School counselors and psychotropic medication: assessing training, experience, and school policy issues.

This article reports the results of a national survey of school counselors that gathered information about the extent of school children's psychiatric diagnoses and usage of psychotropic medication, school policy issues arising from these practices, and counselors' perceived need for further training. Results support the assertion that psychotropic medication is widely prescribed to school-aged children creating school policy concerns and that school counselors desire further training regarding children and psychotropic medication.

Note: A copy of the survey instrument is available upon request from the authors.

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The discussion surrounding the proper role and duties of the school counselor began when the role was first implemented and continues today. School counseling textbooks written in the 1960s (Boy & Pine, 1968), 80s (Cole, 1988), and 90s (Schmidt, 1999) as well as recent articles (Baker, 2001; Gysbers, 2001; Whiston, 2002) all grapple with a definitive description of proper duties of the school counselor. A problem associated with the ambiguity of the role occurs when counselors are assigned quasi-administrative functions that compete for time with more proper counseling activities.

Paisley and McMahon (2001) suggested that it was possible to look at the fluidity of the role as a strength rather than a detriment. Simply put, as the world changes, the needs of students change, and school counselors respond to those changing needs. As the divorce rate went up in our society, school counselors responded by leading divorce support groups. With the current emphasis in the school community on testing and academic accountability, school counselors focus more on academic intervention and support. The schools that were sites of mass violence such as Columbine High School or the Westside Middle School in Jonesboro, Arkansas, have required support to heal from the attendant trauma. In any case, it is the fluidity of the school counselor's role that makes it possible for school counselors to respond to the needs of the environment in which they are placed. Given that, it makes sense to suppose that a change in the way society as a whole and the medical profession in particular treat children will affect the parameters of the service offered by school counselors.

This article focuses on how the increased prescription of psychotropic medications to school-aged children is affecting schools and school counselors. The latest large-scale study confirming this increase is Zito et al. (2003). These researchers found that despite a lack of evidence of efficacy, prescriptions for psychotropic medication for school-aged children continue to increase annually. The history of this trend began with the pediatric use of stimulants.

The use of stimulants to treat what was initially labeled as Minimal Brain Dysfunction (MBD), now referred to as Attention-Deficit/Hyperactivity Disorder (ADHD), began in the 1960s. Since then, there has been a steady increase in the number of children taking stimulant medication (Werry, 1999). In a summary of several studies from 1971 to 1997, Gadow (1999) concluded that drug treatment for ADHD had doubled every 4 to 7 years. During that period of time, in the process of fulfilling their role as consultant, school counselors had to deal with a variety of scenarios resulting from the increased number of children diagnosed with ADHD. Physicians, teachers, parents, and students vary in the degree to which they support the diagnosis of ADHD and subsequent treatment with psychotropic medication, and school counselors are sometimes called upon to mediate when parties disagree. School counselors have supported the educational process of those students diagnosed with ADHD by consulting with teachers and parents and offering individual and group counseling services tailored to these students (Thompson & Rudolph, 2000). In order to offer these supportive services, school counselors have sought out information about the treatment of ADHD in texts, professional journals, and in-services or workshops (Schwiebert, Sealander, & Tollerud, 1995).

A new element was introduced into the picture in the 1990s when the medical profession began to expand the application of psychotropic medications to the treatment of children's emotional and behavioral problems. Diagnoses and medications that had previously been restricted to adult populations were now being applied to children. Safer (1997) summarized the following changes regarding the prescription of psychotropic medication to children during the 1990s: (a) an increase in overall use of psychotropic medications, (b) an increase in the use of multiple concurrent medications, and (c) a marked increase in the use of serotonin reuptake inhibitors antidepressants. Nonstimulant medication for children and adolescents included antipsychotics, antidepressants, and mood stabilizer compounds. In contrast to the use of stimulants to treat children with the diagnosis of ADHD, there is a paucity of information available regarding the effects of these other agents on children (Coyle, 2000; Zito et al., 2000).

Confirming the continuation of this trend, Zito et al. (2003) noted that the increase in the number and variety of psychotropic medications for school-aged children continued throughout the 1990s. This trend continued despite the dearth of efficacy studies supporting the practice and the lower validity and reliability of psychiatric diagnoses for children. In addition, Brown and Sammons (2002) noted that the clinical use of psychotropics in children exceeds the available efficacy and safety data. Costello et al. (1996) reported that at some point, 17% to 25% of children and adolescents experienced a DSM-IV disorder, but Levant, Tolen, and Dogen (2002) identified the lack of a national epidemiological study of child psychopathology as making such estimates difficult. In view of these concerns, it is important to assess school counselors' knowledge of psychotropic medications prescribed for school-aged children as well as counselors' perceived need for continuing education in that area.

This article reports the results of a nation-wide survey of school counselors that studied their knowledge of the types of mental health problems suffered by children in their schools, school policy issues related to the dispensing of psychotropic medication, and school counselors' perception of the need for training about children's psychotropic medication. The overall purpose of this study was to assess the impact of these changes in schools from the perspective of school counselors. This study explored three research questions.

1. What kinds of psychiatric diagnoses and psychotropic medications are school counselors encountering in the student population?

2. What school policy issues are created by students taking prescribed psychotropic medications?

3. Have school counselors received sufficient training to deal with issues arising from students taking psychotropic medications?

METHOD

Procedure and Participants

A national list of 400 randomly selected school counselors was purchased from the American School Counselor Association (ASCA). Copies of the questionnaire and an informed consent statement were mailed to those on the list. Simultaneous with the mailing, an additional 20 questionnaires were distributed at a state level counselors' conference. As both an incentive to respond and a thank you for their efforts, respondents were given access to a Web site containing information on pediatric psychopharmacology that is updated monthly. Of the 420 questionnaires, 158 (38%) were returned. Of the 158 returned, 19 were unusable for the study. Eight counselors had not signed the informed consent statement, one did not complete the questionnaire and requested to be taken off the mailing list, one reported not working, seven were returned as undeliverable, one was a graduate student, and one wrote, "I am not a candidate for this study." This left a sample of 138 school counselors, which is 34.5% of the original distribution number.

Demographics of Respondents

Since the survey was mailed to 400 randomly selected members of the American School Counseling Association, all of the respondents were members of that association. At least one response was received from 45 different states and 2 territories. The gender composition is fairly typical of the traditional composition in the field of education. Of the 138 respondents, over three fourths were female (81%). Ages ranged from 21 and older, with 56 years plus as the modal age range. When asked to indicate their highest level of education attained, the majority (86%) had received a master's degree. A smaller percentage had earned a doctoral degree (8%) and a few reported a Baccalaureate (6%) or an associate degree (less than 2%).

The reported years of experience ranged from zero to 16 plus. Less than half had 4 or less years of experience (40%). A similar number of participants reported between 4 and 14 years of experience (43%) while a few participants indicated 16 or more years on the job (6%). About half the respondents appear to work at the elementary level and half at the secondary level. Because of the variety of grades that might be called middle school or junior high in different school systems, it is not possible to be sure which of the respondents are working at that level.

Instrument

A pilot questionnaire was administered to 30 school counseling students in June 2001. As a result, additional items relating to the experiences of teachers and other educators in dealing with children taking psychotropic medications were included in the questionnaire. The pilot instrument otherwise supported the face validity of the questionnaire items.

The 21-item survey covered three broad areas. First, checklists assessed the proportions of schools of students taking psychotropic medication by examining the types of diagnoses and percentage and type of medication present in the student population. Second, the survey posed forced-choice questions and scaled responses probing school policies related to students taking psychotropic medication. Third, forced-choice and scaled responses assessed the scope of training in children's psychotropic medication that school counselors had received, identified the sources of that training, and examined the perception of need for further training. Additional questions were asked seeking demographic information. Aside from the pilot data, we have no other source of reliability or validity for the questionnaire.

RESULTS

What kinds of psychiatric diagnoses and psychotropic medications are school counselors encountering in the student population?

Respondents were asked to estimate the percentage of students in their classrooms or on their caseloads who were taking prescribed psychotropic medication. Out of the 138 respondents, over half (66%) chose to respond to this item. The most frequently selected estimated range of students taking psychotropic medications was from 1% to 10% with just under half of those responding to this question (42%) selecting that range. The next most frequently estimated range (11% to 20%) was selected by about 17% of the respondents answering this question; 21% to 30% was selected by 7% of the respondents, and one respondent (less than one percent) estimated that from 61% to 70% of the students in his or her classroom or caseload were taking psychotropic medication.

Respondents were given a list of 15 psychiatric conditions and asked to identify those for which their students were taking psychotropic medication. (See Table 1.) The categories of conditions that were chosen are listed in the order of decreasing frequency. The most frequently reported condition listed as requiring psychotropic medication was Attention-Deficit/Hyperactivity Disorder (ADHD). Depression and Attention Deficit Disorder were the next most frequently reported. Hyperactivity, Bipolar Disorder, Anxiety Disorder, Obsessive Compulsive Disorder, and Mood Disorder were moderately reported. Oppositional Defiant Disorder, Behavior Disorder, Conduct Disorder, and Post Traumatic Stress Disorder were reported less frequently. The least reported conditions were Adjustment Disorder, Borderline Personality Disorder, and Social Adjustment Disorder.

Respondents were provided with a checklist of common categories of psychotropic medications that included stimulants, antidepressants, antipsychotics, mood stabilizers, and antianxiety medication and asked to check those that were being taken by students. Since they were asked to check as many as applied, the number of choices exceeds the number of respondents. The most commonly selected class of psychotropic medications was stimulants, typically prescribed for ADHD, which were selected by most (94%) of the respondents. Antidepressants were selected by 78% of the respondents, followed by antipsychotics that were selected by 28% of respondents. Both antianxiety medications and mood stabilizers were indicated by approximately 25% of the sample as medications given to their students. 7% of the respondents indicated that students were taking some other class of psychotropic medication. Two of those selecting the category "other" indicate students were taking clonidine, prescribed for ADHD; one mentioned anticonvulsants, and one listed zolpidem, a non-benzodiazepine hypnotic. The remaining five that selected the category "other" listed the proper names of classes of medication that were already listed.

What are some of the school policy issues created by students taking prescribed psychotropic medications?

Quantitative data about school policies. Students taking psychotropic medication on a regular basis while attending school must have that medication dispensed by someone. When asked to list personnel besides the nurse who dispensed psychotropic medication, some respondents selected more than one alternative. The most frequently selected alternative was administrator or principal, which was reported by more than half of the respondents (63%). More than a third (37%) of the respondents said that the secretary or office manager could administer psychotropic medication. Some (8%) of the respondents indicated that teachers could dispense medication, while guidance counselor and health technician were reported as alternatives to the school nurse by 4 (3%) and 2 (2%) of the respondents respectively. One person replied that they had no school nurse and dispensing medication was the job of the attendance officer. Two of the participants indicated that teachers were responsible for dispensing medication. In one case, the subject stated that the homeroom teachers dispensed all medication; in the other, teachers dispensed medication for students with ADHD, and office personnel dispensed all other medications. A fourth individual stated that students themselves were responsible for their own medication. In that instance, school policy stated that students were to carry a one-day supply; but the respondent reported that the policy was seldom enforced and, as a result, routinely ignored. Another individual indicated that "anyone employed by the school and not just a volunteer" could administer medication to students.

Qualitative data about school policies. When asked if the guidance plan in their school system contained guidelines addressing students who are taking psychotropic medications, more than three fourths said either "no" (60%) or "I don't know" (20%). Less than one fourth (19%) of the respondents said "yes." Those participants that indicated knowledge of guidelines addressing psychotropic medication were asked to provide a summary of those guidelines. Their open-ended responses present widely varied data and were analyzed using a qualitative method outlined by Glesne (1998). Responses were coded and sorted according to topic. Structured in this way, three themes emerged. The first theme grouped data about access to a school nurse and what school personnel were assigned the task of dispensing medication. The second theme that emerged addressed the paperwork required regarding the handling of psychotropic medications in the sampled school systems. The third theme looked at how the medication was transported to school and where it was stored once it arrived. Within each theme, statements were arranged in descending order from best practices to questionable practices. Table 2 displays a qualitative analysis of the responses to this question.

An important observation concerns the diversity of school policies (or lack thereof) concerning psychotropic medications. Responses varied from simple statements (e. g. "the school nurse is responsible for handling all medications") to a detailed five-step process described by one participant that included a policy for disposal of expired medication. In that particular school system, the school nurse, witnessed by another staff member, flushes outdated medications. In some cases, doctors are required to sign forms. In others, parent permission is sought. In still others, both are required. Sometimes students carry their own medication, sometimes parents are required to bring the medication to school where it might be stored in the office or the classroom. No standard pattern of practice was emerged from an examination of the data.

Theme 1: Access to school nurse and dispensation of medication. In examining the first theme, it is clear that degree of access to the services of a school nurse has a direct impact on dispensing medication. The statements "all medications are handled by the school nurse" or "students report to the nurse to take their meds" imply the regular presence of a school nurse. With only a part-time school nurse or none at all, the responsibility for dispensing daily medication falls on other shoulders such as secretaries, teachers, or students themselves. Sometimes it becomes the job of whoever is available as is demonstrated in the following response to the probe asking who besides the school nurse dispensed medication: "Really, I don't know of any limitations, probably only school staff, not volunteers."

Theme 2: Attendant paperwork. Examining the second theme reveals that requiring a form signed by the prescribing physician is relatively common, although the degree of information requested varies from a simple signature to more detailed information about potential side effects and contact numbers. Signed parent permission was not mentioned as frequently. The record of medication dispensing had many names such as log sheet, register, book, chart, master sheet; and the degree of detail required varied as well. Sometimes both a signature and a witness were required for each dispensation of medication, and sometimes just the time and date were recorded. Only one participant mentioned that medication was brought in, counted, and recorded.

Theme 3: Transportation and storage of medication. The third theme, transportation and storage of medication, examined how medication got to the school setting and what happened to it once it arrived. Several respondents mentioned the requirement that medication had to be in a prescription bottle. A few required that parents or an adult must bring the medication to school. The office was a popular choice for the storage of medication although one respondent indicated the classroom was a storage location. A locked cabinet or storage area was another frequently mentioned requirement.

Additional quantitative data regarding school policy. In addition to the open-ended question about school policy, respondents were asked to choose to "strongly agree," "mildly agree," "mildly disagree," or "strongly disagree" with several statements regarding school policies about students taking psychotropic medication. Most of the respondents either agreed or strongly agreed that school policies about psychotropic medication are needed (92%), and that new teachers should be apprised of these guidelines as a part of the orientation process (94%). It was generally either agreed or strongly agreed that school counselors should know which students are taking psychotropic medication (86%). Fewer participants agreed or strongly agreed that other school personnel should also have this knowledge (75%). Almost all of the respondents agreed or strongly agreed that there should be school personnel available for consultation about psychotropic medication (97%).

In a related question, respondents were given the following list and asked to indicate to whom they would go if they had concerns about a student's medication: psychiatrist, school guidance counselor, nurse, parent, guardian, administrator, student, other therapist, teacher, school social worker, and other. Since they were given the instruction to check all that apply, the number of choices exceeds the number of respondents. The responses are listed in the decreasing number of frequency that they were selected. The most frequently selected person to consult with questions about the effectiveness of a student's medication was parent; 89% of respondents checked this category. More than half of the participants selected school nurse as someone to consult about psychotropic medications while almost half selected guardian (60% and 48% respectively). More than a third of the respondents indicated administrators or psychiatrists would be appropriate to consult with questions about psychotropic medication (40% and 36% respectively). Slightly less than a quarter selected teacher (23%). One fifth of those who responded to the survey checked either "other therapist" or "school counselor" (20%). Slightly less than one fifth of participants indicated student or social worker as someone they would go to with concerns about psychotropic medication (18% and 17% respectively). Almost a quarter of the respondents checked "other" (23%). When asked to specify, all but one of those selecting "other" wrote in school psychologist (23% of sample) while one (less than 1%) added student assistance team.

Have school counselors received sufficient training to deal with issues arising from students taking psychotropic medications?

Respondents were asked to check the source of the training they had received in psychopharmacology. They chose from the following categories: graduate course, undergraduate course, continuing education course, professional development workshop, or no formal training. Responses are listed in decreasing frequency of selection. Since respondents were directed to check all that applied, the number of responses is greater than the number of respondents. Over half of the participants (53%) indicated that they had received no formal training about psychopharmacology. More than a fourth of those responding to the survey (28%) had attended professional development workshops. Less than one fifth (15%) of the participants had been enrolled in continuing education courses or taken graduate coursework that offered training in psychopharmacology (13%). A few of the participants (5%) had taken an undergraduate course that had provided training in psychopharmacology.

When queried as to how well they were prepared by their counselor training program to deal with issues related to psychotropic medication and asked to choose between "very well,", "fairly well," and "poorly" as responses, the majority of the respondents (81%) indicated that they had been poorly prepared. Less than one fourth of the participants (17%) responded that they had been fairly well prepared, and few felt well prepared (2%). When asked to check either "yes" or "no" in response to being queried if the school in which they were employed had taken an active role in preparing them to deal with issues relating to psychotropic medication, most of respondents (91%) said "no."

Respondents were asked to choose to "strongly agree," "mildly agree," "mildly disagree," or "strongly disagree" with several statements about training in psychotropic medication. Almost all of the respondents (93%) agreed or strongly agreed that it was important for school counselors to know about childhood psychotropic medication and that training about such medication would be helpful to them in their work (96%). Most thought training about psychotropic medication should be included in teacher education as well (81%). Almost all thought that it was important to know about the indicators and side effects of psychotropic medication (96%). The majority of the participants (80%) agreed or strongly agreed that information on the psychopharmacology of childhood mental health disorders should be included in license renewal Continuing Education Units.

DISCUSSION

Children's Mental Health Problems and Related Psychotropic Medications

Zito et al. (2003) analyzed the pattern of psychotropic medication treatment for 900,000 American youths over the 10-year period from 1987 to 1996. They found a consistent two- to three-fold increase in total psychotropic medication ending with about 6% of those 20 years or younger prescribed such medication across all surveyed sites. Stimulants and antidepressants were ranked first and second in degree of use with a notable rapid growth in the use of neuroleptics and "mood stabilizer" anticonvulsants. By 1996, the utilization of psychotropic medication for youth was almost the same as that for adults. There was a proportional increase during this time period of males receiving antidepressants and females taking stimulants, most notably in the 10- to 14-year-old age group.

Findings from our study reporting the high rates of ADHD, Mood Disorders and Anxiety. Disorders parallel the sparse epidemiological data on related diagnoses that we are aware of to date (Ingersoll & Previts, 2001). Findings from our study and the Zito study also confirm the types of medications used to treat these diagnoses reported in the limited material currently available on prescription trends (Jensen et al., 1999). As noted, prescriptions to treat these disorders are being written at an exponential rate (Rushton & Whitmire, 2001). Pharmaceutical companies are also seeking "on-label" status for antidepressants used to treat childhood mood and anxiety disorders (Bostic, Wilens, Spencer, & Biederman, 1997) because the prevalence of these disorders among children is believed to be high. Eli Lilly Pharmaceuticals just received FDA on-label approval for fluoxetine (Prozac) for children and adolescents.

On-label status means that the Food and Drug Administration (FDA) has approved the use of a particular medication for a particular disorder. Presently, most of the psychotropic medications only have on-label status for adults, and are thus "off-label" for children and adolescents. This means they are used at the discretion of the prescribing professional who judges that the drug (or drugs) in question will help relieve the symptoms of the child or adolescent (Koplewicz & Green, 1998). It is estimated that 80% of all medications used on children are prescribed "off-label" and that it may not be accurate to extrapolate findings of adult studies to children (American Academy of Pediatrics Committee on Drugs, 1996). It should also be noted that prescriptions and profits increase once a drug gets on-label approval (Healy, 1997).

School Policy Issues

The wide variety of responses to items about school policy concerning children taking prescribed medication in the school setting is worrisome from a legal and an ethical viewpoint. School systems are best protected from legal and ethical violations if they follow a standard of best practice. There was no standard practice described by our sample, and several statements indicated risked violations. Charging teachers and other school personnel not trained in the dispensing of medicine with that duty seems outside the boundary of ethical practice, as does storing medication in classrooms. Although several respondents mentioned steps that seemed prudent such as locked storage of medication and forms signed by doctors or parents, none of them had a complete procedure to safeguard students, school personnel, and the school system from potential problems.

Almost all of our sample (92%) agreed that school systems need guidelines about psychotropic medication, yet less than a fourth (19%) of the participants were aware of such guidelines for their school system, a problematic gap. In a discussion of the connection between school counselors and school reform, Herr (2002) pointed out that counselors have the potential to fulfill an important role in issues of policy and practice. The supposed purposes of prescribing psychotropic medications to children include improved academic performance as well as facilitating functional behavior and healthy emotional states. At a minimum, school counselors should be aware of what the school policies are. Ideally, school counselors should be an important part of the team including a trained school nurse that creates and supports school policies that facilitate the safe and effective dispensation of children's psychotropic medication.

Questions of confidentiality arise regarding the identities of students taking psychotropic medications. In our sample, most participants (86%) thought counselors should have this information; 75% thought teachers should have access to it. It obviously becomes difficult to keep this information from teachers if they are the ones dispensing the medication, as was the situation in two cases. Relevant information about children who may be taking psychotropic medication could help counselors and teachers be alert to negative effects from the medication, but revealing this information begs a thorough debate about the legal and ethical issues involved.

Related Ethical and Legal Issues

The ethical and legal issues related to confidentiality are only the beginning of such issues. While other helping professions have begun to address the role of the non-medical therapist in discussing and dealing with issues related to psychotropic medication, counseling has yet to discuss such guidelines. While court decisions have favored non-medical therapists discussing psychotropic medications with clients in a purely informational and non-medical manner, more research is needed to come up with specific recommendations (Ingersoll, 2000). In addition, the legal ramifications of administrators, secretaries, and teachers getting involved with dispensing medication requires a thorough exploration in order to establish appropriate guidelines.

Access to the Services of a School Nurse

One of the problems with maintaining a consistent pattern of good practice about psychotropic medication in the school setting may be derived from the inconsistent access to a school nurse. Nurses are trained in proper procedures for handling and dispensing medication and checking for potential side effects. If a school nurse is sufficiently available to supervise all dispensing of medication, as was described in two cases, it becomes more likely that proper procedures will be followed. With limited access, the school nurse may be able to provide some supervision; but as the expertise available becomes diluted, the question must be asked, how trained are those involved in the process? Without a school nurse to provide supervision and training, the chances of inappropriate practices grow. It may be that school systems that choose to do with part-time or no school nurse at all, are doing so to save money. With the growing number of children taking a complex variety of medications, cost cutting in such a way is risky practice.

Suggested Standard Practices

We began this study intending to explore school counselors' perception of the impact of the changing patterns of prescription of psychotropic drugs to school-aged children. While we learned a great deal about that, what also emerged were the potential legal and ethical issues that arose from some of the school policies about psychotropic medication within our sample. Clearly, further research needs to be done on the plethora of legal and ethical issues related to dispensing psychotropic medication in a school setting. As is evident in our sample, an accepted standard of practice needs to be established. At a minimum, school policy should enforce the following steps:

* A school nurse, or someone supervised and trained by a school nurse, should dispense medication.

* If medication is to be dispensed at school, there should be paperwork signed by the prescribing physician with information about proper administration of that medication as well as potential side effects and contact numbers in case of questions or concerns. There should also be accompanying permission forms signed by parents.

* Medication should be brought to school by an adult, in the original prescription bottle, and stored in a locked cabinet in the clinic or office.

Perceived Need for Training

The school counselors within our sample have had little training in the area of psychopharmacology, feel unprepared to deal with the array of psychopharmacological issues children bring with them to school, and the vast majority of the sample felt such training was necessary. Traditionally, schools counselors-in-training have not received instruction in either diagnosis or psychopharmacology, and as long as the diagnosis and treatment of children was restricted to ADHD that was treated with stimulants, that may have been adequate. School counselors sought to fill the gaps in their training and information through texts, articles, and workshops. As is clear from both the literature and this survey, the diagnosis and treatment of children's psychiatric conditions has become as complex as that of adults. School counselors need access to this information to function effectively as child advocates and consultants in the school system. The school counselors who responded to the survey strongly agreed with this conclusion. In order for that to happen for school counselors-in-training, course work covering children's diagnosis and psychopharmacology could be added to the master's level curriculum. For that to occur consistently, CACREP would have to add this requirement to the school counseling specialty standard.

Adding course requirements to the standard can take years of discussion and planning and is not the only way to disseminate important information to counselors-in-training. Besides, there are a large number of practicing school counselors who do not have ready access to crucial information. In fact, given the prevalence and scope of psychiatric disorders reported by the sample and the increasingly complex pattern of prescription of medication for children to treat those disorders, school counselors are going to need regular updates to keep abreast of the changes in child psychopharmacology.

RECOMMENDATIONS

Limitations

It is important not to over generalize the results of this survey. First, all of the respondents were members of ASCA, and it is possible that there is a difference in the way members and non-members would respond. Although there was an effort to make this a national survey, state representation was uneven with some states having only one respondent and others as may as seven. A 34.5% response rate could be considered a reasonable return rate for a mailed survey, but that still leaves 65.5% that did not respond.

School Policy and Training Issues

The changes in the field of children's psychotropic medication provide the profession of school counseling with an opportunity to be proactive rather than reactive. One method of doing so would be to advocate for adequate access to the services of a trained school nurse as a critical team member in providing services to students. Another might be taking a look at existing school policies with an eye to establishing a standard of practice that answers legal and ethical concerns about the dispensation of psychotropic medication.

Having uncovered a potential need for further education opportunities concerning children's diagnosis and psychopharmacology, the next logical step is to explore recommendations for a model curriculum and methods of disseminating the information. The American Psychological Association (APA, 1995) has the only curriculum in psychopharmacology in place for non-medical mental health professionals. Their training is in three levels. Ingersoll (2000) has described how the level one guidelines can be adapted for counselors for general training in psychopharmacology. Training specific to children is in the APA (1997) level two guidelines and could be similarly adapted.

Given the pace with which developments in psychopharmacology, occur and the number of practicing counselors who need training in this area, perhaps course work is not the most efficient way to provide training. An alternative method would be to prepare training modules in a continuing education format that could be delivered through workshops or online course work. Online course work allows for easier update of information as well as possible continuing education credits. Another alternative would be a grant-funded Website that contains information on commonly used medications and the conditions for which they are used.

Involvement by Professional Associations

Many critics of medicating children note that the practice is questionable since there are very few efficacy studies, and the ones that exist show mixed results (Zito et al, 2000, 2003). Even studies on stimulant medication for ADHD conclude that many times positive gains associated with medication are not maintained beyond 6 months (Greenhill, 1998). Since psychotropic medications could negatively impact the developing brain (Coyle, 2000), ASCA and the American Counselor Association (ACA) need to consider acting as advocates for children faced with prescriptions for psychotropic medication.

Suggestions for Further Research

Future research should include a similar nationwide study with a larger number of subjects and a more representative sample to see if the findings of the current study really do generalize across the nation. In addition, school counselors and school administrators need to examine best practices for receiving, storing, and dispensing students' medication as well as identify the ethical and legal issues inherent in questionable practices. School nurses and other medical professionals should weigh in on this latter point considering whether all medications should be treated the same way or whether medications should be treated according to their dangerous effects and/or abuse potential. Based on the results of this study and Ingersoll (2000), curricula should be developed specifically for school counselors and school counselors-in-training. We would also recommend dialogue across relevant professional organizations about the most efficient way to conduct training. As noted, adding course work to counselor training does not seem to be the best solution in this case. Finally, research should continue into the political and economic power of pharmaceutical companies and the extent to which school counselors and their relevant professional organizations need to advocate for children who are the next large market for pharmaceuticals.

Table 1: Identified Conditions Within Student Population
of Research Sample

Conditions                            n        %

ADHD                                 130       94
ADD                                  111       80
Depression                           110       80
Hyperactivity                         88       69
Bipolar Disorder                      78       57
Anxiety Disorder                      66       48
Obsessive Compulsive Disorder         55       40
Mood Disorder                         53       38
Oppositional Defiant Disorder         39       28
Behavior Disorder                     37       27
Conduct Disorder                      30       22
Post Traumatic Disorder               25       18
Adjustment Disorder                   16       12
Borderline Personality Disorder       13        9
Social Adjustment Disorder            11        8

Note. N = 138 school counselor respondents

Respondents were asked to check all that applied so the
total of responses is greater than the number of respondents.

Percentages were rounded to the nearest whole percent.

Table 2: Summary of Major Themes Emerging from School Policy Responses

Theme 1.                            Theme 2.
Access to school nurse and          Required paperwork
dispensation of medication

"All medications are handled by     "All prescription medications
the school nurse."                  must have an accompanying
                                    form signed by the doctor &
"Students report to the school      parent listing dosage, time to be
nurse to take their meds."          given, side effects, dr's number
                                    if there is a question."
"Nurse is the only person who
can give meds."                     "Dr. must fill out forms."

"... school nurse not at school     "... written consent from a
on a daily basis."                  psychiatrist...."

"The school nurse is only in the    Parents must give written
school for about 2-3 hours one      permission for the medication
day per week."                      to be given."

"We have no school nurse."          "The school staff must have
                                    written permission."
"Students who do not self-
administer a single dose daily      All medication must be logged
must give ... to our attendance     into a sheet in the office,
officer who dispenses it."          counted in, and initialed on a
                                    log sheet who gave it out."
"Homeroom teacher is
responsible for dispensing all      A register is kept with the
meds."                              names of the students on
                                    medication and the amount,
"Attention Deficit Medication       this list is initialed after the
will be administered by the         med. is dispensed."
classroom teacher ..."
                                    Times are logged in a book & a
"There are one or two               witness initials the area where
secretaries who may dispense        the nurse/school secretary has
medication. Otherwise, students     also initialed."
may have a letter on file that
authorizes them to carry            "Daily charting signed by two
medication at school. They may      adults when meds.
carry a one-day supply. This is     administered."
rarely followed. Parents don't
file letters, and students carry    "... recorded on a master
large supplies and there is no      sheet."
enforcement."
                                    "Teachers document time/date
Really, I don't know of any         dispensed on form."
limitations-probably only
school staff, not volunteers."

Theme 3.
Transportation and storage
of medication

"Parents required to obtain
refills and bring to school."

Medicine must be brought to
school in prescription bottle."

"All prescribed medication must
be brought in a container
appropriately labeled by the
pharmacy."

"Adult must bringing medication
to school. Medicine kept in a
locked cabinet.

"... parents need to bring it in
the original prescription
container which is stored
separated from other
medication in a locked storage
area."

"... prescriptions must be in
original container with
pharmacy label."

"parents must give all meds. to
the school nurse. Nurse keeps
meds. in a locked closet. If
meds. are discontinued, nurse
puts meds. down toilet &
witness present."

"Meds kept in locked cabinet
and only nurse, counselor,
secretary have access."

"... all medications must be kept
under lock and key."

"Medication is kept in the
office."

"... meds. kept in office or other
specified location."

"Meds. are locked in
classroom."

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Ann L. Bauer, Ph.D., CCR, is an assistant professor.

Elliott Ingersoll, Ph.D., is an associate professor and chair of the Department of Counseling, Administration, Supervision, and Adult Learning. Laura Burns is a graduate student. All are with Cleveland State University, OH. E-mail: [e-mail]