;(b) multimodal, individualized treatment and monitoring plans; and (c) innovative future work in thisarea (Hendren, 2009; Molina et al., 2009). The need for scientist-practitioners who are well-trainedin school-based medication monitoring is irrefutable.

Indeed, well-trained practitioners coordinate school-based medication monitoring with multiplecomponents. Medication monitoring is neither a simple evaluation of symptom reduction nor ameasure of positive response to a prescription medication. Risk–benefit considerations must beongoing, especially given frequent off-label prescribing in the pediatric population (AAP Committee

Correspondence to: Laura Anderson, Department of Psychology, East Carolina University, 104 Rawl Building,Greenville, NC 27858-4353. E-mail: [email protected]

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Medication Monitoring 821

on Drugs, 2002; Anderson & Phelps, in press; Phelps, Brown, & Power, 2002). To closely monitormedication effects, examine drug responsiveness, and determine the suitability of a medicationregimen for a particular child, brief controlled trials may be the most feasible option for school-based practitioners. Single-subject, data-driven designs seem particularly well-suited for informingprofessionals as to the impact of pharmacological treatments on a child’s functioning.

The above empirical and training issues suggest that school psychologists are the optimal co-ordinators of medication monitoring (Abrams, Flood, & Phelps, 2006; DuPaul, Coniglio, & Nebrig,2004; Volpe, Heick, & Gureasko-Moore, 2005). Carrying out this function with elevated ecologicalvalidity requires attention to fundamental considerations similar to those cited by Gureasko-Moore,DuPaul, and Power (2005): acceptability, feasibility, and perceived effectiveness. This article at-tends to such matters to inform best practice. For example, how might medication acceptabilityor treatment integrity influence the specific objectives of the school-based medication-monitoringplan? Although a specific protocol for medication monitoring would surpass the scope of this article,the reader will find specific guides in Carlson (2007); DuPaul and Carlson (2005); Pelham (1993);and Power, DuPaul, Shapiro, and Kazak (2003). It is critical to note, however, that the field of pe-diatric psychopharmacology is young; an informed scientist-practitioner will emphasize proximal,functional monitoring techniques within the context of a collaborative team-based model.

ECOLOGICALLY VALID MEDICATION MONITORING: FUNDAMENTAL CONSIDERATIONS

Nelson and Steele (2006) emphasized the importance of attending to multiple levels of treatmentevaluation. For example, medication monitoring is only one facet of a comprehensive, multifacetedmodel considering cost effectiveness, consumer satisfaction, provider evaluation, and outcome eval-uation (Nelson & Steele, 2006). Our discussion adjusts somewhat when framed within the contextof school-based medication monitoring. Consider provider evaluation within Nelson and Steele’smodel, for example, which refers to the perceived acceptability of or satisfaction with a particularintervention or treatment protocol. Given the modern context of school psychology and associatedstressors, we cannot recommend bloated medication-monitoring protocols that we would not im-plement ourselves. In the current flurry of evidence-based practice and RTI, it would be a mistakefor persons who deliver treatment protocols to de-emphasize the evaluation of acceptability andappeal of these techniques. For example, Gureasko-Moore and colleagues (2005) surveyed schoolpsychologists. Practitioners rated reduced time, inefficient measures, and reduced access to physi-cians as impediments to medication monitoring. These features were also correlated with lowerevaluations of the utility of medication monitoring. Likewise, recent literature and policy suggestthat the ecological considerations cannot be ignored, regardless of the protocol of choice (DuPaulet al., 2004; Nelson & Steele, 2006). School psychologists working within school systems requirefeasible and acceptable monitoring approaches (Abrams et al., 2006; Volpe et al., 2005).

Fundamental Consideration #1: Acceptability of Medication-Monitoring Plan

The use of psychoactive medication with children is a sensitive issue unto itself. Considerablemedia attention has been given to black box labeling, cost–benefit analyses, and side-effect profilesof psychotropic medications in children and adolescents (Abrams et al., 2006; Anderson & Phelps,2009). Parents may be self-conscious and sensitive about others having this information. Schoolpsychologists must be aware of barriers to parent acceptability of medication monitoring, especiallywhen children are first prescribed medication.

For example, at our local medical school pediatric outpatient clinic, staffed by a bilingualpediatric school psychologist, most prescribing physicians automatically write one prescription withan order for home–school duplicate bottles for any child prescribed a shorter-acting psychoactive

Psychology in the Schools DOI: 10.1002/pits

822 Anderson et al.

medication. The parent is empowered during the first medication encounter to communicate openlywith the school. We are uncertain if duplicate bottling is the norm or exception (i.e., our literaturesearch yielded unreliable results); however, this practice seems to suggest to parents that home–school communication is important and to increase openness to involving school personnel inmonitoring plans. This area is ripe for future work. Parents who receive transparent information andsupport from practitioners may be more amenable to school-based medication-monitoring practices.

Teachers are critical members of the medication-monitoring team. Teachers may have an evengreater need for transparent, sensitive discourse, given their relatively less proximal relationshipto the child (i.e., versus parent). They may have limited or inaccurate information in terms ofpediatric psychopharmacology, yet knowledge about treatment typically informs acceptability ofinterventions (Von Brock & Elliott, 1987). There is currently little research specific to the influenceof teacher knowledge on acceptability of medication monitoring (DuPaul et al., 2004); however,in a related line of research, Wodrich and colleagues have linked increased teacher knowledge ofchronic health impairments with more positive teacher attributions and greater perceived ability togenerate appropriate accommodations (Cunningham & Wodrich, 2006; Wodrich, 2005). It is likelythat an informative, transparent, and sensitive approach could increase teachers’ acceptability of amonitoring plan. Volpe and colleagues (2005) provide a unique rating scale for assessing teacheracceptability of medication-monitoring procedures.

Fundamental Consideration #2: Feasibility of School-Based Medication Monitoring

Volpe and colleagues (2005) have called attention to a much-needed set of tools for school-basedmedication monitoring. Although blinded, placebo-controlled trials produce the most internally validresults, they are not typically feasible for school-based practitioners given the resources required.Furthermore, a validated, standardized scale for medication monitoring would likely make med-ication monitoring more feasible for school psychologists (Gureasko-Moore et al., 2005). Datacollection and communication across parents, medical personnel, and school staff are also consid-erably difficult for an average school psychologist with a typical caseload (DuPaul et al., 2004;Gureasko-Moore et al., 2005). Along those lines, with more children being prescribed psychoactivemedication in conjunction with school budget reductions, medication monitoring with validity andfidelity may be unfeasible without innovative change.

Fundamental Consideration #3: Perceived Effectiveness of School-BasedMedication Monitoring

What medication-monitoring techniques do school psychologists perceive to be effective?There has been limited research in this area. Student grades, student self-report, and curriculum-based assessment have been given the lowest ratings by school psychologists and, thus, may beunlikely to be used with high fidelity. In contrast, school psychologists rated direct observations,teacher ratings, and teacher interviews as the most effective methods for medication monitoring(Gureasko-Moore et al., 2005). Typically, high levels of communication with and trust in a physiciancontribute to perceived effectiveness and greater adherence to treatment protocols (Thom, Hall, &Pawlson, 2004). It is reasonable to assume that higher levels of trust and communication betweenthe school psychologist and other key players (parents, teachers) will also increase adherence to amedication-monitoring protocol.

SOCIALLY VALID MEDICATION-MONITORING OBJECTIVES

Medication monitoring that is acceptable, feasible, and perceived as effective must involvemeaningful informants and contexts of the child’s life. With this in mind, the school-based team



can formulate socially valid objectives for medication monitoring that not only include reductionof core symptoms associated with the impairment, but also improve the daily life functioningof the child (i.e., by reducing the functional impairment of the disorder) (DuPaul et al., 2004;Pelham, 1993). No doubt, the monitoring plan may encompass specific medication administrationor follow-through procedures, as applicable to the individual/family; however, the primary emphasiswill likely be specific behavioral goals related to symptom reduction (e.g., out-of-seat behavior),increased academic production, and improved social interactions with peers.

Socially valid objectives are particularly important in monitoring response to pharmacologicaltreatments because research has found that determining proper dosage may depend on the outcomesconsidered. Most research in this area has examined children with Attention-Deficit/HyperactivityDisorder (ADHD). For example, higher doses of stimulant medications were not superior to lowerdoses when examining improvements in social behavior (Pelham et al., 1999) or academic tasks(Swanson et al., 1998). The most recent MTA results have further reiterated the need for highlyindividualized, socially valid medication-monitoring objectives (Molina et al., 2009).

IMPLICATIONS FOR SCHOOL PRACTITIONERS

The optimal medication-monitoring plan will have social validity and utility for the child as wellas ecological validity, being feasible, acceptable, and perceived as effective across contexts. Althoughempirical data are still emerging, there are several practical implications for school psychologists toconsider.

Confidentiality and Parent Consent

As aforementioned, trust and knowledge contribute to intervention fidelity. If medication mon-itoring is our intervention, school psychologists should strive to gain the trust and respect of theparent first and foremost, while keeping in mind the inherent sensitivity of this matter. Even the mostsensitive school psychologist can lose sight of this when data are demonstrating positive momen-tum. Cultural sensitivity is critical as well. Extended family members and/or members of a spiritualcommunity who are close to a family may ultimately be involved in the medication-monitoring plan.The school psychologist may choose to extend an invitation to the parent regarding a confidentialsupport person to include in the medication-monitoring plan: “Is there anyone in your extendedfamily or community whom you would like to include? Would you like to invite that person to ourmeeting?” Having an additional support person during the first medication-monitoring contact mayput the parent at ease.

Of course, the physician should be invited as a collaborative school-clinic gesture. It is possiblethat a social worker, pediatric nurse, or other representative from the physician’s office could attendthe meeting, given the limited availability of most physicians. A conference-call option is oneway to increase the likelihood of physician contact, at least in our practitioner experiences. Finally,if the physician prescribed duplicate bottles for home and school or a similarly aligned action, theschool-based team is encouraged to reinforce this plan with a positive note or similar gesture.

Multifaceted Assessment and Monitoring

Effective medication monitoring should aggregate hard data across levels. Unfortunately, thereare no scales currently designed for this explicit purpose. Standardized behavior-rating scales canbe used, and some have demonstrable sensitivity to medication effects (e.g., see Angello et al.,2003). Pelham’s Daily Report Card (DRC) (1993) also has been found to be sensitive to changes inprescription medication when implemented with fidelity. Because a socially valid treatment protocolshould include monitoring the functional impairment of a child’s disorder, other potential scales


824 Anderson et al.

have emerged to assess problems in daily life functions. These include the adaptive functioningsubscales on the Achenbach System of Empirically Based Assessment (ASEBA) and the BehaviorAssessment System for Children, Second Edition (BASC-II). In addition, Fabiano and colleagueshave developed a brief and practical tool called the Impairment Rating Scale (IRS) to assess multipleareas of psychosocial impairment (Fabiano et al., 2006). This scale also has demonstrated sensitivityto changes in medication (Fabiano et al., 2007).

There are more practical resources emerging for single case design. For example, Riley-Tillmanand Burns (2009) developed a practical guide that may be well-suited for medication monitoring.Indeed, recent research suggests that highly individualized goals and monitoring strategies are re-quired when dealing with complex behavioral disorders requiring psychoactive medication (Molinaet al., 2009). Volpe and colleagues (2005) recommend the Agile consultative model for medicationevaluation and, as noted, have published treatment acceptability scales related to this model. Ulti-mately, documented, sensitive data points for each specific objective are critical to achieve effectivemonitoring. The Volpe et al. application of the Agile model is useful because of its attention toacceptability of monitoring and documentation.

Reporting Results

When engaged in a functional medication-monitoring plan, data should move bidirectionally.Data should include feedback from all informants whenever possible, and the school psychologistmay vary the format of presentation (e.g., brief consultation report versus table versus graph ver-sus raw data). Physicians must be updated regularly. Weekly communication with the physician’soffice is highly recommended during the initial titrating stages (DuPaul et al., 2004). In fact, manypediatricians report a desire for more information from the schools (Gureasko-Moore et al., 2005).Additionally, whenever possible, any experimental controls should be explicitly documented.

Finally, children may be capable of reporting data specific to psychostimulant medicationeffectiveness, although this research is only emerging (Thorell & Dahlstrom, 2009). Regardless,self-monitoring could be incorporated into the plan, depending on the child’s age. Of course,any child-derived data must be considered within the context of cognition, development, social–emotional functioning, and motivation.

Determining Clinical Significance

Clinical significance is the practical importance of an intervention effect (Kazdin, 1999). Theteam monitoring medication effects must determine which specific changes are desired and howmuch improvement is enough. Traditionally, change was considered clinically significant if coresymptoms diminished from the clinical range to the acceptable or functional range after takingmedication for a specified time period. Clinical significance is often assessed by measuring the levelof symptom reduction, but how much change is sufficient to consider the pharmacological treatmentsuccessful?

Kazdin (1999) suggests that the level of a child’s impairment is an important index of clinicalsignificance. Some children may have symptoms of a disorder but may function well at homeand school, whereas others may continue to struggle with school or peer relationships despite areduction in their core symptoms. For example, research suggests that children with ADHD whosecore symptoms of inattention, hyperactivity, and impulsivity significantly lessen in response tostimulant medications may nonetheless continue to have peer relationship problems (Hoza et al.,2005). As such, it is essential to consider other measures of clinical significance beyond symptomreduction, such as improvements in quality of life and specific functional skills required acrosscontexts (Gladis, Gosch, Dishuk, & Crits-Christoph, 1999).



SUMMARY

School-based psychoactive medication monitoring is a multilevel process requiring increasinginvolvement by school psychologists, especially given the growing numbers of students receivingpsychotropic medications during the school day. Team-based, collaborative strategies are funda-mental to the process. Feasible and acceptable monitoring methods have the greatest chances ofbeing implemented with fidelity. As Gureasko-Moore et al. (2005) indicated, perceived effective-ness is an additional fundamental consideration when attempting to carry out an effective school-based medication-monitoring plan. There are many practical implications for school psychologists;however, empirically based standardized tools and techniques for socially and ecologically validmedication monitoring are lacking. This area is in need of investigation and innovation.

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