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This is to certify that the

thesis entitled
The number and types of interventions developed and
employed by an Advanced Nurse Practitioner for the
population of ADHD students in a middle-sized urban
school district in Michigan Title I Health Program
during the 1995- 1996 school year.

presented by

Rhoda Kahn

has been accepted towards fulfillment

of the requirements for

Master of Science Nursing
degree in

 

 

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The number and types of interventions developed and employed for a population of
ADHD students by an Advanced Nurse Practitioner
in a middle-sized urban school district in Michigan Title I Health Program
during the 1995-1996 school year.
By

Rhoda Kahn

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1997

ABSTRACT
THE NUMBER AND TYPES OF INTERVENTIONS DEVELOPED AND EMPLOYED
FOR A POPULATION OF ADHD STUDENTS
BY AN ADVANCED NURSE PRACTITIONER
IN A MIDDLE-SIZED SCHOOL DISTRICT IN MICHIGAN
TITLE I HEALTH PROGRAM
DURING THE 1995-1996 SCHOOL YEAR
By

Rhoda Kahn

ADHD is a disorder affecting a sizable percentage of the school population.
Without intervention this problem leads to a higher degree of psychosocial difficulties
and emotional maladjustment than occurs in the general population. In order to explore
the role of an Advanced Nurse Practitioner in managing this disorder in a school setting,
a data analysis was done of the number and types of interventions developed and
employed for a subset of ADHD students in a Title 1 Health Program. The 17
interventions were categorized according to the Omaha System of data organization.
Imogene King’s Systems framework was utilized as a means of examining these
interventions in the light of nursing theory. The Study indicated that the ADHD
population required more intensive intervention than the other illnesses and disorders
provided care in the Title I Health Program. Findings revealed that case management, or

coordination of care, was the area of greatest need for the ADHD children.

ACKNOWLEDGMENTS.

This work would not have been possible without the assistance of the Advanced
Practice Nurse in a middle-sized urban Michigan school district. Her willingness to share
data and methods for intervention have given me a better understanding of the multiple
and complex needs of students with ADHD or ADHD-like characteristics.

My thesis chair, Linda Spence, has devoted much time in assisting me with the
thesis process. Her efforts and encouragement are deeply appreciated. The other
committee members, Joan Wood and Jackie Wright, have also generously given of their
time and expertise. I have been privileged to work on this project with these
distinguished faculty members. A

Finally, I would like to thank my husband, Theodore Kahn, and my children,
Jeremy, Cynthia, David and Daniel, for their encouragement and support during the
writing of this thesis. It is a time-consuming process, and they have been patient and
understanding. Jeremy and Cynthia’s knowledge of the computer has also been

invaluable.

iii

TABLE OF CONTENTS

INTRODUCTION...

Background of the problem
Statement of purpose...

CONCEPTUALFRAMEWORK.....
OverviewofKing’smodel.........................................................
Conceptualdefinitions.............
Personalsystems............................
Interpersonalsystems.......
Social Systems

Personal systems... .. ..
Pharmacological interVention”
Interpersonal systems...

Social Systems...

Summary and critique of literature review”

METHODOLOGY... . . .

Research design...
Instrumentation“
Description of the subjects

Vi

viii

..hu—t

10
10
12
15
16

16
16
22
24
25
28

29
29
29
32

Datasummarizingprocedures...............................
Protectionofhumansubjects........

RESULTS...

Description of sample in relation to the larger population... .. ..

Summary...

DISCUSSION... .
Interpretation of the findings
Limitations...
Significance to nursing... .. ..
Implications for further research
Summary and conclusions...

LIST OF REFERENCES......... ....

32
33

34
34
47

47
47
50
52
55
56

59
61.
62
63

64

Table 1.:

Table 2:

Table 3:

Table 4:

Table 5:

Table 6:

Table 7:

Table 8:

Table 9:

Table 10:

Table l 1:

LIST OF TABLES

Primary reason for initial referral to the Title I Health Program.

Number of total contacts per student with the Title I Health
Program during the 1995-1996 school year...

The ten most frequent health programs identified for the Title I
Health Program students described by the number of times a

nursing intervention occurred for each problem... . . ..

Distribution of ADI—ID students and nursing interventions by
school building for the 1995-1996 school year...

Most frequent nursing interventions for all students and ADHD
students 1n the Title I Health Program during the 1995-1996
schoolyear...
Number of initial interventions per grade for students with
ADHD and number of follow-up interventions for the 1995-
1996 school year... .. .. . .. ...

Nursing interventions for the subset of ADHD students for the
1995-1996 school year... ..

Medication used in treatment of ADHD in the Title 1 Health
Program during the 1995-1996 school year... ..

Communication methods utilized in the Title I Health Program

subset ofstudents with ADHD

Case management nursing activities for ADHD students in the
Title I Health Program...

Health teaching, guidance, and counseling... .....

Page
34

35

36

38

39

4O

41

42

43

44

45

Table 12: Treatments and procedures.........

Table13: Surveillance

vii

46

47

Figure l :

Figure 2:
Figure 3:

Figure 4:

LIST OF FIGURES

Page
The four categories listing nursing interventions utilized in the Title I Health
Program for the ADHD population according to the Omaha System of
Classification ............................................................................ 6
A conceptual framework for nursing: dynamic interacting systems ............ 8
A process of human interactions ..................................................... 14
APN interventions related to the ADHD student utilizing a modification of
Imogene King’s Conceptual Framework and the Omaha System of
Classification ............................................................................ 3 1

viii

INTRODUCTION

Background of the Problem

Attention Deficit Hyperactivity Disorder (ADHD) is characterized as a “persistent
pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe
than is typically observed in individuals at a comparable level of development” (DSM-
IV, 1994, p. 78). The brain is unable to adequately filter information in this medical 1
condition. (Rector & Young, 1994, p. 8). The multifaceted and complex nature of this
malady is underscored by the fact that the DSM-IV (the Diagnostic and Statistical
Manual of Mental Disorders) lists 18 items, six (or more) are required in order to confirm
the diagnosis. (See Appendix A) Because of its complicated nature, intervention is
necessary in order to assist children with ADHD to achieve their full potential.

Diagnosis of ADHD is difficult, and generally requires input from a number of
sources, including parents, teachers and health care providers. There is not yet a single
diagnostic tool which will confirm the presence of the disorder. Currently it takes a
comprehensive, intensive effort from all of these sources in order to make an accurate
evaluation.

ADHD is a prevalent disorder. Although sources vary somewhat, it has been
estimated that three to five percent of children in the elementary school age group in the
United States may be afflicted, with a significantly greater number of boys thus affected
than girls. (Williams, 1995, p. 102). No cultural, racial, or social group is untouched by
such incidence, though it appears more frequently in some than in others. With such a

large percentage of youngsters affected, it can be deduced that every classroom is likely

2

to have one or more children with ADHD. Thus, the scope of the problem is enormous
and widespread.

Theories abound as to the causes, but it seems apparent that there are multiple
contributing factors. It appears that the etiology may include family or genetic factors,
biochemical factors, neurophysiologic factors, gross or minimal brain damage,
environmental and/or dietary factors (Barkley, 1981). As the DSM-IV delineates, there
are varying symptoms and contexts, but a certain number must always be present. To
add further confusion and thus making diagnosis more challenging, there are subtypes of
the disorder, with some persons manifesting only one pattern predominantly (DSM-IV,
1994, p. 80). Finally, there are a number of associated features and mental disorders
which might be found in the individual.

“The core characteristics (i.e., inattention, impulsivity, and overactivity) of
ADI-ID can lead to a myriad of difficulties for children in school settings” (DuPaul &
Stoner, 1994, p. 3). The behavioral manifestations of the ADHD child include disruption
in the classroom and poor achievement levels. Without assistance, it is difficult for
teachers to make a significant difference in reversing these problems. Reasons for this
may partially be due to the difficulty in implementing the behavioral modification that
ADHD students need in a regular classroom. The normal classroom, which may range
from 25 to 30 students, leaves the teacher with little extra time. In addition, there are
other needs of these children, which include periodic health care management,
medication, and related social services which cannot be provided in the classroom setting
alone. Thus, even with valiant attempts on the part of teachers to provide help, the

student’s behavior ofien remains a source of classroom disruption. This frequently has

3

both short and long-term negative consequences in terms of self-esteem on the part of the
youngster, and frustration for the well-meaning teacher.

Once it was thought that this disorder was “outgrown” in adolescence, but this
philosophy is no longer the case. It is now understood to be a relatively persistent
condition which manifests itself early in life and tends to endure over time, resulting in
impairments in psychosocial behavior and occupational functioning. (Cantwell & Baker,
1987, p. 43). Adults with ADHD exhibit inattentiveness or hyperactivity. The adult may
also have an “inability to complete tasks, impaired personal relationships or inability to
sustain relationships over time, hot or explosive temper, and stress intolerance” (Krener,
1995, p. 259). Needless to say, such behavior creates many difficulties in daily living for
the person so afflicted.

The basis for much of the emotional dysfunction of adults with ADHD stems
from the childhood problems relating to the disorder. The manifestations of
hyperactivity and impulsivity create conflicts with peers as well as others. Intense
feelings of being bad which often precede low self-esteem and depression is a common
finding in students with ADHD. These students typically do not have many friends
(Bishop & Beyer, 1995, p. 40).

Studies have shown that children from poor families frequently have a higher
proportion of developmental disabilities, chronic illness, and other disorders than
children from families in higher income brackets. “A chaotic, stressed, unstable
environment (frequently seen in children living in poverty) seems to produce more

hyperactive, out-of control children” (Murphy & Hagerman, 1992, p. 4). Thus, these

4

children are at an even higher risk for difficulty or failure in school for multiple reasons,
among which is their economic status.

Awareness of the health care needs in their student body prompted a middle-sized
urban school district to institute a Title 1 Health Program to provide services for certain
populations of children. The majority of these youngsters are disadvantaged, and have
achievement levels which lag behind others in the classroom. The program is managed
by a master’s prepared APN.
fiatement of purpose

The contribution of the Title I Health Program in the care of children with ADHD
is significant. Research in the area of school-based health care should add to the body of
nursing knowledge related to school children with ADHD and how those needs can be
managed by the APN. Analysis of the role of the APN in providing care to ADHD
students is the basis for this research.

The research question which is the underlying interest in this study concerns the
provision of comprehensive health care for a group of ADHD students by an Advanced
Nurse Practitioner. That goal can be accomplished by examining the interventions which
are the outward expression of the role of the APN in the academic setting with this
population. Therefore, the purpose of this study is to describe the number and types of
interventions developed and employed for a population of ADHD students by an
Advanced Nurse Practitioner in a middle-sized urban school district Title I Health
Program in Michigan during the 1995-1996 school year. By doing so we can develop an
understanding of the role of the APN and how it might affect the course of treatment for

those diagnosed with ADHD during their elementary school years.

5

Either there is scant research done in this area, or quite possibly management of
ADHD is more often handled by other practitioners. More than likely, due to budget
constraints, many school systems lack an APN to oversee their health care programs. In
fact, many schools do not even have a school nurse in their employ, or if they do it is
ofien a part-time position. Yet ADHD for the young student lends itself to behavioral
dysfunction which, in most cases, is most evident in the academic environment.

A vital role of the APN in providing for the needs of the ADHD student, as well
as youngsters with other disorders, is coordination of care in order to meet their
educational and health needs. Case management is one way nurses in many different
types of agencies have organized and overseen patient care. In the school setting this
means coordination of care for populations of youngsters with physiological, emotional,
and social needs. There are many interventions which can benefit the ADHD child in
particular and these can be determined and evaluated by the APN in the school setting,
who can thus furnish access to care for this group. A

The Omaha System for classification and documentation of interventions has
been utilized as a means of organizing relevant data. In the context of this paper, the
interventions will be grouped into four categories corresponding to the Omaha
Classification System: domains, problems, modifiers, and signs/symptoms. These larger
groupings encompass the interventions, or targets, of the APN in dealing with youngsters
with ADHD, which are many, while allowing for categorization which will lend itself to
a more manageable discussion in the body of this work. An alphabetized list of 62
interventions comprise the second level and describe the nursing activities provided.

Since this list is not meant to be self-limiting the last designation is that of “other”, where

 

 

Health TeaQirgiGuidance. and Counseling
Parent Communication

Support Group

Treatments and Procedures
Cast Care
Medication Set-Up

Prescriptions

Case Management

Coordinating Visits to ICHD (Health Dept.) Nurse/Physician Consults
Family Practice Pediatrician
Medical/Dental Care Protective Services
Mental Health School Consults
MSU Nursing Referral Specialist ,
Surveillance
Medication Side-Effects

Physical Signs and Symptoms

Blink

Generic designator

 

 

F igule 1. The four categories listing nursing interventions utilized in the Title I Health

Program for the ADHD population according to the Omaha System of Classification.

7

the nurse is able to enumerate any action not covered by one of the 62 targets. The
interventions, or targets, employed by the APN in a middle-sized urban school district’s
Title I Health program have been sorted according to these categories (See Figure 1)
Conceptual Framework I

Overview of King’s Model

This section describes the conceptual framework and concurrently examines the
appropriateness of its use in relation to the research question. Imogene King identified
the interaction of individuals in a myriad of social settings as the focus of her conceptual
framework. She developed her conceptual framework from general systems theory,
which focuses on organized wholes. Nursing espouses a holistic approach to patient
care, so a general systems framework embodies that point of view. The ultimate goal of
such care is the health of the patient, whether that be an individual, group, or community.

King’s conceptual framework (Figure 2) was used to develop a model with which
to examine school based nursing interventions for children with ADHD. She identifies
three major model components; a) personal systems, b) interpersonal systems, and c)
social systems. These are dynamic, open systems, which are continuously interacting.
The goal of nursing interventions is health for the client. Health, according to King’s
conceptual definition, is the goal of nursing, and is defined “as dynamic life experiences
of a human being, which implies continuous adjustment to stressors in the internal and
external environment through optimum use of one’s resources to achieve maximum
potential for daily living” (King, 1981, p. 5). Functional status is an integral part of the

definition and reflects both physical and psychosocial well-being.

SOCIAL SYSTEMS

I
’
'I'II

INTERPERSONAL SYSTEMS
PERSONAL SYSTEMS

 

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~—-—.—.———————--—--.—————--————_———-—————-—-’

Fig1_1_re 2. A conceptual framework for nursing: dynamic interacting systems.

 

King, I.M. (1981). A Theory for Nursig. New York: John Wiley & Sons, p. 11.

9

Children are independent beings with their own experiences and perceptions, and
can thus be denoted as personal systems. Along with others, these children as students
and their teachers help to comprise the next level, that of interpersonal systems.
Interpersonal systems are groups of two or three. In addition to dyads and triads in the
school, the ADHD child also interacts in other interpersonal systems, such as their
family. These groups, or combinations of personal and interpersonal systems, combine
to form the next level of the conceptual framework. The social systems, or society, can
also be thought of in terms of this study as the larger school environment, which is both a
group and a mini-society, and the community, which is the society in which the students
live.

The three systems forming King’s conceptual are applicable to children with
ADHD. As a personal system, the ADI-H) student will be seen as a unique type of
individual with many needs which differ from others in terms of number and complexity.
The child with ADHD affects the functioning of all the groups in which he/she is a
member due to his/her often disturbing and disruptive behavior. Thus, the interpersonal
systems includes the child with ADHD and show interactions between the individual, the
APN, and the family. Both the personal and interpersonal systems can be shown to be
part of and impinge upon the functioning of society, or as denoted in King’s framework,
the social systems.

King defines the goal of nursing as providing help to individuals so that they are
able to maintain their health and function in their various roles. Health, according to
King, is not simply the absence of disease. Rather, “health is defined as dynamic life

experiences of a human being, which implies continuous adjustment to stressors in the

10

internal and external environment through optimum use of one’s resources to achieve
maximum potential for daily living” (p. 5). Thus, Figure 2 reflects a continuous
interaction between the personal, interpersonal, and social systems as they affect the
health of the individual, which is not simply an outcome, but also an implied and
dynamic part of the model.

In the context of King’s model, ADHD, and its consequences, would be defined
as the internal stressor to the personal system, to which the student must adjust.
However, ADHD impairs the students’ ability to adjust to those external stressors which
confront people all the time. These external stressors might be the need to sit still in
class, the necessity of waiting to be called upon before speaking, and the meeting of
deadlines for homework assignments It then can be seen that ADHD hampers the ability
to perform the role of student optimally, and thus limits their capacity to achieve full
potential.

Conceptual definitions

“Child health is theoretically defined as developmentally appropriate physical,
biological, psychological, and social functioning” (Frey, 1988, p. 139). The goal of
nursing interventions are to maximize the child’s potential, thus promoting their health.
In the case of a youngster with ADHD, miless such assistance is obtained from a health
care provider, the prognosis for a positive future is less than optimal, and the youngster’s
health would be impaired according to King’s definition.

Perm svsfins
King (1981) has identified selected concepts which pertain to the understanding

of personal systems, which are “(1) perception, (2) self, (3) body image, (4) growth and

11

development, (5) time, and (6) space” (p. 10). These concepts have relevance for all
individuals. However, King has identified perceptions as the dominant concept of the
personal system, and the building block of the concept of self. It “is a process of
organizing, interpreting, and transforming information from sense data and memory”
(King, 1981, p. 24).

Perceptions are the basis of one’s reality and give meaning to experiences.
Ultimately, perceptions determine who and what a person is and how they comport
themselves. Although they are thus totally subjective and present-tense occurrences
which cannot be exactly determined, one can have some understanding of what another is
thinking and feeling by observation or by asking them about that which they are
perceiving. In this way we can gain some understanding of perceptions held by another.
This is fundamental if one is to appropriately assess an individual and develop goals for
health care. The APN, and her staff, have the ability to gain understanding and influence
the child’s perceptions positively in the course of their work. ADHI) children are more
vulnerable than many to the development of a poor self-image, since their behavior tends
to generate recurrent negative feedback.

Self is defined as the person’s inner world, and is an open system. It is subjective
and is developed as a result of one’s experiences which have influenced their
perceptions, and contributed to the aggregate of all that one is. Body image is part of the
person’s subjective world and is a contributing factor in the development of one’s self-
concept.. The environment can aid in the child’s grth and development, and result in
the ability to actualize one’s self. However, the child with ADHD generally has

difficulty in moving smoothly through this process, particularly if left untreated. King

12
views self as being goal-oriented. If the ADHD child has a negative image of

him/herself, his/her goals are unlikely to be positive ones aimed at self-actualization and
personal long-term fulfillment.

Space and time are described by King as being universal concepts, since they are
within everyone’s experience. Use of space and time, which are part of the personal
system, will affect the student’s development. For example, the ADHD student has
difficulty in focusing on the task at hand while excluding the constant barrage of stimuli
from the environment. Arrangement of desks in classrooms and the amount of pictures
and other visual stimuli can be modified to benefit the youngster with ADHD, while not
depriving the other students of necessary materials. Lessening distractions can alter the
ADHD students’ perceptions of their surroundings. Instead of constant distraction
leading to an inability to focus, an environment or personal space free of extraneous
objects and decorations will assist the student to better utilize their time. However, these
ideas are also unique to the individual in that everyone has their own personal space.
Time is unidirectional and nothing is ever repeated in exactly the same way.
Interpersongl systems

Interpersonal systems are defined as two or more individuals interacting together
as a group. Such systems are formed as dyads, triads, with four or more beings coming
together to form small or large groups. However, unless there is interaction between
individuals, they do not constitute interpersonal systems. The concepts characterizing
interpersonal systems are interaction, communication, transaction, role, and stress.

When possible, King advocates mutual goal setting between client and nurse.

When this is not totally feasible, as in the case of an extremely young child or a

13
debilitated patient, the nurse needs to perform this role for the client. With as much

input from the ADHD child as is developmentally possible and appropriate, the APN,
along with teachers, family, and other health care providers, can develop objectives for
the child.

It is through the relationship of involved individuals that the youngster is helped
to grow, change and develop. The youngster spends a large percentage of time in school.
It is likely that these young people have more demands placed on them in school than in
any other setting. Therefore, the APN in the school setting may be seen to have a unique
and pivotal role in the child’s development due to their level of education, knowledge of
the special needs of the child with ADHD, contact with the youngster, and access to
resources.

When two people interact this is termed a transaction. Although the proximity
of two people in close contact implies interaction, a transaction is much more than just
being together. In figure 3 the concepts and actions which come together to form a
transaction are depicted. This dynamic process must include active participation in the
events taking place. This connection does not have to be verbal, but King denotes
communication as one of the highest forms denoting interaction.

The APN uses communication with the ADHD student in order to modify their
self-image, behavior, and academic success rate. The last two concepts which pertain to
interpersonal systems, role and stress, will be considered together. One can have many
roles, including that of student, teacher, parent, and health care provider, so this concept

is situational. The child with ADHD has various degree of difficulty in performing

14
" """"""" Feedback """"""""""" '

I
Perfeption

J udfment

Nurse Action

4|

Reaction ——9 Interaction —» Transaction

 

 

Action /
0

Patient I

Judgment

T

Perception
l

-------------- Feedback ------—----------—--——'

F igigre 3. A process of human interactions.

King, I.M. (1971). Toward a Thech for Nursing, New York; John Wiley & Sons, p.145.

certain roles to the satisfaction of parents, peers, and school personnel. The one which is
the most problematic is generally that of student. That is often due to the increased need
to focus on detail in order to perform this role up to the standards set by the classroom
teacher. That is why the teacher is, in many cases, the one who refers the child for
evaluation.

Difficulty with academic performance and adherence to school rules and
regulations contribute to stress in the life of the young person with ADHD. There are
three primary ways in which stress can manifest itself: physiologically, psychologically,
and socially (King, 1981, p. 95). Stressors which are manifested in one of these areas

contribute to its development in the others. However, people react to stressful situations

1 5
differently, depending on their perceptions and past experiences. Nonetheless, it will be

seen that those with ADHD have a higher number of problems in all the areas delineated.
It is suggested that the amount of stress engendered by ADHD is out of proportion to that
of the general school population and this leads to multiple social and emotional
dysfunction. Intervention on behalf of the ADHD student on the part of the APN can
lead to a reduction in stress, thus helping to reduce or eliminate the negative outcomes
seen in this population.
Sociatl systems

“A social system is defined as an organized boundary system of social roles,
behaviors, and practices developed to maintain values and the mechanisms to regulate
the practices and rules” (King, 1981, p. 115). Social systems are the many units in our
society which provide organization, such as family, school, religion and peers. There is
an interplay between these systems. Learning experiences which take place in the
context of social systems contribute to behavioral modification in which individuals grow
and acquire aptitude in coping with change. The social system with the most impact on
the growing child is frequently the school, where he/she spends much of his/her waking
hours. I

King has identified certain concepts which are relevant characteristics of social
systems. These are organization, power, authority, status, and decision making.
Organization can be formal or informal, but it provides structure so that it can
contribute to the achievement of goals. Authority is the power to make the decisions
that guide one’s own conduct and that of others. Status is one’s position in an

organization and it also lends itself to the ability to make decisions. An illustration is the

16
nursing decision made by the APN on behalf of children with ADHD who would not

have the resources to receive other help.
Summary
All of the components of King’s conceptual framework; personal,
interpersonal and social systems, are part of the Title I Health Program effort to establish
goals for the treatment of ADHD, as well as other health needs, in the school system.
The child diagnosed with ADHD constitutes both the personal system, as defined by
Imogene King, and is part of the interpersonal system. In carrying out planned
interventions, the APN and her staff, as representatives of the school, must interact with
other social systems, including the health care and educational systems, and other
providers. This systems framework guided the literature review and analysis of this
study’s data.
Review of the Literature
. There is a vast amount of literature on attention deficit hyperactivity disorder. It

has been a subject of interest in the health care community for some years. The research
reflects a description of behaviors, assessment techniques and tools, comorbidity,
medications, and outcomes. Pertinent research with regard to ADHD and the
interventions utilized will be discussed and summarized in light of King’s conceptual
framework.
Persogl svstems

Literature reviewed relating to personal systems concerned brain activity and
behaviors of the child with ADHD, and the nursing role in providing care for such

chronic disorders. Both are considered to be personal systems until interaction occurs

l7

and they enter into the realm of interpersonal systems. In order to provide appropriate
treatment for one with ADHD it is necessary to develop an understanding of how the
condition affects them.

The mind of the ADHD child was described as follows in a publication by the
National Institute of Mental Health (1994):

Imagine living in a fast-moving kaleidoscope, where sounds, images, and

thoughts are constantly shifiing. Feeling easily bored, yet helpless to keep your

mind on tasks you need to complete. Distracted by unimportant sights and
sounds, your mind drives you from one thought or activity to the next. Perhaps
you are so wrapped up in a collage of thoughts and images that you don’t notice
when someone speaks to you.
The person with ADHD is less able to filter out the stimuli entering the brain. This
constant assault on the mind results in the hallmark characteristics of ADHD:
inattention, impulsivity, and overactivity. Some children go undiagnosed, while there is
a strong likelihood that others are misdiagnosed. By gaining an understanding of how the
mind of the individual with ADHD works, the practitioner can move toward developing
and initiating interventions which will maximize the child’s potential and minimize
dysfunction.

Zentall (1993) indicates that “an attentional deficit connotes a lack of attention,
whereas an attentional bias more correctly connotes adequate attention, memory, and
comprehension, but associated with specific tasks, time periods, and conditions” (p. 143).
Their use of the syntax of “bias” instead of the traditional ADI-ID label was due to their

study results which showed that children with ADHD could attend to tasks for varying

18

short periods of time, but in all academic areas where nonrelevant stimulation impinges
on the child’s consciousness, school performance declines due to the resulting
inattention. What follows in many children with ADHD is, according to the study,
excessive verbal and motor activity. Impulsivity, the third major hallmark of ADHD, is
illustrated by the child’s inappropriately speaking out of turn or grabbing materials. In
spite of these, and other concomitant manifestations which affect school performance,
Zentall’s study indicated that ADHD children have difficulty in asking for help, exhibit
poor planning skills, and do not have the self-control to wait until the suitable time or
appointed time for allotted tasks.

These hallmark characteristics of ADHD have been thought to be attributable to
impairment in executive control. This is higher level behavior which refers to the ability
to adapt behavior in response to changes in one’s environment. One study found that
since inhibitory control and response re-engagement are inadequate in youngsters with
ADHD, this implies a generalized deficiency in executive control (schachar, et a1. 1995).
F urtherrnore, that research indicated that those with ADHD were more likely to manifest
these responses in the school setting.

Longitudinal research conducted by Hart, et al., (1995), with ADHD children ages
7 to 12 years at the onset of the study utilized patient psychotherapy and pharmacology.
The control group was not given treatment, but was free to take advantage of services on
their own. The authors concluded that ADHD is a chronic disorder for most children, but
if symptomotology does not persist past the first year of diagnosis then ADHD problems
are developmental in nature and will resolve spontaneously or with short-term treatment.

The latter group formed a much smaller segment of the sample.

19
Barkley, et al., (1990) found in their research that there were differences between

children with the diagnosis of ADHD without hyperactivity and those in the subtype with
hyperactivity. While both subtypes had similar problems with attentional tasks, the
group with hyperactivity had double the amount of impulsive errors and more off task
behavioral dysfunction. Thus, it would appear that children with ADHD without
hyperactivity display a different behavioral picture than do those with ADHD with
hyperactivity. Those who are not hyperactive show less aggression, impulsivity, and
overactivity both at home and school when rated by parents and teachers in their
respective settings (Barkley, et al, 1990, p. 787). Their study also showed less difficulty
with peer relationships among the sample of children without hyperactivity.

There have been those who are skeptical of the validity of the psychiatric
diagnosis of ADHD. However, recent literature has pointed to a physiological difference
in the brains of those with a DSM-IV diagnosis of ADHD. Giedd , etal., (1994) used
MRI technology to examine the corpus collosum, whose functioning includes allocation
of attention and arousal in the two hemispheres. They found that while gross
abnormalities were not present “sensitive imaging techniques are able to show subtle
differences between the brain morphology of ADHD subjects and comparison subjects”
(p. 668).

According to the literature it is clear that the youngster with ADHD needs to
concentrate on those factors in the environment which should have priority and be more
able to ignore the continuous extraneous barrage on the senses, which most people are
able to shut out. The difficulty in doing so contributes to a myriad of problems. Krener,

(1996) has suggested that such difficulties include directing and sustaining attention,

20
being easily overwhelmed by routine daily tasks, having less ability than others in

maintaining an orderly home environment or work place, inconsistent job performance,
inattention to detail, instant gratification, a need to constantly seek stimulation,
restlessness, low frustration level, and impatience (Krener, 1996, p. 259). In the light of
this multiple dysfunction school work and the ability to relate to peers and teachers
deteriorate rapidly without intervention.

A two year study was conducted by Stein, et al. (1994) on adaptive skills in
ADHD children. They defined adaptive functioning as typical performance, and not
ability per se. In other words, the knowledge and ability to perform appropriate
behaviors was not the criteria, rather the performance of those behaviors. The ADHD
children were compared to others with similar IQ and another group with lower IQ and
impaired mental status. The ADHD children, although in the normal range of
intelligence, were found to execute adaptive skills poorly. Impairments in the
performance of skills were, in many cases, noted to be greater than those with pervasive
developmental disorder or mild mental retardation in the areas of daily living,
communication, and socialization skills. Deficits in performance, in spite of the
knowledge of appropriate or expected behavior, has important implications for
adjustment and adequate functioning as adults. This weakness in adaptive functioning
may clarify the reasons why people with ADHD have poor success in job situations or in
socialization and personal relationships (Stein, et al., 1994).

Even when symptoms are better controlled in adulthood, years of inappropriate
behavior in the young person frequently lead to poor social adjustment, and emotional

and psychological scars in the adult. This contributes to a higher incidence of

21
dysfunctional behavior in the ADHD adult population. Studies have been conducted

which point to a greater level of drug use and delinquent behavior on the part of those
afflicted. In one fifieen year longitudinal study individuals who had been identified as
having ADHD in elementary school were followed into adulthood. The sample displayed
significantly more social dysfunction than was seen in the control group. The subjects
with ADHD had a significantly higher rate of occurrence of school suspensions, trouble
with the law after leaving school, and higher incidence of having been taken into custody
for illegal offenses. They were also more likely to have been wounded in a fight, been
considered accident prone, and to smoke marijuana at least once daily (Howell, et al.,
1985).

Fischer, et al. (1993) did a prospective study which compared the severity of
conduct problems of 158 hyperactive children as compared to 81 normal children over an
eight year period. They found a significantly higher amount of deviant behavior in the
hyperactive group. Thus, ADHD contributes to a higher incidence of antisocial behavior,
which includes property damage, theft, drug abuse and other negative repercussions.

A relationship between ADHD and conduct problems in adolescents was also
found in research by Taylor, et al., (1996). Their study indicated a high risk for poor
psychosocial adjustment in the ADHD youngster by the time they reach adolescence.
ADI-ID was predictive of violence, both by self-report and parental account, and of
defiant and disruptive behaviors; and it is often followed by poor relationships with age
peers, a lack of involvement in social activities, a lack of engagement in constructive

activities generally, and poor academic achievement. (p. 1224).

22
Adjustment to a satisfactory adult life in terms of both higher education and work

situations were other areas of marked dysfunctional behavior. Those with attention
deficit disorder tend to drop out of school or choose not to pursue a higher education.
Furthermore, they were more likely to have had a number of different employment
situations in the past, which indicated a higher level of instability within the job market,
and when they were employed generally held the lowest level jobs (Howell, et al.,1985,
p. 188). This trend was shown to hold true for both sexes, when confounding factors
were taken into consideration.

Emotional and psychological dysfunctioning affects a high percentage of adults
with ADHD. Depending on the study, findings of depression, anxiety, and oppositional
disorders have been estimated at 15% or more (Krener, 1995). Other works found that
given this evidence, treatment which may prevent the development of at least some of
these complications, should be instituted as soon as identification can be made during the
formative years. Other studies support this conclusion because of the overwhelming
evidence for a negative outcome during adulthood for those with attention deficit
disorder. Thus, early identification and successful intervention is important for society as
a whole and vital for the emotionally well-being of the individual with ADHD (Howell
1985)

Pharmacological Intervention

Pharmacotherapy has been one of the major routes pursued in the quest to help

the mind of the ADHD individual focus and stay on task. A number of different

categories of medications have been used in treatment, including psychostimulants,

23

antidepressants, and centrally acting antiadrenergics, such as clonodine. All of these
drugs can have negative, unwanted results, some of them serious.

Since the 1970’s methylphenidate (Ritalin) has been the psychostimulant
prescribed most ofien in the treatment of ADHD. Although it has its side-effects, and has
not proven effective in all patients, it has remained the drug of choice in the treatment of
ADHD. It has been shown that more than 90% of children treated with pharrnacotherapy
are given a trial of methylphenidate at some point (Safer & Krager, 1983, p. 217).

Ritalin is metabolized rapidly, and this has both positive and negative
consequences. Because it has a relatively short half-life it is less likely to cause adverse
symptoms in the user. Since most of those treated for ADHD are children, this is an
important consideration. However, this means that Ritalin must be administered during
school hours, as it is short-acting. This may be psychologically adverse for the student
because having to take a pill during school hours is another situation which singles out
the child as being different. An extended release tablet is available,iand is used in
treatment, but studies have shown it to be less effective.

In any case, the research has shown that medication alone is of limited value
without academic, emotional and social intervention. This is supported by research
which indicates that despite the positive responses to such pharmacologipal intervention
as methylphenidate, the percentage of youngsters who show improvement cross-
situationally or normalize even in only one setting does not approach 100% (Buitelaar, et
al. (1995). The conclusion follows that there is the need for additional types of treatment

and supports along with medication.

24

InterpemonaLSvstems

It has been found that there is a difference in the parents of children with ADHD.
Parents of children with more severe exacerbation of symptoms were more likely to be
younger, have less education, have a lower socioeconomic status, and report more
symptoms of psychological distress. In addition, these parents were more likely to
display ADHD symptoms themselves. Such findings suggest that it is important to assess
not only the children’s ADHD symptomotology, but also other comorbid factors. The
conclusion is that treatment would have a better outcome if all possible confounding
factors are taken into consideration. (Murphy and Barkley, 1996)

Once diagnosis is confirmed, interventions should be employed. However, while
the ADHD child is frequently in desperate need of help in order to facilitate his or her
adjustment and functioning in the school, that label carries with it a taint. Harris, et al.,
(1992) found that “a stigrnatizing label may lead to a self-fulfilling prophecy with respect
to peer rejection, but not necessarily with respect to symptomatic behaviors of a given
stigma” (p. 49). The meaning of this for teachers and other school personnel, is that they
must be on guard that they avoid projecting adverse expectations of the ADI-II) student.
If they expect negative outcomes, then they are likely to create a climate where this
becomes so when it would not have otherwise occurred.

Attempts to modify behavior of all children is frequently made with
use of positive reinforcement. However, even this approach appeared ineffective in a
study conducted by Douglas and Parry (1994). They found that ADHD children respond
to rewards uniquely and differently from their control group without the disorder. There

was more intense frustration on the part of the sample when rewards were not immediate,

25
or when they were not forthcoming. Armstrong (1996) suggested methods which can be

employed in the school setting such as:

Focusing and attention training techniques, managing the environment by finding

the child’s best time to learn, a strong physical education program, building self-

esteem and social skills, using contracting, immediate feedback, learning logical

consequences, promoting communication and social skills, making education a

creative and stimulating process, and using computers and hands-on learning.
Socjal svstems

The social systems portion of King’s paradigm contributes to care of the ADHD
youngster from the beginning of treatment, starting with diagnosis of the condition.
Diagnosis is a formidable task and is frequently made with great reliance on input from
the mother, although information from other sources, including the teacher, is typical.
Diagnosis is most frequently confirmed by a physician or psychologist. The focus of this
work is the school system and the provision of care for the child afflicted with ADHD.
Literature in the section, therefore, will focus on how the social systems handles
diagnosis and treatment of the disorder.

In a one-year study conducted by Faraone, et al., reliability of maternal report was
investigated and compared with input from the teacher. It was previously found that the
teachers’ diagnosis was highly reliable. Results of this research indicated that mothers’
reports were highly correlated with that of the teachers. The conclusion was that
accuracy could reasonably be expected from input of the mother, although a definitive
diagnosis must be made by a health care provider. With input from parent and various

school system personnel, the practitioner is thus able to formulate a diagnosis. In

26

practice it can then be concluded that diagnosis would of necessity include various
members of the community, including the school system, medical and psychological
services. Thus, diagnosis would be considered part of King’s social system segment of
the paradigm.

DuPaul and Barkley (1992) not only looked at the comparison between parents
and teachers perceptions of ADI-II) behavior, but examined the setting in which
manifestations of the disorder are the most problematic. They found, as did Faraone
(1993), that both parents and teachers rated the extent of the behaviors similarly.
However, severity was site related, with exacerbations more frequent and intense in the
school setting. The discrepancy in behavior in these settings would be expected given
that the demands for attention-related behaviors are not the same in the home as opposed
to the school environment (DuPaul & Barkley, 1992, p. 186). Thus, their research
validates the greater need for intervention in the academic arena.

Substantiation of the need for intervention and coordination by the nurse in the
school setting for children with ADHD was supported by a study done in the San Diego
School District. This school-based support project followed youngsters from varied
cultural backgrounds for over two years. Evaluation was made by the physician from
reports from parents, teachers and school nurses. “Nurses are trained to be the
coordinator who pieces together information from the teacher, parent, school counselor,
and physician to achieve an optimal management strategy for each child” (Williams, et
al., 1993, p. 297). Results of this study indicated an improvement of 70% in school

performance in those students taking part in the program.

27

A multi-modal treatment approach based on individual needs is advocated by
Burcham (1993), at the Federal Resource Center (FRC) at the University of Kentucky.
Burcham conducted research on identification of school-based interventions which
appear to hold promise in the treatment of the ADHD pupil. In order to ascertain and
develop practices which would have a likelihood of success five community-based
groups were identified and were designated stakeholders. Burcham (1993) points out
that five groups are essential to the educational identification and intervention of children
with ADI-ID; these include school personnel, parents, health care professionals, family
support professionals, and researchers who have the task of selecting and evaluating
school-based interventions.

Although Burcham did not designate specific interventions, she did enumerate
broad areas which must be addressed in each school system. They first must address
whether the intervention will have a positive effect when employed in the school setting.
For example, some techniques are best used in the home, rather than the classroom.
Next, the three major components of ADHD, inattention, impulsivity, and overactivity
must be incorporated into the plan. Although it seems obvious, the financial assets to
adequately carry out the intervention must be available. Burcham (1993) asserts that
“better outcomes for students with ADHD can be achieved from practices that
proactively plan for continuous, positive parental involvement in the assessment and
intervention process” (p. 178). Cultural issues and school responsibility for monitoring
the effects of medication and providing feedback to the primary health care provider are

essential.

28

Summgg and Critique of Literature Review

The bulk of the research in connection with ADHD is in the realm of
pharmacology. Unfortunately, this emphasis on medications used in the treatment of
ADHD ignores the many other factors which affect the child with this malady. ADHD is
a disorder which has been shown to be complex; school supports and educational
modifications, as well as the home environment, also require attention. The literature
indicates that a combination of medication with educational, community, and
psychosocial supports has been the most beneficial. However, there is not as much
research done in regard to such a holistic approach to treatment.

A strength of the literature is that it strongly substantiates the fact that the
majority of people fare the worst in the school and work setting. It also indicates,
including the DSM-IV criteria, that the disorder manifests itself early in life. Since
school and peer relationships are extremely important to the child, these studies show
support for a school-based management program.

More research should be done on interventions for ADHD in the school setting.
There is a gap in the literature regarding the role of the APN in case management in the
primary care setting. There is very little research on the position of the school nurse, and
even less on the use of the APN in the education setting in the role of case management
of ADHD. The school is the milieu in which ADHD presents the greatest challenge.
Therefore, the present study is an important addition to the literature, by presenting a
program managed by an APN in the school environment, and which employs multiple

interventions.

29
Methodology

The purpose of this study is to describe the number and types of interventions
developed and employed by an Advanced Nurse Practitioner for the population of ADHD
students in a middle-sized urban school district in Michigan Title 1 Health Program
during the 1995-1996 school year.

Research design

An exploratory/descriptive design is the basis for this non-experimental Level I
study. It is a retrospective examination of data collected by the APN coordinating the
Title I Health Program in a middle-size (1 urban school district in Michigan. The APN
coordinating the program has been collecting data since 1993. The information was
initially compiled for the purpose of organizing management data for children receiving
nursing services from an Advanced Nurse Practitioner. The population of interest, 71
ADHD students, is a subset of youngsters in the Title I Health Program. The 1995/1996
school year was first year information on medications was included. 9 Since
pharmacological treatment is employed in a large proportion of children to manage
ADHD, it was included as an important intervention in this study.

Instrumentation

It is necessary to have a method of data organization which will facilitate
understanding of the information. The Omaha System has been used by the APN as the
basis for the data collection on children who were receiving assistance through the Title I
Health program during the 1995/96 school year. This system was developed to codify
and standardize data in order to make data collection more cost-effective for nursing and

other health care providers. The Omaha System, a research based model, has been used

30

and tested for reliability, validity, and usability in multiple service settings. It is a vehicle
one can use to document, measure, and communicate client-clinician practice. (Martin
& Norris, 1996).

The Omaha System embodies three components. The first is that of classification
of the problem, the second involves interventions, and the last is devoted to rating the
problems in regard to outcomes. The four levels; domains, problems, modifiers and
signs/symptoms classify intervention data into the four nursing domains of environment,
psychosocial, physiologic, and health-related behaviors. (Martin, 1995). Finally, the third
level of the Omaha System’s Intervention Scheme denotes client-specific information,
i.e., the actions and responses of both the health care provider and the recipient of that
intervention. For example, with an intervention such as medication administration one
might see client-specific data such as “compliance with prescribed medications” (Westra,
et al., 1996, p. 29). Thus, the final portion of the Omaha System establishes a means of
measuring client progress.

A problem rating scale for outcomes and subscales pertaining to knowledge,
behavior, and status of the outcome, is the third and final section. It includes information
on the knowledge gained, behavior demonstrated, and status of the client for the
intervention or target being documented. Thus, as a whole, the Omaha System provides
a concise method of gathering, describing, and evaluating client progress, and has been
used in a variety of health care settings.

The Omaha System interventions have been illustrated in a model combining it

with King’s conceptual framework. Figure 4 depicts the interventions which have been

31

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Advanced Practice Nurse H Social, Health and
Educational Subsystems
Case Management:

Nurse/Physician Consult Medical/Dental Care
Family Practice School Consult
Pediatrician Parent Communication
Health Department Specialist

Protective Services MSU Nursing Referral
Mental Health

...................................................................................................

Interpersonal Systems
Advanced Nurse Practitioner H Child

/

 

 

 

 

l

I

I

I

I

E Family

I

iiiealth teaching. GuidancL and Counseling:

i Support Group

. Treatments and Procedures:

: Medication Set Up

i Prescriptions

i Cast Care

iSurveimtnce:

i Medication Side Effects

E Physical Signs an§,$,y_mmp_t91_t_1_8_ ______ I ____________

I : ;

E Personal System=Student §

I I With ' """""""""""""" '

l . ADHD or

i E ADHD-like symptoms

i 5 “—3

I .................................

L ____________________________________________________ _1
HEALTH

 

 

 

F igare 4. APN Interventions Related to the ADHD Student Utilizing a Modification of
Imogene King’s Conceptual Framework and the Omaha System of Classification.

32
employed by the APN in the Title I Health Program for the population of ADHD

students.
Description of the subiects

The middle-sized urban school district is located in Michigan’s lower peninsula.
The majority of the children reached by this Title 1 Health Program are from
disadvantaged families. The sample in this research study was a non-probability,
convenience sample of students participating in the Title I Health Program. The students
were identified by teachers and other health care personnel as having ADHD or ADHD-
type characteristics which had resulted in delayed academic progress. They came from
20 of the 29 Title I designated schools in the district and were from kindergarten through
the sixth grade. The need for services and intervention were identified by teachers as
being in the academic, social, and behavioral areas. Since nine of the schools did not
contribute to the population of ADHD students in the Title I Health Program, they were
excluded from the study.

The convenience sample of 71 students was drawn from the population of 394
pupils involved in the Title I Health Program during the 1995/1996 school year. Thus,
nearly 20% of the total number of students receiving health care services from the APN
were due to ADHD. They were referred to the Title I Health Program by teachers,
parents and health care providers.

Qfla smmgizinggrocedmes

The intent of this study is the examination of the types and frequency of

interventions utilized with ADHD children by the APN in the selected Title I Health

program in a middle-sized urban school district. The types of interventions were grouped

33
into four categories used by the APN in accordance with the Omaha System of

classification, i.e., a) Health Teaching, Guidance, and Counseling; b) Treatments and
Procedures; c) Case Management; and d) Surveillance. (See Appendix B) Frequency
tables were computed to indicate the number of interventiOns and the category into which
each nursing action fell. These tables quantify the specific interventions, thus indicating
areas of the greatest needs of the ADHD student. Frequency tables were also compiled
comparing the ADHD population with the other most frequently diagnosed disorders
included in the Title I Health Program.

Protection of human subiects

Procedures were taken to protect the subjects in this research. The data was
received by this investigator on a computer disc that did not include names or other
identifying designators. Thus, the identities of those making up the sample was not
revealed to the investigator. To further protect the sample the school district where the
data originated has not been identified in the title or body of this work by name. Rather,
it has been identified only as a middle-sized urban school district in Michigan. Since this
study is a retrospective, Level I, non-experimental work, the data was already collected
prior to beginning the research. Therefore, the study does identify the subjects or place
them at risk.

According to Michigan State University requirements, an application was
submitted to the University Committee on Research Involving Human Subjects which
upon review granted approval. (See Appendix C) Work on the original data set was not
begun until those steps were appropriately completed. Approval was granted to do

research from the school district from which the original data was received. (See

34
Appendix D) The only stipulation was that the name of the school district not be

revealed as a means of protecting the individuals involved.
Results

This Level I descriptive retrospective study examined the number and types of
interventions developed and employed for a population of ADHD students by an APN in
a middle-sized urban school district in Michigan during the 1995-1996 school year. The
data collected by the APN included the school, grade, medications, and the number and
type of the interventions utilized. These interventions were sorted according to
Intervention Scheme Categories delineated in the Omaha System, i.e., health teaching,
guidance and counseling; treatment and procedures; case management; and surveillance.
Description of sample in Lelation to thelarger population

The APN responsible for the Title I Health program provided care to a total of

394 students during the 1995/1996 school year. Referrals to the program come from a

Table 1.
Primary Reason For Initial Referral To The Title I Health Program

 

 

Reason Number Percent
Vision 116 40.0
Injury/Sick care 38 13.3
ADI-ID 36 13.0
Dental 27 9.4
Primary Care 25 9.0
Hearing 22 8.0
Chronic Illness 20 7.0
Other 1 0.3

TOTAL 285 100%

 

35

variety of sources, including the school nurse, parent, special education staff, health care
providers, or others. Table 1 examines the reasons for initial referrals and reveals
that(40%), injury or sick care (13.3%), and ADHD (13.0%). Thus, these four account for
over half of the first-time encounters in the Title 1 Health Program. It is assumed that
vision difficulties are generally managed by referral for corrective lenses. Injury and sick
care is also most often managed in one visit, unlike ADHD, which requires intensive
input. The percentage of interventions for the ADHD group encompasses 22% of the
total number (N=311) instituted by the APN and her staff for the ten most frequent health
problems of those in the Title I Health program. To further illustrate and support the
assertion regarding the chronic nature of ADHD and its treatment, Table 2 indicates that
many of the contacts made by the nurse in the Title I Health program were on a one time
only basis (29.4%) and 22.1% had only two contacts. This would indicate that with
many problems (51.5%) the parent was able to follow through on their own after the
initial contacts were made with the school nurse.

Referrals to the Title I Health program are due to a range of acute and chronic

problems. Injury or sick care is frequently a triage type of visit to the clinic and is

Table 2. Number of total contacts per student with the Title I Health Program during the
1995/1996 school year.

 

 

Number of Contacts Number of students Percentage
1 116 29.4
2 87 22.1
3 or more 191 49.5

394 100

 

36

resolved with one encounter with the school nurse, as is the case with vision referrals.
However, that would then leave almost half (49.5%) of the students in the Title I Health
program who required more intensive and ongoing assistance.

Table 3 represents the three most frequently occurring needs addressed by the
Title I Health Program. These were vision (23.7%), ADI-ID (22%), and asthma (13.2%).
This gives support to the assertion that ADHD is the top most time-intensive and
complicated of the ten most common diagnoses, since vision was previously identified as
requiring short-term intervention, generally one referral to an optometrist. It can then be

deduced that ADHD students, in the Title I Health program, make up the largest group of

Table 3.

The Ten Most Frequent Health Problems Identified For Title I Health Program Students
Described By The Number Of Times A Nursing Intervention Occurred For Each Problem

 

 

iiiHealth Problem NumberofTrmesan Percentage

Intervention was utilized
Vision 334 23.7
ADHD 311 22.0
Asthma 187 13.2
Dentition 156 1 1 .0
Hearing 117 8.2
Health Care Supervision 111 7.8
Skin Rashes/Lesions/Burns 69 5.0
Genital-Urinary Function 65 4.6
Seizures 27 1.8
Uninsured Medical 25 1.7
Expenses

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37

students utilizing services over an extended period of time.

Table 4 shows that the convenience sample of 71 students with ADHD or ADHD-
like characteristics was drawn from 20 of the 29 schools in the district. Nine of the
schools did not have children participating in the Title I Health Program, and therefore
were not part of this study. It would be of interest to know why almost one-third of the
schools had no children in the Title I Health Program. Given the number of ADHD
students in the overall population, it is unlikely that nine schools had no children with
this diagnosis. It may be that there are youngsters with the diagnosis of ADHD in those
schools, but because they are not disadvantaged, the services of the Title I Health
program were not required. Such students would require services from their own
physician, private tutors, and therapists. It would be beneficial for the school system to
know if there were large numbers of students with ADHD who were not receiving
supportive services due to a failure to qualify for the Title I Health Program.

Table 4 also illustrates the number and percent of nursing interventions for the
population of ADHD students in 20 of the 29 schools in the district. Certain schools
have a larger number of children diagnosed with ADHD or ADHD-like characteristics
than others. It may be of help in predicting future needs to determine the reasons for
these differences.

Five of the schools had the same number of ADHD students (N=4). However, the
number of interventions per school for the same amount of ADHD students varied greatly
(Range=lO-l 7). It would be useful information to know how the characteristics of the
students needing extensive assistance distinguished them from those pupils who required

less.

Table 4.

Distribution of ADHD students and nursing interventions by school building for the
1995-1996 school year.

 

Number

 

Schools with Number of Percent Percent
ADHD ADHD students per interventions interventions
students Students per building per building per school
building building with
ADHD
population
1 4 .06 15 .05
2 1 .01 12 .04
3 4 .06 17 .055
4 2 .03 17 .055
5 2 .03 4 .01
6 3 .04 12 -04
7 2 .03 4 -01
3 4 .06 10 .033
9 6 .08 36 .12
10 2 .03 11 .036
11 5 .07 16 .052
12 1 .01 Undetermined Undetermined
13 2 .03 22 -07
14 8 .11 31 .10
15 6 .08 35 .114
16 1 .01 Undetermined Undetermined
17 7 .10 26 .085
18 3 .04 07 -022
19 4 .06 15 -05
20 4 .06 17 -055
TOTAL 71 100 307 993
Bimodal Mean number Mode = 17 Mean number
distribution of of ADHD interventions interventions
ADI-ID students = 3.55 per building per school
students = 2,4 building =

15.55

39
The total number of services for all types of health problems for the 1995/1996

school year was 1,603, a large percentage of which was for ADI-1D (N=311). Table 5
represents the most frequent nursing interventions (N=1430) of the total number of
nursing actions (N=l603), during the 1995/1996 school year, for all 394 pupils in the
program, as compared to the ADHD students (N=25 8) of the interventions employed
(N=311). This does not represent all the interventions, only those which were the most

frequently employed, therefore all 311 are not indicated.

Table 5.

Most Frequent Nursing Interventions for All Students and ADHD Students in the Title I
Health Program during the 1995/1996 School Year

 

 

NURSING INTERVENTION All ADI-ID Percent for

Students Students ADHD
Students

Coordinating primary care visits 336 87 .26

(pediatrician, family practice, Ingham

County Health Department)

Health Provider contact 252 47 .19

Dental visits 165 19 . 12

Home visits 150

Coordinating Mental Health visits 77 58 .75

Title 1 payment of glasses 66

Coordinating medication set up at school 66

Prescriptions covered by Title 1 34 10 .29

Assisting families with medication side 30 18 .60

effects

Assisting families with obtaining Health 19

Insurance

Coordinating Speech & Hearing visits 9 3 .33

Coordinating lab, x-rays, CT scans 8

TOTAL 1,430 258 .18

 

40

The frequency and percentage of initial interventions for each grade level for
those students making up the ADHD population, as well as the number of follow-up
actions, is presented in Table 6. The largest number of initial contacts is made during the
third grade (N=11), with more during the previous school years (N=17), and fewer first-
time encounters for all combined elementary school grades after that year (N=11). The
number of initial interventions were presented in Table 6 as being employed for those in
kindergarten to seventh grade. However, it is likely that the seventh grader was
miscoded, and should have been indicated as a sixth grade student, since the Title I

Health Program only services Kindergarten to grade 6. Nonetheless, it would be

Table 6.
Number of Initial Interventions per Grade for Students with ADHD and number of

follow-up interventions for 1995/1996 school year

 

Grade Frequency Percent

K 4 1.3

1 5 1.6
2 8 2.6
3 11 3.5
4 6 1.9
5 4 1.3
6 0 0

7 l 0.3
Follow-up interventions 272 87.5
TOTAL 311 100.0
Mean = 2.692 Median = 3.000 Mode = 3.000

 

Std Dev = 1.608 Variance = 2.587 Range = 7.000

 

41

beneficial to know the reasons why the first contact with the APN comes during certain
years as opposed to other times.

There are 17 different interventions for those identified as having ADHD or
ADHD-like symptoms, plus one blank. The Omaha System purposely has at least one
generic target, or intervention, named in this way in order to give flexibility to the
practitioner. The list of interventions in the Omaha System is not meant to be self-

limiting. A frequency table for these are depicted in Table 7. The 18 different

Table 7.

Nursing Interventions for the Subset of ADHD Students for the 1995/1996 School Year

 

 

Intervention Frequency Percent
Mental Health 5 8 1 8.6
Nurse/Physician Consult 46 14.8
Family Practice 37 11.9
Medication set up 30 9.6
Pediatrician 27 8.7
Health Department 23 7.4
Medical/Dental Care 19 6. 1
Medication/ Side Effects 18 5.8
Physical Signs/Symptoms 15 4.8
Prescriptions 10 3.2
School Consult 9 2.9
Parent Communication 8 2.6
Blank 4 1.3
Specialist 3 1.0
Protective Services 1 0.3
Support Group 1 0.3
Cast care 1 0.3
MSU Nursing Referral 1 0.3
TOTAL 311 100
Mean=62.383 Median=66.000 Mode=74.000

Std dev=17.616 Variance=310.321 Range=79.000

42

interventions were counted, and a sum of 311 actions were found to have been taken on
behalf of the ADHD population during the 1995/1996 school year.

Psychosocial problems are one of the most frequent comorbid findings with
ADHD. Thus, it is not unexpected that the intervention mOSt often employed was in the
area of mental health. Medication set-up was the fourth most employed intervention.
However, if that is combined with medication action/side effects the total nursing
interventions involving pharmacology would be 48. Prescriptions also tie in with these
interventions, making a total of 58 which relate to medication. If taken together
interventions relating to medication would then equal the most ofien employed target,

mental health, which is a part of the case management category.

Table 8.

Medications Used in Treatment of ADHD in the Title I Health Program during the
1995/1996 School Year.

 

 

Medication Type Number
Ritalin 3O
Ritalin Sustained Release 2

Cylert 4
Tofranil 2
Catapres 3

TOTAL 4 1

 

43

Medications are generally utilized in the treatment of ADHD and many of those

diagnosed with ADHD are at least placed on a trial of medication at some point. Over

half of the ADI-1D children in the Title I Health program are on some type of medication,

with Ritalin (methylphenidate) being the drug of choice. Table 8 represents the types of

medications used in the Title I Health Program.

One must have communication with people making up the other systems which

interact with the student in order to carry out the role of the case manager effectively.

Table 9 illustrates the breakdown of the types and number of communications employed

by the APN. It was seen that there were 311 nursing interventions for the subset of

students with ADHD. The number of communications also totaled 311. This correlation

might indicate that for every nursing intervention some type of communication was

 

 

necessary.
Table 9.
Communication Methods Utilized in the Title I Health Program for the Subset of
Students with ADHD
Type of communication Frequency Percentage
Telephone 170 54.7
Not coded 56 18.0
Mail 30 9.6
Not coded 29 9.3
Home Visit 20 6.4
School Visit 6 1.9
TOTAL 311 100
Mean=2.7 3 Median=l .000 Mode=1 .000
Std dev=2.456 Variance=6.034 Range=6.000

 

The literature review indicated that ADI—ID frequently found with such comorbid
conditions as depression, poor peer relationships, and interpersonal dysfimctional
behavior. Substantiating that greater need for intervention in the area of mental health
was demonstrated in Table 5. That table indicated that of the most frequently employed
nursing interventions a total of 77 were in the area of Mental Health. Of those 77
interventions in the area of mental health a significant number was for the group of
ADHD students (N-5 8) or 75%. This data thus supports previous research.

Use of medication, particularly Ritalin, is common in the treatment of ADHD. However,
it has side-effects, as does all medication and thus requires follow-up. Combined the
total number of actions in relation to pharrnacotherapy was 58. Nursing interventions
were in the area of: medication set up (N=30), medication/side effects (N=l 8), and
prescriptions (N=10). In this area a significant percentage of such interventions were on
behalf of the population of ADHD students.

Case management is a primary role of the Advanced Nurse Practitioner, and it
seen in Table 10 that nurse/physician consults, in this category, was the second most used
intervention, following mental health. However, ADI-ID, due to behavioral and
psychosocial manifestations, has marked affects on the family. This ties in with the third
nursing intervention, that of family practice. In Table 11, looking at nursing actions as
they pertain to the four Omaha System intervention scheme categories it is seen in that
there were significantly more actions in case management (74.6%) than in any other area.

197 of the total 311 interventions were aimed at one of the nine types of case

45

Table 10.

Case Management Nursing Activities for ADHD Students in the Title I Health Program

 

Vii-Interventions Frequency Percentage of case Percentage of total
management 311 interventions
Mental Health 58 .29 18.6
Nurse/Physician Consult 46 .20 14.8
Family Practice 37 .19 11.9
Health Department 23 .13 7 .4
Medical/Dental Care 19 . 1 1 6. 1
School Consult 9 .05 2.9
Specialist 3 .02 1 .0
MSU Nursing Referral 1 .005 0.3
Protective Services 1 .005 0.3

management activities. In looking at that amount it clearly supports the assertion that
ADHD is a complex disorder, because its case management needs are quite involved.
Table 11 looks at the domain of health teaching, guidance and counseling.

It can be seen that the APN does direct care, but this does not approach the number of

Table 11.
Health teaching, Guidance, and Counseling

 

 

Targets Frequency Percent of total targets
Support Group 1 0.3
Parent communication 8 2.6

TOTAL 9 2.9

 

46

interventions relating to case management. Most of the nursing interventions in this
category relate to parent or family communication (N=8), which is part of the

interpersonal system.

 

 

Table 12.
Treatments and Procedures
Targets or Interventions Frequency Percent of total targets
Medication Set Up 30 9.6
Prescriptions 10 3.2
Cast Care 1 0.3
TOTAL 41 13.1

 

Table 12 lists the number of treatments and procedures carried out by the APN
and her staff in order to provide care to the population of ADHD students in the Title 1
Health Program. An important area in the management of the ADHD child, this domain
accounts for 41 of the total number of interventions (N=311). Surveillance accounted for
10.6% of the targets (N=33) as illustrated in Table 13. As previously discussed, the 311
interventions constituted almost 20% of the APN’s caseload. The APN is in a position to
assess the benefit of medication in the school setting in which it is generally

administered, and significantly more often required, than in any other environment.

47

 

 

 

Table 13.
Surveillance
Targets Frequency Percent of total targets
Medication/Side Effects 18 5.8 A
Physical Signs/Symptoms 15 4.8
TOTAL 33 10.6
Summary

Data collected by the APN regarding the number and types of interventions
developed and employed with ADHD children were examined. The Omaha System
allowed the APN to group the contacts in a consistent and orderly way. While the data
indicates that ADHD is a frequent problem accounting for 13% of the referrals during the
1995/1996 school year, the percentage of interventions for this group greatly exceeded
that amount. There were 311 nursing interventions during the 1995/1996 school year for
ADHD. That accounted for 19.4% of the total number of actions taken for all problems.
Thus, although there were over ten diagnoses which came under the auspices of the Title
I Health Program, ADHD required almost 20% of the total attention of the APN. This
data supports the assertion that ADHD is a disorder requiring intensive intervention.

Discussion
Interpretation of the finding

This research is unique in that while it describes the number and types of

interventions for an ADHD population, it creates an overview of the role of the APN in a

leadership role in the treatment of ADHD in the school setting. There were no other such

48

studies found in the literature. In determining the number and type of nursing
interventions, data compiled by the APN in a middle-sized urban school district in
Michigan, was examined. It can be seen from the 18 nursing interventions, 17 which are
specific and one blank which is generic, that such children have multiple and complex
needs.

The findings included data revealing that most children diagnosed with ADHD in
the Title I Health Program had initial contact in the 3rd grade or before. This indicates
that there is a need for the ADHD to provide teacher education on ADI-ID, behavioral
manifestations, associated problems, and methods of handling the disorder in the
classroom. Teachers, as well as parents and families of students in the earlier grades,
will require information and emotional support in dealing with the disorder.

Pertinent findings revealed that most students in the Title I Health Program were
identified in the early grades, with the majority in the third grade. This points to the need
for supports for teachers in those grades, with additional education regarding
identification and management in the classroom. It also reveals the need for support for
parents of ADI-II) students, particularly in the early school years. Armed with
information supporting the prevalence of the disorder, and the knowledge that ADHD is a
chronic problem which may continue into adulthood, parents may not feel as alone or as
frustrated in their inability to find a quick cure.

Table 4 indicated the distribution of ADHD students and interventions for that
population in the twenty elementary schools serviced by the Title I Health Program.
These results excluded nine of the elementary schools in the district because they have no

ADHD students in the program. It would be beneficial to explore the reasons for that,

49
since given the distribution of ADHD in the general population it is highly unlikely that

there are no students with the diagnosis in nine schools. If there is a need for teacher
and/or parent education regarding signs and symptoms or treatment, these issues could be
addressed by the APN or other qualified personnel.

Nursing in today’s society, as well as other types of health care, is called upon to
be cost effective and productive. In order to ensure accountability in regard to the value
of the interventions on the client’s behalf one must have a means of evaluation. There is
a need for the APN “to recognize the power of data management and demonstrating
positive outcomes about their services as well as the necessity of sharing meaningful
clinical information with those who both support and challenge them” (Martin & Norris,
l996,p.82)

Medications, which fall under the interpersonal system, was seen to require a
large number of interventions. In the case of the ADHD student, much of that is
concerned with pharrnacotherapy in terms of medication set up, and Observation for side
effects. Although medication alone has not been effective in all those with the disorder,
it can be a helpful adjunct in treatment. Since so many of the ADHD students are treated
with pharrnacotherapy, parents and teachers need to be aware of the optimal time for
dosing and the side-effects. Ritalin, being the most frequently prescribed, should be
understood by those who form the interpersonal systems interacting with the ADHD
student.

The data collected by the Advanced Nurse Practitioner in the Title I program was
examined in order to delineate the number and types of interventions used for the

population of ADHD students. The needs of ADHD students were reflected by an

50

examination of the types of interventions used in treatment. The findings were
categorized according to the Omaha System intervention scheme categories. They were
also considered in the light of a systems framework, based on that of Imogene King. The
data indicated that most of the interventions came under the auspices of case
management, with needs pertaining to medications being the second most significant
area. Case management, however, is frequently not available for most ADI-ID students.
All too often there is no one coordinating the myriad of needs typical of one with a
diagnosis of ADHD.
Limitations

In this Level I descriptive study the population was a convenience sample of
ADHD children referred to the APN for treatment and follow-up. Some of these children
may carry the diagnosis of ADHD without a full evaluation of the diagnostic criteria.
This sample included children who exhibit ADI-ID behaviors, but may not have received
a definitive diagnosis. Thus, the first limitation of the data is that diagnosis is not strictly
according to DSM-IV guidelines in many cases. Therefore, some of the children may
have other behavioral problems, or there may be other confounding factors which may
affect the accuracy of the diagnosis. In order to accurately assess outcomes for a
definitive ADI-II) diagnosis, DSM-IV guidelines should be followed. That would help to
make the results more generalizable.

This is a sample made up of youngsters from generally disadvantaged, low-
income families. These children “are at risk for developmental disabilities, chronic
illnesses, infectious diseases, and elevated blood lead levels” (Martin & Norris, 1996, p.

82). ADI-ID has not been found to be a disorder exclusively of any one socioeconomic

51
group. This study may not reflect the typical number of ADHD students or the number of

nursing interventions required due to this being the data of one APN in one school
system, out of many in the United States, Thus, the findings may not be entirely
generalizable to other school districts.

There appears to be an error in the categorization of one of the interventions. The
codebook, which is used for all student interventions in the Title I Health Program,
indicates that “9” is cast care. However, it is more likely with a diagnosis for ADHD that
cast care is not indicated, although it may have occurred. Target 8 is
caretaking/parenting skills and it would be a more logical need for a child with ADHD
than cast care.

Another error in coding was found in the data shown in Table 7. It was indicated
that there was one intervention for a student in Grade 7. However, the Title I Health
Program services students from Kindergarten to 6th grade. It is more likely that there was
one 6th grader receiving the benefit of an intervention, as there were no 7th graders in the
program.

The Omaha System was originally developed to be used in the Home Health Care
setting. It has since been used in a number of types of agencies, and thus has undergone
thorough examination. It has been adapted onto dBase IV and modified for use in the
school district in this work. Although the Omaha System has held up to rigorous
examination, alterations may affect its reliability. Further reliability testing in this setting
as guided by an Advanced Nurse Practitioner would address that issue.

Another disadvantage of the Omaha System lies in the measurement of outcomes.

It is difficult, if not impossible, to measure knowledge. Many factors affect school

52

performance and academic success, making it extremely difficult to accurately assess the
difference made by confounding variables over which the APN has no control.

Another limitation in the data was that there was no breakdown of services by sex
of student. The literature substantiates that a greater propOrtion of those affected by
ADHD are males. It would be helpful to have the data to either support that, or if that is
not a finding, to give a starting point to research which would delve into the factors
behind it.

Significance to nursing

The metaparadigm of conceptual models in the nursing profession has been
denoted in literature and research as person, environment, health, and nursing. These
concepts embody the holistic nursing approach to health care and can be applied to all
disorders and illnesses which plague mankind. However, they are particularly relevant to
those with attention-deficit disorder, which is manifested by dysfunctioning in many
areas. Thus, ADHD is an excellent example of a disorder where the multifaceted holistic
approach of nursing is very applicable. It embodies an approach which looks not only at
the person and their health, but also at the environment in which the disorder is manifest.
It would be difficult to successfirlly treat an individual with ADHD without taking a
holistic approach.

The role of the nurse is to care for the person, either on an individual basis or in a
group environment. There are other health care providers who also do that. Nonetheless,
their professional functions differ from that of the nursing role in several significant
ways. The nurse is educated to view the individual in a holistic fashion, looking at all the

needs of the individual and family, physical, emotional, mental, and psychosocial. It is

53

not always the case that other practitioners are unaware of the holistic needs of the child.
However, the physician in family practice, or the neurologist in private practice, is
unlikely to have the time to coordinate care, and the psychologist or social worker does
not have the background to supervise a medication regime. None of the providers
mentioned have the background or the practice setting which lends itself to holistic,
coordinated health care as does the APN.

A vital role of the advanced nurse practitioner, or APN, is that of management of
students with ADHD. It has been suggested that such a provider is able to plan and
coordinate multifaceted programs. (Cantwell & Baker, 1987, p. 50). As a school based
case manager, the APN enhances care by reaching out into the larger community. This
role requires communication with the family, participation in referrals for needed
services, educational staff consults, and coordination of care with other health
practitioners. The findings in this study, as shown in Table 11, revealed that case
management interventions, which are part of the social systems, were found to be
significantly greater than any other type.

Community nursing is an integral part of undergraduate BSN education. It lays
the groundwork for an understanding of the individual as a part of the larger community
setting. The Advanced Practice Nurse is given an education which expands on that
foundation. The role of family, the larger community, and the political environment are
all included as part of the preparation for the Masters Degree in Nursing. These add to
the holistic philosophy of nursing and prepares the APN to assume a broader or expanded
management role. This academic preparation should continue to be part of the APN’s

educational program. Given that background, the APN is well-prepared to assume a case

54

management and leadership role in schools for those students with ADHD, as well as
many other disorders.

There is a need for comprehensive management for the ADHD student, in order
to meet needs which are presently not coordinated in the majority of cases. The primary
care physician is limited in time, and case management requires a great deal of input,
including telephone calls, referrals, and follow-up. The psychologist also has time
constraints, and does not have the same background in pharmacology that the Advanced
Nurse Practitioner does. While the psychologist does understand the psychosocial issues,
combining that with the ability to meet overall health care needs is not within their scope
of practice. The school teacher, with a classroom of approximately 20 students or more,
would have great difficulty filling this role. Furthermore, the educator generally does not
have a holistic viewpoint or in-depth health care knowledge. Thus, although most of the
needs of the ADHD population in the Title I Health Program were in the area of case
management, in the typical school situation where such coordination would be most
logical, there is generally no one able to fill that role.

There is a large proportion of students with ADHD in our schools. Much could
be accomplished in the treatment of children with ADHD if more school districts desired
and were able to implement a program similar to that of the Title I Health Program in the
middle-size, urban community described in this work. These children have multiple
problems and a poor prognosis if they do not receive help. An APN has the education
and focus to provide appropriate interventions and coordinate care for the ADHD student

in the school setting. Particularly in a disadvantaged group, such as that serviced by the

55
Title I Health Program, there is a tremendous need for the skills, education, and expertise

of the Advanced Practice Nurse.

In relating the distribution of interventions to the systems framework based on the
work of Imogene King, it is clear that the Advanced Nurse Practitioner’s role is for the
most part related to the social systems. While there is a certain amount of direct care on
the part of the APN in the Title 1 Health Program, which is denoted as part of the
interpersonal systems, much of the effort is involved in case management. Interaction
among such different social systems as the health department, family practice or other
health providers, school personnel and parents is a significant part of the APN’s effort.
Implications for further resea_rc_h

Since the academic setting is that in which most children spend the majority of
their time, further research on school-based intervention programs is needed in order to
see what might be accomplished in that area. The role of the Advanced Practice Nurse in
the capacity of case manager, should be further explored. Programs such as the Title I
Health Program can lend itself to other school settings. As previously pointed out, there
is little in the literature about school based programs for ADHD, and almost nothing in it
regarding its treatment which is described as headed by an Advanced Practice Nurse.

The goal for children with ADHD or ADHD-like symptoms, is to assist them to
reach an optimal state of wellness and more research is needed to substantiate the
benefits of school-based case management. The focus of future research needs to
compare the results of a holistic approach in the school setting with those treated with
medication alone, or pharrnacotherapy along with emotional/mental supports. In future

research, when outcomes are considered, it would be interesting to determine the

56

progress of students on medications, in such a program, as compared to those who are
treated with other interventions. Efforts which show the most positive results for this
group, in terms of academic, behavioral, emotional stability, and social successes, could
be the focus of future study.

ADHD has been seen to be a pervasive problem affecting school performance.
Thus, outcomes pertaining to specific interventions need to be explored in order to
determine the greatest needs in the ADHD student population, and those actions which
show the best results. Since cost-effectiveness is an integral part of the health care
system, and will become more so in the future, outcomes research will help to establish
long-term savings of this and similar programs. An increase in the productivity of those
with ADI-ID, and a reduction in drug use and law-breaking are endpoints in the treatment
of this disorder. Thus, long-term follow-up studies are needed to validate whether the
time and effort in a school-based program are both cost-effective and able to produce
results lasting into adulthood.

Not only is further research on school-based programs for ADHD important, it
would be beneficial to explore such programs with a variety of socio-economic groups.
The Title I Health Program was developed to reach the disadvantaged population, who do
not have easy access to health care, or the funds or insurance to pay for it, many are on
Medicaid. Therefore, the benefits of similar programs for other groups should be
explored.

Summm and Conclusion_s_
ADHD is a disorder requiring multiple interventions in order to provide

comprehensive health care. The school setting is the place where much of the student’s

57

waking hours are spent. Thus, the Advanced Nurse Practitioner in the academic milieu is
in a position to provide the coordination of care, in the form of case management. Yet
the Title 1 Health Program, under the auspices of an Advanced Nurse Practitioner, has
been seen to have an awareness of the multiple needs of this group, and provide the
holistic approach vital in its treatment Particularly in a group which is also
disadvantaged, difficulty in gaining access to care and the financial means to cover the
costs for medications and therapy, make the treatment of ADHD even more challenging.

This study has focused on the role of the APN in the Title I Health Program
through an examination of the number and types of interventions provided for a
population of ADHD students. By organizing the data using a systems approach, analysis
was facilitated. It has been shown that case management is the significant part of that
role. This attests to the complexity and intensive nature of treatment for students with
ADHD, and the need for coordination in delivering that care.

Imogene King’s conceptual framework has provided a means of putting the
nursing interventions in the Title 1 Health Program into perspective. It has given a
framework to this study which has been one way to logically explore the data. ADHD
has been shown to be both a chronic and a complicated disorder. It affects not only the
student, or personal system, but also interpersonal systems such as the classroom and the
family. Much of the interventions utilized by the APN were in the area of social systems,
such as coordinating and communicating with the health care providers and government
organizations. The key implication is that comprehensive care for ADHD requires a

practitioner who is able to provide case management.

58
An identification of what can be done for the student with ADHD is an important

first step. Before there is research on outcomes and the long-term cost-effectiveness of
early intervention for ADHD, coordinated by an Advanced Practice Nurse in the school
setting, it was necessary to identify the number and types of interventions which have

been utilized in treatment. That was the goal and focus of this work.

APPENDICES

APPENDIX A

59

APPENDIX A

 

 

DSM-IV
Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder

 

A. Either (1)7» (2):

(1) six (or more) of the following symptoms of inattention have persisted for at
least 6 months to a degree that is maladaptive and inconsistent with
developmental level:

[nattention

(a) often fails to give close attention to details or makes careless mistakes in
schoolwork, work, or other activities

(b) often has difficulty sustaining attention in tasks or play activities

(c) often does not seem to listen when spoken to directly

(d) often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (not due to oppositional behavior and
failure to understand instructions

(e) often has difficulty organizing tasks and activities

(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort (such as schoolwork or homework)

(g) often loses things necessary for tasks or activities (e.g., toys, school
assignments, pencils, books, or tools)

(h) is often easily distracted by extraneous stimuli

(i) is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have
persisted for at least 6 months to a degree that is maladaptive and inconsistent
with developmental level:

Hyperactivity

(a) often fidgets with hands or feet or squinns in seat

(b) often leaves seat in classroom or in other situations in which remaining seated
is expected

(0) often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjective feelings
of restlessness)

((1) often has difficulty playing or engaging in leisure activities quietly

(e) is often “on the go” or often acts as if “driven by a motor”

(f) often talks excessively

Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn

 

60

(1) often interrupts or intrudes on others (e. g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were
present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e. g., at
school [or work] and at home). '

D. There must be clear evidence of clinically significant impairment in social, academic,
or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not
better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety
Disorder, Dissociative Disorder, or a Personality Disorder).

Code based on type:
314.1 Attention-Deficit/Hyperactivity Disorder, Combined Type:
if both Criteria Al and A2 are met for the past 6 months

314.0 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive
Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

314.1 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-
Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the
past 6 months

Coding note: For individuals (especially adolescents and adults) who currently
have symptoms that no longer meet full criteria, “In Partial Remission” should be
specified.

APPENDIX B

6 1
APPENDIX B

Health Teaching, Guidance, and Counseling

Support Group

Parent Communication

Treatments and Procedures

Cast Care
Medication Set-Up
Prescriptions

Case Management
Pediatrician Family Practice
Medical/Dental Care Nurse/Physician Consults
MSU Nursing Referral School Consults
Coordinating Visits to ICHD (Health Dept) Specialist
Mental Health Protective Services

Surveillance

Physical Signs and Symptoms
Medication Side Effects

Blank

APPENDIX C

, MICHIGAN STATE

UNIVERSITY

May 9, 1997

TO: Linda S ence.
A230 Li e SCiences

RE: IRB#: 97-231

TITLE: THE NUMBER AND TYPES OF INTERVENTIONS DEVELOPED
AND EMPLOYED FOR A POPULATION OF ADHD STUDENTS
BY AN ADVANCED NURSE PRACTITIONER IN A
MIDDLE-SIZED URBAN SCHOOL DISTRICT IN MICHIGAN
TITLE I HEALTH PROGRAM DURING THE 1995/1996
SCHOOL YEAR

REVISION REQUESTED: N/A

CATEGORY: 1-A,E

APPROVAL DATE: 04/22/97

The university Committee on Research Involving Human Subjects'(UCRIHS)
review of this project is complete.. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately
rotected and methods to obtain informed consent are appropriate.
Egrefore, the UCRIHS approved this project and any reVisions listed
a ve.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a progect beyond one year must use the green renewal
form (enclosed with t e original approval letter or when a
pr03ect is renewed) to seek u date certification. There is a
maXimum of four.such expedite renewals ossible. Investigators
wishing to continue a progect beyond tha time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the.time o renewal, please use the green renewal form. To
reVise an approved protocol at an 0 her time during the year,
send your written request to the. CRIHS Chair, requesting revised
approval and referenCing the pr03ect's IRB # and title. Include
in our request a description of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

 

pRosmnrs/ .
OfimEmZ CHANGES: Should.either of the followin arise during the course of the
work, investigators must noti UCRIHS romptly: (1) roblems
RESEARCH (unexpected Side effects, comp aints, eEc.) involving Euman
AND subjectSOor 121.changes in the research environment or new
GRADUATE information indicating greater risk to the human subgects than
existed when the protocol was preViously reViewed an approved.
STUDIES '
If we can be of any future hel lease do not hesitate to contact us

Universflvmmmmm'" at (517)355-2180 or FAX (51714553171.
Research Involving

Human Subjects
(UCBIHS

Michigan State University
246 Administration Building
East Lansing. Michigan

Sincerel

    
  
 
  

 
  
 

id 8. Wright

433244046 RIHS Chair
51 ”355-2180 DEW : bed
FAX: 517/432-1171
cca/thda Kahn
flammgmamnmwmn
maemwmummmwy
EmwmwMAMM

navamNMmmunmi
«unmannwmwumi 62

APPENDIX D

ll

-
SCHOOL—
DISTRICT

Committed to Quality

April 23, 1997

Rhoda Kahn, BSN
4428 Westover Dr.
W. Bloomfield, MI 48323

Dear Ms. Kahn:
In regard to the proposed study, ”The Number and Types of Interventions Developed and
Employed by an Advanced Nurse Practitioner for the Population of ADHD Students in
the ' Public School System Title I Health Program During the 1995-1996 School
Year", the request to conduct the study in the Lansing School District has been approved.
The following comments apply to the study:
No personally identifiable infannation concerning students will be published or
released 17w School District will not be specifically identified in any
publication.
If you have any questions or need additional information, please contact me (325-6460).

Thank you.

MP/mlc '

cc: Research Review Committee

Research & Evaluation Services Office

63

64
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