Abstract
This study explored service use patterns and services needed for children with attention deficit/hyperactivity disorder (ADHD). Children and adolescents with ADHD are at higher risk for emotional and social problems, and their families are at risk for increased stress and disruption of family life. Research has documented that children with ADHD and their families use more services in academic and health care systems, yet many have needs that are unmet. Costs of prescriptions, health care, and education also are reportedly higher. These factors prompted investigation of the amount and type of services used by families of children with ADHD, the degree of helpfulness of the services, and variances across sociodemographics.
The researchers recruited 157 mothers with at least one child with ADHD living at home (Caucasian, 33%; African American, 31%; and Hispanic, 36%). Children with ADHD ranged in age from 6–18 years, with a mean age of 10.8 years. Seventy percent of the participants had annual incomes of less than $40,000. Participants completed a demographic questionnaire and a structured interview. The researchers developed a semistructured, 16-item interview tool to assess treatment information and perceived treatment effectiveness. The questions related to ADHD treatments, health care and services used, and health care and service needs.
Three major categories, along with corresponding subcategories, were identified as themes. The first major category was traditional child-focused services with four subcategories of counseling, support services, school services, and auxiliary services. The second was alternative child-focused services with subcategories of diet, vitamins, herbs, spiritual, exercise, and mind/body. The third category, family services, included family counseling, support, religion, informal services, medical, and mind/body.
The most frequently used service was school services, and the least used was auxiliary services (speech, music, and occupational therapy). The most frequently identified themes under alternative child-focused services were diet and religion; mind/body services (massage, aromatherapy) were used least. The most frequently reported subcategory for family services was support services (family therapy and counseling), and least frequent was religious services. Based on the mean number of services used, traditional services were used most frequently, followed by family services and alternative services.
Ethnic differences were noted relative to service use. Caucasian families used more total services than Hispanic families did, but there was no significant difference between service use of African American families and Caucasian families. Hispanic families used fewer traditional child services than Caucasian and African American participants did. In addition, single mothers used more total and traditional services than the two-parent families did. Single-parent families used therapy, counseling, and support services more frequently. Families with boys diagnosed with ADHD used more total services. Income was not a factor in total services used in any of the categories. A significant relationship was found between school-service use and ethnicity. Hispanic families used school services less than Caucasian or African American families.
Traditional services were rated as moderately helpful by 68% of the respondents. Alternative services were rated moderately helpful by 56%, and 73% rated family services as moderately helpful. Sixty-eight percent of respondents stated their children were taking ADHD medication, and 85% rated this treatment as moderately helpful.
Thirty-eight percent of the families had unmet service needs. The most frequently requested services were support services, followed by social services, school services, and therapy or counseling services. Single mothers, Hispanic families, and families with boys were identified as having the most difficulty with ADHD children. Single mothers used services for ADHD children more than others. Hispanic families utilized the least amount of services due to limited access to culturally and linguistically appropriate services. The researchers concluded that there is a need for a case management model with culturally sensitive strategies and matching services to family needs. They also viewed schools, where the majority of participants were receiving services, as the ideal setting for implementation of case management of children with ADHD.
TAKE TO WORK MESSAGE
This study presents several pertinent outcomes related to the school nurse role.
School services were the most frequently used traditional services. The school nurse can be a visible facilitator of school services for children with ADHD. Coordinating on-site services, including counseling, parent support, student health plans, and in-service/support for teachers to provide an effective educational experience for students with ADHD is part of the school nurse role. Awareness of ethnic differences, especially in the Hispanic populations, in seeking and using services is an important aspect of working with families of children with ADHD. Educating and assisting families in finding and using appropriate services to support them in the challenges associated with ADHD children is another component of the school nurse role.
School nurses also need to target single-parent families and families with boys with ADHD, because these families may have a higher need for services. Another critical role of the school nurse is monitoring the effectiveness and side effects of ADHD medications. In addition, school nurses need to educate teachers and staff about observable behaviors associated with medication effects.
Development of case management models in the school setting is a major recommendation of this research study. The school nurse is the ideal person to lead the development and implementation of such a model and is a key professional in facilitating success for students diagnosed with ADHD.
School nurses often provide health services in early childhood educational settings and know the importance of instituting positive health behaviors at an early age. The problem of overweight and obesity in children is a major health concern, and effective prevention strategies at earlier ages are being evaluated. This study examined parental perceptions related to health status and play activities of a group of overweight toddlers and preschoolers.
The researchers cited data documenting that 25% of children in the United States are overweight or at risk for becoming overweight, and certain ethnicities and those of lower socioeconomic status are at higher risk. They also point out the multitude of pathophysiological and psychological problems resulting from overweight and obesity. The researchers view overweight within the family system and delineate related variables of genetics, heredity, family perceptions of overweight, lifestyle patterns, and family nutritional status. Early intervention is critical to change behavioral patterns within the family, cultural, and socioeconomic systems.
The purpose of this study was to examine parents’ perceptions regarding their children’s current health status; parental perceptions and understanding of the relationship between obesity and current and future health risks; play opportunities and preferences; and family activity–level patterns to develop more appropriate intervention programs. Taped interviews were conducted with 76 parents served by a Women, Infants, and Children (WIC) program. Seventy-four respondents were mothers of overweight toddlers or preschoolers. The population was primarily Hispanic (66%). Seven African American and 3 Caucasian parents were the other ethnicities represented. The criterion for overweight was established at or above the 95th percentile weight for length. The interviews focused on two main areas, the first being an assessment of family members’ perceptions about the child’s health status, concerns regarding health, and understanding of long-term health consequences of obesity. Second, family play patterns (physical and sedentary activities) were examined.
Results examining the parental perception of the relationship between body weight and health indicated that 81% thought their overweight child was healthy, and 83% responded that absence of illness indicated the child was healthy. Fifty percent of the parents stated they were not concerned about their child’s weight. Reasons for not being concerned included not believing their child was overweight, overweight was a familial trait, and the child was “large boned.” Fifty percent of the parents were concerned about their child’s weight. Reasons for concern included recommendations from health care professionals, consideration for their child’s future, the child’s current health, and problems related to physical activity and eating.
Results of parent perceptions regarding play provided information about various factors. Eighty-two percent stated their children had a safe place to play; however, 48% stated the safe place was inside the home. The majority had a playground or park nearby, but 5% were concerned about safety and did not use the playground or park. More families with boys used the playgrounds and parks for activities. In the entire participant population, 63% of all activities were reported as active and 37% were reported as sedentary.
Analysis of the data indicated no significant relationship between the amount of active play and the age of the child or between parental concern regarding overweight and the amount of active play. Results did show that participants with safe playground access (69%) reported more active play than those with no access did. There was wide variance in television viewing, with no significant differences between genders or active play indicators.
Key points for more effective intervention programs gleaned from this study were (a) inclusion of the family and parental perceptions of obesity treatments and prevention, (b) interventions appropriate to the developmental level of toddlers and preschoolers, (c) culturally sensitive programs, and (d) socioeconomic considerations. The researchers stated the findings indicated a lack of parental understanding of the gravity of the problem of overweight, because one third of the participants were unable to give an example of obesity-related health risks and consequences. Parents also lacked an understanding of age- and developmentally appropriate sedentary and active play activities.
Health care professionals involved in children’s health and prevention of overweight need to provide education to parents regarding prevention of overweight and obesity, as well as age-appropriate strategies for active and sedentary activities. Parents also need to be valued partners in prevention and reduction of obesity in the preschool and school-age population.
TAKE TO WORK MESSAGE
School nurses play a major role in prevention and early intervention. School nurses who are associated with child care centers can screen preschoolers, identify those at risk for overweight and obesity, and refer families to appropriate resources. Linking with community clinics and collaborating with other agencies also can provide the school nurse with assistance in identifying at-risk children and possible intervention strategies.
Identifying at-risk or overweight kindergartners and providing in-class teaching and parent education can be effective strategies to minimize the problem of overweight in the younger population. When a child is identified as at-risk or overweight, following up with the family to assess the other children for overweight is another strategy the school nurse can employ. The school nurse can use the opportunity with the family to identify cultural and socioeconomic issues that may be influencing the child’s weight. The school nurse can obtain written information regarding developmentally appropriate sedentary and active play activities to share with parents. Assisting school administrators to develop daily, organized playground activities or movement sessions incorporated into the school curriculum is another area where the school nurse can be effective.
Overweight and obesity has been classified as an epidemic in the preschool and school-age population. The national focus on this problem provides support for school nurses to pursue the problem in their schools. As programs are developed, school nurses need to verify that parental and cultural perceptions are considered and that parents have the necessary tools to support their children in making healthier choices. Although education is an important aspect of addressing the problem of overweight and obesity in children, several other factors need to be considered and integrated into programs to have successful results. School nurses can successfully coordinate strategies needed to make the necessary changes.