School nurses are playing a major role in giving children safe access to attention deficit hyperactivity disorder (ADHD) medication in schools. Beyond delivering secure access to controlled medication, they are helping children to recognise and talk about their ADHD symptoms and any medication side effects they may have. Amid a reported rise in diagnoses and presentations, Madeleine Anderson explores the situation
Jane Graham is a school nurse at St Thomas’ Putney Vale Schol and a medical lead for the St Thomas’ schools’ group. She says around a third of the students she cares for have diagnosed ADHD and are prescribed medicine to manage it.
Though she notes that St Thomas’ Putney Vale opened as a new school in September 2023 and is understood to have a higher percentage of students with ADHD than older ones due to admission criteria.
As a controlled drug, ADHD medications need to be kept in a locked drawer inside a larger controlled drugs cupboard, with two separate keys to open each one. ADHD medications also require two people to sign them in and out, with at least one of these signatories being trained to administer medicines. In a school environment, the second signatory can be the child who is taking the medication.
‘You’ve also got to make sure you’ve got the right dose, the right person, the right format, the right time of day,’ Ms Graham explains.
While controlled drugs must be stored and handled with care, this ‘often creates a problem’ in a busy school environment, especially when children are taking on additional clubs and activities alongside their schoolwork and breaktimes, she says.
‘It’s imperative to have a school nurse’
Ms Graham believes it is ‘imperative’ to have a school nurse overseeing medication for children in schools – noting the ‘potential for risk’ when busy admin staff are asked to do this instead.
‘If you gave the wrong child somebody else’s medication, that could be quite detrimental to that young person, it may change the way they behave and then the way they think about that medication,’ she says.
‘So, I think to protect both the staff responsible and facilitate a positive medical experience, it’s imperative to have a school nurse – somebody whose role is designated to the wellbeing of that young person.’
Ms Graham says her role is vital in reminding children to take their medications throughout the day, and for safely providing ADHD medication to pupils who may have forgotten to take their medication before school.
She explained that ‘most children’ who take medication throughout the day will need to do so during lunchtime, which can be a challenge for those who struggle with timetabling and focusing.
She also stressed the educational role that the school nurse can play in answering pupil’s questions about their ADHD medication, and any side-effects they may experience.
‘I think it’s massively important to have a school nurse, because a lot of people have questions about their medication. They may come and say, “I don’t think this is working” and we can talk about side effects and dose changes.
‘I can answer questions if they’re struggling with their appetite or their mood changes, as ADHD medications can affect those sorts of thing,’ she continues.
She adds: ‘The younger we educate children, the better they are at managing their own medical conditions.’
Coordinating care
Julia Parsons, a school nurse at Leicester Grammar School, says school nurses offer a crucial line of communication between parents, teachers and specialists outside of the school environment.
‘I think it’s really important that there’s a registered nurse’s involvement in coordinating the care for a child with ADHD in the school, down to that communication with the specialist practitioner who is assessing the child and prescribing the medication.
‘It is that link between the school and the external specialist that we find is really, really important for the benefit of the child in the school,’ Ms Parsons explains.
She adds that she has found external specialist prescribers ‘more likely to work effectively and communicate better’ with a registered school nurse than with other school staff, especially because of their mutual understanding of the specialist terminology that may be used.
‘The numbers have definitely gone up’
Both Ms Parsons and Ms Graham told Nursing in Practice that they had seen a significant rise in parents seeking diagnosis or pupils presenting with ADHD symptoms since the Covid-19 pandemic.
Meanwhile, last year, a study from University College London (UCL) and funded by the National Institute of Healthcare Research (NIHR) found that diagnoses and prescriptions for ADHD had ‘increased significantly’ in recent years.
The research reviewed seven million individuals aged three to 99 between 2000 and 2018. It found a 20-fold increase in ADHD diagnoses amongst those studied across this timeframe.
Among boys aged 10 to 16, 1.4% had an ADHD diagnosis and 0.6% had been prescribed ADHD medication in 2000. This had risen to 3.5% and 2.4% respectively in 2018.
In this study, the proportion of ADHD diagnoses approximately doubled for boys and trebled for girls in the period during 2000 to 2018.
As the study focused on ADHD medication prescriptions in NHS primary care, researchers believe these figures are an under-estimation of the overall picture.
Providing a safety net
Chief executive and founder of charity ADHD UK, Henry Shelford, says it is unrealistic to expect children with ADHD to always remember to take their medication at home, especially if they take different prescriptions throughout the day.
‘The idea that kids should take their medication at home before school will work for some, but it won’t work for all,’ he explains.
Mr Shelford described how children with ADHD are often reminded to take their medication via texts and specialised app alerts and warned that steps to remove phones from some schools lacked ‘meaningful consideration’ for the ‘different needs’ of pupils with ADHD.
Indeed, Ms Graham described regularly using Google Meets to remind pupils to visit the nurse to receive their medication during school hours.
Given this, Mr Shelford believes schools should provide a ‘safety net’ for students who have forgotten to take their ADHD medication and sees school nurses as a key part of this.
‘There are real opportunities for school nurses to have interactions with kids, to check they’re okay and not spiralling into a terrible place,’ he says.
‘They can offer interventions before things become a crisis, so there’s a real opportunity to help prevent issues before they happen, and in some cases save lives.’
As flagged by mental health charities like Mind, people with ADHD are more likely to experience mental health problems than the general population, with evidence that anxiety, depression, and sleep problems are all more common among this group.
‘ADHD can make children feel very isolated, and a school nurse can be that person they trust to help them,’ Mr Shelford says.
He adds that conversations around ADHD often overlook the pressures faced by parents who may have ADHD too.
‘Quite bluntly, ADHD is commonly a genetic condition, so that can mean both parents and children are really struggling. Potentially, it can be quite chaotic at home, so the opportunity to have a fail-safe with backup medication supplies at school can be very meaningful.’
Earlier this month, Nursing in Practice reported on findings from the School and Public Health Nurses Association (SAPHNA) which found that more than four in five school nurses do not have enough staff to deliver a school nursing service.
A striking majority (96%) of school nurse respondents also reported an increase in mental health concerns and 86% reported a rise in self-harm and suicidal behaviours among pupils.
Last month, SAPHNA launched a petition calling for ‘a school nurse in every school. It is currently at 3,000 signatures with the goal of reaching at least 5,000.
