Last modified at 1/4/2013 4:07 PM by System Account

Home and School Connection

Introduction

ADHD is a complex disorder in which functional impairments occur both at home and school as well as other contexts. To facilitate optimal outcomes for students with ADHD, clear and frequent communication between home and school is essential.1 Communication may involve initial concerns, school-based intervention strategies, and progress monitoring.

Creating a collaborative and supportive relationship

Communication is critical to building solid relationships between home and school. For instance, to help a child with ADHD, parents and teachers need to understand the unique demands and needs associated with each context. Moreover, given the chronic and impairing nature of ADHD, it is essential that this communication is positive and supportive and that it encourages the planning and monitoring of interventions across both settings. Parents are a great resource for teachers regarding the student's interests and educational history. Likewise, teachers can provide parents with clear descriptions of the actions that they are taking to help the student succeed in the classroom (for example, teaching the student how to use a homework planner) and how they will monitor the students' progress.

There are a number of ways for teachers and parents to communicate with each other, including phone calls, newsletters, log books, notes, informal visits, conferences, and report cards.2 Parents may have preferences regarding the nature and frequency of the communication. That is, some parents may prefer a structured school-to-home notebook system in which communication occurs on a daily basis, whereas others may prefer alternative forms of communication on a less frequent basis. Moreover, given that ADHD is a highly heritable condition (in other words, a child with ADHD may also have a parent with the symptoms), the type and quality of communication between the two settings may be affected

For students with ADHD, parents and teachers may find it useful to set up a Daily Report Card (DRC). Evidence suggests that DRCs can help the student, parents, and teacher monitor progress towards goals, and goal attainment can be reinforced either at school and/or by parents. However, it is important to consider several factors before using school-to-home notes:2

  • Teachers should discuss this method of communication with parents to determine whether they would find it useful.
  • Communications should be clear and positive.
  • Situations that require a problem-solving approach should be handled by a different type of communication, such as an informal meeting or a phone call.

Homework

Children with ADHD frequently experience difficulty with their homework.3 These troubles are important to address, as they can negatively affect a child's academic achievement. Researchers have found that children with ADHD frequently:

  • forget to record the homework assignment
  • forget to bring the materials that they need to complete homework
  • put off starting homework at home
  • tend not to persist or stay focused on the homework assignment
  • may complete the homework in a careless manner
  • forget to hand in assignments that are completed

These early homework problems may be the result of weaknesses in receptive language, memory, or organizational skills.4 However, as students get older, homework problems may become more problematic as assignments increase in complexity and in the amount of independent work required.

Research on homework practices

It is important for all students, but particularly for students who are struggling academically, that homework is matched to the student's abilities in terms of difficulty level and length of time to complete.5 That is, students should be able to complete homework assignments with a high degree of accuracy. In addition, other strategies that have been used successfully with students to improve homework completion are:

  • graphing of homework completion
  • cooperative study teams
  • homework planners and teaching students how to use them
  • real-life assignments
  • family involvement

Students who struggle to complete homework, including students with ADHD or learning disabilities, may require additional skills instruction to help them complete assignments. For example, one study provided explicit instruction to students with learning disabilities.4 In this study students were taught how to:

  • accurately record an assignment
  • plan how much time would be needed to complete an assignment
  • organize their materials
  • start and check their work
  • keep track of assignments

In these explicit classes, the instructor first modelled each of the strategies. Then the students orally rehearsed the tactics and used them in guided practice under simulated conditions.

Students with learning disabilities may acquire and utilize strategies that foster organization and homework completion, but only when they are presented in a direct and supported manner. Likewise, children with ADHD may require similar levels of explicitness and guided practice in using homework planners. These students may also benefit from graphing their homework completion, as this process helps self-monitor performance.

In addition to the above strategies, students with ADHD may also need enhanced reinforcement systems (such as token economies or behavioural contracts) to address homework completion problems.5 Teachers may wish to refer to the book Homework Success for Children with ADHD: A Family-School Intervention Program5 for more ideas. In this program the following strategies are taught:

  1. how to setup a system for reporting homework assignments
  2. how to setup establish a homework routine
  3. how to give effective instructions
  4. how to implement positive reinforcement strategies
  5. time management and goal setting
  6. how to use punishment effectively
  7. how to maintain homework strategies and skills

In this program, collaboration between home and school is stressed as well as the importance of monitoring progress to see if the program is meeting the stated objectives.

What types of medication are used to treat ADHD?

Information is provided here about the medications that have been officially approved for the treatment of ADHD by federal regulators of drugs, such as:

  • Health Canada
  • FDA (Food and Drug Administration), U.S.A.
  • EMEA (European Medicines Agency)
  • MHRA (Medicines and Healthcare products Regulatory Agency), UK

There are two main types of medications used to treat children, adolescents, and adults with ADHD: stimulant medication and non-stimulant medication.

Stimulant medications

Stimulant medication, particularly methylphenidate (Ritalin®), has been the most widely used medication in the treatment of ADHD for the past four decades.6 Its beneficial effects on children's behaviour and school problems were discovered serendipitously by Dr. Charles Bradley in 1950. He was using one of the earliest types of neuroimaging techniques (pneumo-encephalogram, which is no longer in use) to study the brains of children with behaviour disorders. One problem was that this procedure produced severe headaches in many of the children. So he used one type of stimulant medication (an amphetamine) that was involved in regulating pressure in the brain's ventricles, which he thought might alleviate the headaches. To his surprise, most of the children showed marked behavioural improvements and about half showed improved schoolwork.7 These children referred to the pills as "math pills" because they were able for the first time to sit and complete their math sums! These findings marked the start of the use of stimulant medication to treat children with persistent and impairing symptoms of inattention, hyperactivity, and impulsivity — what is now called ADHD.

Mechanism of action of stimulant medications (how they work)

There are two classes of stimulants:

  • Methylphenidate-based drugs

  • Most of what is known about stimulant medication has come from studies of methylphenidate. Over 1500 randomized controlled trials have shown that methylphenidate is effective for the majority of children, adolescents, and adults with ADHD. The most widely used form of methylphenidate is Ritalin®; more recent forms include Concerta®, Metadate-CD®, and Focalin®.
  • Amphetamine-based drugs

  • Amphetamine medications are considered equally effective as the methylphenidate-based medications. Response to one type of stimulant medication does not predict response to the other. However, some individuals respond more favourably to one class of stimulant medication than to the other. Commonly used forms of amphetamines for ADHD are Adderall® and Dexedrine®.

Stimulant medications used in the treatment of ADHD work by increasing the levels of brain chemicals (neurotransmitters, such as dopamine and norepinephrine) that help transmit signals between nerves. For example, methylphenidate has been shown to increase dopamine levels in the brain, which enhances the ability to distinguish signal from noise and increase the saliency of stimuli.8 9

These research findings are relevant for the classroom setting. For example, many students with ADHD claim that most schoolwork is boring. Treatment with methylphenidate increases their dopamine levels, which in turn would increase the saliency of the task (suddenly it would appear interesting) and improve their performance. This is exactly what has been shown to happen in randomized controlled clinical trials; children's academic productivity is far greater when being treated with methylphenidate compared to when those same children are given placebo.10

Effects of stimulant medications

With these medications, individuals with ADHD are better able to focus and ignore distraction. This can help them regulate their own behaviour and thinking. In the classroom, students with ADHD may be less fidgety, less emotional, and better able to concentrate when they are being treated with stimulant medication. Also, they may be able to get more work done and experience better relationships with others, so they may get along better at school and at home.11

However, students with ADHD are likely to have missed out previously on a lot of instruction and may also have learning problems. Medication cannot solve these problems and so adaptive, tailored academic instruction is essential for these students to succeed in school, regardless of whether or not they are being treated with medication. Also, it is unclear whether medication treatment for ADHD improves academic achievement (as measured by standardized tests) over the longer term in students with ADHD.

Duration of effects of stimulant medications

The two major classes of stimulants vary in how long the beneficial effects last, and can be classified broadly as those with longer duration versus those with shorter/intermediate duration of action (see Tables 8-1 and 8-2). Stimulant medications for ADHD are usually given in the form of pills or capsules that need to be swallowed and not chewed. However, for children who have difficulty swallowing pills, some types of stimulant medication come in capsules that can be opened and the contents sprinkled on or mixed with food, such as apple sauce or yoghurt.12

Table 8-1: Short-Acting Stimulants*

Trade Name Class of Stimulant Duration of Action Can Open Capsule and Sprinkle on Food Need for School Administration
Adderall® amphetamine 4 to 5 hours No Yes
Dexedrine® amphetamine 4 to 5 hours No Yes
FocalinTM dexmethylphenidate 3 to 4 hours No Yes
Ritalin® methylphenidate 3 to 4 hours No Yes

* Stimulant medications have been listed in alphabetical order. Note that not all of these forms of stimulants have been approved in Canada or in countries other than the U.S.A.

These short-acting stimulants are taken at three- to four-hour intervals, usually about 30 minutes before the previous dose wears off. This means that students have to take the pills at school, either at lunchtime or at another time during the day. Note that if the student took the first dose at home upon waking or very early in the morning (6:30 or 7:30 a.m.), the beneficial effects will start to wear off well before the lunchtime recess, when it is common for schools to administer the second dose. Likewise, the beneficial effects of a dose given at noon will start to dissipate by around 3:00 to 4:00 p.m. — a time of transition, coinciding with after-school daycare or activities, transportation by school bus, and unsupervised time en route home. This means that the student's behaviour and ability to concentrate may deteriorate before the next dose can be given. If this situation arises, it should be discussed with the parents, so that they can explain the difficulty to the prescribing physician.

Notwithstanding the practical problem associated with the need for multiple doses per day, short-acting drugs are useful in many ways. First, they do help control many children's ADHD symptoms and the dose can be adjusted easily, so medical treatment guidelines recommend that doctors start with the short-acting stimulants before switching to a longer-acting type.12 Also, doctors may prescribe a short-acting stimulant in the afternoon - after the longer-acting stimulant wears off — so the child can participate in after-school activities or have quieter evenings at home.

The past decade has witnessed the development and approval of longer-acting preparations of methylphenidate and amphetamine for the treatment of ADHD in children, adolescents, and adults. The main goals of this drug development are:13

  • to eliminate the need for multiple doses per day (particularly the need for a mid-day dose, which often has to be given at school)
  • to minimize the "roller-coaster" on-off effect of the short-acting stimulants
  • to enhance the clinical utility of longer-acting forms

Table 8-2: Longer-Acting Stimulant Medications for ADHD*

Trade Name Class of Stimulant Duration of Action Can Open Capsule and Sprinkle on Food Need for School Administration
Adderall XR® amphetamine 10 to 12 hours Yes No
Concerta® methylphenidate 10 to 12 hours No No
Dexedrine® Spansule amphetamine 8 to 10 hours No Possibly
Metadate CD® methylphenidate 8 hours No Yes
Metadate ER® methylphenidate 3 to 8 hours No Possibly
Methylin ER® methylphenidate 3 to 8 hours No Possibly
Ritalin-LA® methylphenidate 10 hours Yes No
Ritalin-SR® methylphenidate 3 to 8 hours No Possibly

* Stimulant medications have been listed in alphabetical order. Note that not all of these forms of stimulants have been approved in Canada or in countries other than the U.S.A.

Because the effects of some of these longer-acting stimulants can last up to 10 or 12 hours, a student can take one pill in the morning before coming to school and generally does not need to take another pill at school. Longer-acting stimulants may also help children get through after-school activities. Some children, however, may need a second dose or a shorter-acting form of a different drug if the medication takes longer than expected to take effect in the morning or the effects wear off too quickly during the school day.

Side effects of stimulant medications

More than four decades of clinical application have demonstrated the efficacy and safety of methylphenidate and amphetamine-based stimulants. But like all medication, methylphenidate and amphetamine have some side effects (unwanted effects). Not everyone will experience the side effects, but it is not possible to predict who will and who will not. So it is useful for teachers (as well as parents and the children with ADHD themselves) to know what side effects stimulant medication may cause, so that they can report observed side effects to the parent or physician. Physicians have several strategies for reducing or eliminating side effects of stimulant medication, including changing the dose, adding or omitting a dose, switching to a different stimulant, switching to another type of medication, or using an alternative or adjunctive non-pharmacological treatment approach.12

The following common side effects may occur in up to 20% of children with ADHD, but they are usually very mild and do not last long (they start to decrease within 30 minutes to two hours and disappear completely within 24 hours and when medication is stopped):

  • stomach discomfort
  • headache
  • sadness
  • irritability
  • tendency to cry more
  • rapid heart rate and increases in blood pressure
  • difficulty falling asleep (so that the student may be very sleepy and cranky at school)

Effects of stimulant medication on children's growth are not fully understood. Concerns about the effect of prolonged treatment with stimulant medication on growth (that is, on height and weight gain) have been raised repeatedly in the past three decades, but as yet there are few firm conclusions.14 There is fairly consistent evidence that treatment with stimulant medication in childhood and adolescence is associated with attenuated weight gain.14 15 By contrast, findings regarding the effects of stimulants on height are more complex and inconsistent. For example, some studies report an attenuated growth in height of about 1 cm/year in the first one to three years of treatment, whereas others do not.14 Moreover, it has been suggested that some children with ADHD may follow a different growth trajectory, meaning that children with ADHD may not grow quite as tall as children without ADHD, regardless of treatment with stimulant medication.16 It has also been suggested that there is " growth rebound effect" (a rapid increase in height and weight), when stimulant medication is stopped.17 Although more recent studies do not find evidence of a rebound effect,15 this observation has lead many doctors to recommend "drug holidays" during the weekend or summers. It is not known whether this practice makes any difference for growth or weight gain in the long term. Nonetheless, since children often use psychostimulants for several years, periodic examination of growth in children using stimulants is very important.

Serious but rare side effects of stimulant medication: More serious but rare side effects include hypersensitivity or allergy, facial tics, stereotypic movements, confusion, or hallucinations. Doctors generally believe that the frequency and severity of side effects increase with increasing dose.

Also, Health Canada suspended the market authorization of Adderall XR® in February 2005 due to concerns about the risk of sudden deaths, heart-related deaths, and strokes in children and adults taking regular recommended doses of Adderall® and Adderall XR®. There have been no Canadian reports of death in patients using this medication. This decision has subsequently been re-assessed by Health Canada following the recommendations of an independent Drug Committee and this stimulant medication was reinstated in Canada in August 2005, with a revision of the label to to include warnings against the use of Adderall XR® in patients with structural heart abnormalities as well as the dangers of misusing amphetamines.18

Stimulant medication does not increase the risk for later drug abuse: Stimulants are not considered to be habit-forming when used as prescribed (that is, taken orally at the specified dose and frequency) to treat ADHD in children and adolescents. Also, there is no evidence that their use as prescribed leads to drug abuse. Convergent findings from clinical studies suggest that children with ADHD who are medicated appropriately with methylphenidate are at lower risk for developing substance abuse problems than are children with ADHD who are not medicated.19-21

However, there is a potential for abuse and addiction with any stimulant medication — especially if that person has a history of substance abuse. Also, when methylphenidate is abused, it is mostly taken intravenously or snorted.8 22

The primary concern for schools is not that students with ADHD themselves abuse their prescribed stimulant medication, but rather that they misuse it, because they are frequently approached by other students to sell, give, or trade their prescription drugs (particularly in high school student populations).23

Non-stimulant medications

Atomoxetine hydrochloride is one of a new class of medications being developed, known as "specific norepinephrine reuptake inhibitors."24 Atomoxetine is sold under the trade name Strattera®. It is the first non-stimulant medication approved for the treatment of ADHD. It was approved by the Food and Drug Administration (FDA) in the U.S.A. in November 2002 and was subsequently approved by drug regulatory agencies in Canada, the United Kingdom, Australia, Mexico, Argentina, and several other countries.

Mechanism of action of atomoxetine

Unlike stimulants, which serve primarily to increase dopamine neurotransmission, atomoxetine increases norepinephrine neurotransmission, which is associated with better modulation of attention. Data from numerous randomized controlled clinical trials have shown it to be well tolerated and effective in the treatment of children, adolescents and adults with ADHD.24 25 Like stimulant drugs, atomoxetine is effective in treating and controlling ADHD symptoms at home and at school. Also, improvements have been reported in broader social and family functioning.

Duration of effects of atomoxetine

Atomoxetine is generally given once a day either in the morning or evening. If a second dose is needed, it is given in the late afternoon — after the school day. Thus it is unlikely that students would need to be given this medication during the school day.

Atomoxetine is a slower-acting medication compared to stimulants. The beneficial effects of stimulant medication are evident within about 30 minutes of taking the medication (even after the very first dose). By contrast, those of atomoxetine may not be discernible for almost a week after the student starts taking the medication. Maximum benefits are generally seen starting in the second to third weeks after starting treatment and the beneficial on the behavioural symptoms may not appear as dramatic as sometimes seen with stimulant medications.

However, once the beneficial effects emerge, there is some indication that the effects of a single morning dose of atomoxetine last for about 24 hours. For example, parents' evaluations of their child's behaviour during the evening and early morning activities (prior to the next morning dose) indicate that the children have fewer problems with homework completion, settling at bedtime, and falling asleep at night, as well as getting up and getting ready for school the next morning.25 These routine household activities in the evening and morning typically pose major problems for parents who have a child with ADHD.26

Side effects of atomoxetine

Overall, atomoxetine is well tolerated with minimal side effects.24 25 The most common side effects, which are generally mild, include:

  • upset stomach
  • decreased appetite
  • nausea or vomiting
  • tiredness or fatigue
  • dizziness
  • mood swings

As with stimulant medication, there have been a few concerns about decreased growth in children and teens taking atomoxetine, so doctors generally weigh and measure these youngsters periodically while on this ADHD medication.

Atomoxetine is an eye irritant. Atomoxetine capsules are not meant to be opened and should be swallowed whole. The drug is an eye irritant. If the contents of the capsule come into contact with the eye, the affected eye should be flushed immediately with water, and medical advice should be obtained. Also, hands and any surfaces in contact with the capsule contents should be washed with soap and water as soon as possible.

Serious but rare side effects of atomoxetine

Allergic reactions are rare but do occur, usually as swelling or hives. There have also been rare reports of episodes of paleness, burning, prickling, or pain in hands or feet.

In 2004, atomoxetine began carrying a warning label that the drug should be stopped if patients showed signs of jaundice (yellowing of the skin or whites of the eyes, a sign of liver damage), but this is also a very rare side effect.27 Patients and parents of children and adolescents taking atomoxetine are advised to contact their doctor immediately if they develop itching, dark urine, yellow skin or eyes, upper right-sided stomach area pain, or unexplained "flu-like" symptoms.

In 2005, the US Food and Drug Administration (FDA) warned about an increased risk of suicidal thinking in children and adolescents being treated with atomoxetine.28 Specifically, like many other psychiatric medications, the FDA states that atomoxetine "may increase thoughts of suicide or suicide attempts in children and teens." The prescription bottle now carries a warning label that advises parents should call their child's doctor if their child has:

  • new or increased thoughts of suicide
  • changes in mood or behaviour including becoming irritable or anxious

Thus, teachers are strongly advised to notify parents of students being treated with atomoxetine immediately if they observe any sudden changes in aggression, mood, or behaviour or new or increased talk, thoughts, or action related to suicide.

Atomoxetine does not increase the risk for later drug abuse: This medication is not associated with abuse liability in humans at the usual doses prescribed.29 Thus, unlike the stimulants, atomoxetine is not a controlled substance.

Antidepressants as ADHD medications

Various types of antidepressant medications have all been shown to help children and adults with ADHD, but these medications are not approved by federal drug regulation agencies to treat ADHD.

Response to medication does not confirm a diagnosis of ADHD

An individual's response to medication treatment for ADHD does not rule in or rule out the diagnosis of ADHD. Individuals who do not have ADHD, or who have another type of neurodevelopmental disorder or health condition, may also show a favorable response to medication for ADHD.

The teacher's role in medication treatment of ADHD

Teachers and other school staff play several important roles supporting and monitoring treatment programs for students with ADHD, including when medication is part of the overall treatment approach.

Monitoring initial effects of medication treatment on classroom behaviour and performance

There is no way for doctors to predict in advance which of several medications will be most helpful for a specific child, adolescent, or adult with ADHD, or what the optimal dose will be. A student who does not benefit from one type of stimulant medication may do very well on another type, or on a non-stimulant medication. A student who does not benefit from one dose may do very well on a higher or lower dose. Similarly, side effects may occur with one type of medication but not on another. Thus, the student's response to medication needs to be monitored very carefully.

Teachers play an important role because they can observe and listen to the student during the day, while the medication is active in the student's brain, and report the duration and type of effects of the medication. Without the teacher's input, the parents and physician would not know whether the specific dose or type of medication is beneficial. This is particularly so with younger students, who may not have the capacity to evaluate, nor the vocabulary to describe the effects, or who may not be able to remember them by the time they reach home at the end of the school day.

Medication trial

One procedure for beginning medication that many physicians find useful is to use a very careful trial in which a child is given placebo and different doses of medication, or different types of medication. Typically, in this procedure, neither the parent, the teacher, nor the student are told what dose or medication is being given on any day or when placebo is being given. This is important because no matter how good one's intentions are, it is very difficult to be objective about a child's behaviour when one knows an individual is on medication.

With parental consent, physicians may ask teachers to complete daily or weekly ratings of the child's behaviour and academic performance, as well as any side effects. The parent does likewise.

By comparing the teacher's ratings (and the parent's ratings) for the different medication or dose conditions, the physician has a more objective basis for deciding whether the medication really helped, whether there were any adverse side effects, and what problems remain even if the medication was helpful.

When completing the rating scales or description, it is important for teachers to keep in mind both the improved times that the student has experienced, as well as any periodic "melt-downs" that might occur as the medication wears off. If the teacher's ratings are unduly influenced by "melt-downs" (which might imply little or no improvement), the physician may respond by increasing the dose, which may not help the child and may make the "melt-downs" worse.

Ongoing monitoring of students with ADHD

Once the physician has determined the best dose for a particular student with ADHD, it is very important to monitor how the student is doing on a regular basis. Medical guidelines from bodies such as the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry recommend that follow-up information be obtained from teachers to help ensure that the treatment is still helpful. The regular, systematic feedback from teachers about how well the student's behavioural symptoms are being managed, the amount and quality of work being completed, and the quality of the student's relationships with peers and adults in the school setting, are all essential for ensuring success at school (as well as at home) for the student with ADHD.

Dispensing medication at school

Schools may be required to dispense ADHD medication at school. At some schools, this is not always easy to coordinate. Often there is not a school nurse on site to give the medication. Many school boards and schools have developed systematic policies and procedures to ensure the safe handling of all medication, and particularly stimulant medication or any other controlled substance that can lead to tolerance and dependence of misused or abused. Teachers are advised to check with their school board to determine what policies and procedures are in place.

Major recommendations by the U.S. Drug Enforcement Administration (DEA) are listed in Table 8-3. For further information, please see this web site: http://www.deadiversion.usdoj.gov/pubs/brochures/stimulant/stimulant_abuse.htm

Table 8-3: Recommended School Policies and Procedures for the Safe Handling of Medication

Delivery of Medication to School
1. ADHD medication should be delivered to the school by a parent, guardian or other responsible adult; students should be prohibited from carrying ADHD medication to and from school.
2. Medication delivered to school must be provided in a properly labelled container, indicating:
  • Student's name
  • Name of medication
  • Dosage and time the medication is to be administered at school
Documentation of Medication Kept at School
3. One person at school should maintain primary control and responsibility for medication delivered to school and maintain a Medication Inventory Log, which indicates:
  • date that medication was received, along with its name and amount received (number of pills), and signatures of the deliverer and receiver
  • name of student (grade and home-room) to whom the medication is to be dispensed
  • signed permission for school staff to administer the medication during school hours, along with written and signed medication order from the prescribing physician
  • name and telephone number of prescribing physician
  • emergency contact telephone numbers for that student
  • date and amount of medication destroyed or removed from school, along with name and signature of that person
Storage of Medication at School
4. Medication should be stored in a secure and locked location (room, drawer, or cabinet), with an inventory and accountability for the keys or key-codes.
Dispensing Medication at School
5. Medication should be administered by the designated, responsible school person. The student with ADHD should not be permitted to self-administer medication outside the presence of school staff.
6. A log should be kept indicating the date, time, and amount of medication dispensed, along with the initials of the person who dispensed the medication.

Educating school staff and students about prescription drugs, street drugs, and drug abuse

An understanding of the use and risk for misuse and abuse of prescription medication, particularly controlled substances such as stimulant medication, is necessary for all school personnel, including teachers, principals, school nurses, and school psychologists.

Establishing and adhering to written school policies and procedures for ensuring safe handling of medication at school will decrease the risk of misuse and diversion of prescription medication.

School personnel can play a helpful role in monitoring whether students who take prescribed medication are being approached or threatened to give or sell their medication, or whether their medication has been taken or stolen by others.

We recommend instigating an effective, evidence-based, school-based substance abuse prevention program (such as Life Skills Training or Project ALERT), which should include information about the risks of use, misuse, and diversion of stimulant medication.30 31


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