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A survey of school psychologists' knowledge and training in child psychopharmacology

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Abstract

A national sample of 320 school-based, practicing members of the National Association of School Psychologists provided information on (a) their caseloads receiving medications, (b) types of school psychopharmacology training opportunities available and perceptions of their current training in child psychopharmacology, and (c) information about consultative efforts in monitoring medication effects on school functioning. Results indicated that almost one of every four cases seen by survey participants were being treated with psychotropic medications; nearly all respondents have engaged in consultation related to medication evaluations. Professional workshops and independent reading were the most utilized training opportunities, and participant responses indicated an overwhelming need for basic educational training to improve knowledge and consultation in this area. Implications of these findings on training in evidence-based interventions and current practice are discussed as school psychologists experience legislative pressure to diminish their collaborative involvement in medication treatment consideration and evaluation. © 2006 Wiley Periodicals, Inc. Psychol Schs 43: 623–633, 2006.
A SURVEY OF SCHOOL PSYCHOLOGISTS’ KNOWLEDGE AND TRAINING
IN CHILD PSYCHOPHARMACOLOGY
JOHN S. CARLSON
Michigan State University
MICHELLE KILPATRICK DEMARAY
Northern Illinois University
SHANA HUNTER-OEHMKE
Michigan State University
A national sample of 320 school-based, practicing members of the NationalAssociation of School
Psychologists provided information on (a) their caseloads receiving medications, (b) types of
school psychopharmacology training opportunities available and perceptions of their current
training in child psychopharmacology, and (c) information about consultative efforts in moni-
toring medication effects on school functioning. Results indicated that almost one of every four
cases seen by survey participants were being treated with psychotropic medications; nearly all
respondents have engaged in consultation related to medication evaluations. Professional work-
shops and independent reading were the most utilized training opportunities, and participant
responses indicated an overwhelming need for basic educational training to improve knowledge
and consultation in this area. Implications of these findings on training in evidence-based inter-
ventions and current practice are discussed as school psychologists experience legislative pres-
sure to diminish their collaborative involvement in medication treatment consideration and
evaluation. © 2006 Wiley Periodicals, Inc.
Evaluating the effects of psychotropic medications in individual children is important given
the uniqueness of their biological systems (pharmacokinetics; what the body does to the drug), the
importance of contextual variables on medication response (pharmacodynamics; what the drug
does to the body), and the inability to translate pharmacological research findings from adult
populations to children (Riddle, Kastelic, & Frosch, 2001). Closely monitoring an individual’s
responsiveness to pharmacological treatments is essential to examination of associated costs and
benefits (MTA Cooperative Group, 1999; Phelps, Brown, & Power, 2002). This is especially true
given recent concerns of the potential for harmful effects of psychopharmacological treatments
highlighted within (a) the recent “black box” designation for selective serotonin reuptake inhibi-
tors in child and adolescent populations (Food and Drug Administration Public Health Advisory,
2004) and (b) a recent short-term ban of Adderall XR prescriptions within Canada (Health
Canada, 2005).
Changes in governmental policy likely will funnel hundreds of millions of dollars into the
business and research of child psychopharmacology in the coming decades (Budetti, 2003). An
example of this is the National Institute of Mental Health multi-million-dollar formation of a
group of university-based researchers dedicated to studying the safety and efficacy of psycho-
tropic medications in children and adolescents across multiple sites (e.g., Research Units of Pedi-
atric Psychopharmacology). In addition, a considerable portion of new funding is likely to be
directed toward the development of multisite collaborations to study the efficacy and safety of
combined psychosocial and psychopharmacological interventions for a number of internalizing
and externalizing disorders (Brown, 2005; Kubiszyn, Carlson, & DeHay, 2005). Training in evidence-
based biopsychosocial treatments may now be more important than ever for mental health pro-
fessionals working with school-aged populations.
Correspondence to: John S. Carlson, Department of Counseling, Educational Psychology, and Special Education, 432
Erickson Hall, Michigan State University, East Lansing, MI 48824–1034. E-mail: carlsoj@msu.edu
Psychology in the Schools, Vol. 43(5), 2006 © 2006 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pits.20168
623
Effective special education practice is contingent upon collaboration between schools, fam-
ilies, and physicians (Forness, Kavale, Sweeney, & Crenshaw, 1999). Yet, a number of legal
barriers have emerged in recent years to potentially limit the nature of these consultations. More
than 23 states have either introduced or enacted legislation related to children and psychotropic
drug use (National Conference on State Legislatures, 2004), and the Child Medication Safety Act
(i.e., not forcing or pressuring parents to medicate their children) was included within the Indi-
viduals with Disabilities Education Improvement Act of 2004 (IDEA, 2004) reauthorization bill
(Nealis, 2004). The role of school psychologists’ collaborative efforts associated with school-
based medication evaluations has a number of legal and ethical considerations (Carlson, Thaler, &
Hirsch, in press). The impact that legislative changes may have on children is implicit, yet the
importance or implications of these changes on current professional responsibilities of school
psychologists is unknown.
Training in child psychopharmacology would be essential to carry out the different roles and
responsibilities that school psychologists may assume when working with children treated with med-
ication. The American PsychologicalAssociation (APA; 1995) recommended three levels of train-
ing in psychopharmacology for doctoral-level psychologists: basic education for all psychologists
(Level 1), additional training for those who seek to engage in collaborative practice with physicians
(Level 2), and further intensive training and supervision for those who seek to independently prac-
tice clinical psychopharmacology (Level 3). It is currently recognized that many psychology pro-
grams are currently running beyond capacity, and little room exists to add Level 1 curriculum to training
programs (Kratochwill, 1994). To alleviate this potential barrier, some advocate for the integration
of a comprehensive training sequence in psychopharmacology within psychology internships (Dun-
ivin & Southwell, 2000) or through a more efficient integration of psychopharmacological-based cur-
riculum at the predoctoral level (Tulkin & Stock, 2004). In sum, professional psychology training
programs are moving toward increasing training in this area for the singular ethical purpose of afford-
ing the highest possible care to clients (Barnett & Neel, 2000).
The National Association of School Psychologists (NASP) does not currently provide rec-
ommendations or competencies related to child/school psychopharmacology; however, compe-
tencies in areas of data-based decision making and accountability, home/school/community
collaboration, research and program evaluation, and legal, ethical practice, and professional devel-
opment are quite relevant to this professional organization (Ysseldyke et al., 1997). These com-
petencies are closely aligned to assessment, consultation, and intervention responsibilities that
face school psychologists in their work with children experiencing mental health problems and the
impact such difficulties have on learning and social relations.
The purpose of this study was to examine school psychologists’ knowledge and training in
child psychopharmacology. In addition, the adequacy of professional training that school psychol-
ogists receive in psychopharmacology was explored. Specifically, this study was designed to (a)
gather information on the current role that school psychologists serve to children treated with
psychotropics and illuminate the scope of this responsibility within their service-delivery prac-
tices, (b) examine the opportunities and perceptions that school psychologists report related to
their training and knowledge of child psychopharmacology, and (c) understand the consultative
efforts school psychologists are engaged in with others, including physicians.
Method
Participants
Potential participants consisted of 1,000 randomly selected members (2000 –2001) of
NASP. Seven surveys (1%) were undeliverable due to an incorrect address. Of the 993 surveys
624 Carlson, Kilpatrick Demaray, and Hunter-Oehmke
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sent, a total of 362 surveys were returned, for a response rate of 37%. Of the returned surveys, 42
(12%) were discarded because the respondents indicated that they were not currently practicing
within the schools (e.g., retired, private practice, student, administrator, trainer). Our return rate is
commensurate with other published research with this population, including the 29% rate found in
a pharmacological-related survey of American Psychological Association Division 16 members
(Kubiszyn & Carlson, 1995) and the 42 to 47% participation rate reported in recent school psy-
chology practitioner surveys utilizing multiple mailings (Fowler & Harrison, 2001; Pelco, Jacob-
son, Ries, & Melka, 2000). In summary, a total of 320 surveys were utilized in the data analyses.
The sample was compared to the demographic data provided to us by the NASP for the 1999
membership year as seen in Table 1. Data for 2000–2001 NASP members who were practicing
school psychologists were not available. The study participants appeared to be representative of
NASP members along dimensions of gender and type of degree. Distribution along ethnicity and
years of experience compared favorably to other recent practitioner samples (Curtis, Hunley,
Walker, & Baker, 1999). The age of the respondents ranged from 25 to 75 years (M44.5, SD
10.1), and experience level ranged from 1 to 35 years (M12.3, SD 8.3).
Instrumentation
A two-page survey was developed by the study investigators to gather information about
school psychologists’ caseloads pertaining to medication treatment, responsibilities associated
with evaluation and knowledge of medication, training experiences, and self-perceptions of need
and importance of this knowledge within their professional responsibilities. A pilot study of this
Table 1
Demographic Characteristics for National Association of School
Psychologists (NASP) Membership and Survey Respondents
Respondents (%)aNASP Membershipb(%)
Gender
Males 27.8 27.7
Females 72.2 72.3
Ethnicity
African American 1.3 2.1
Asian American 1.6 .9
Hispanic American 1.6 3.1
Native American .6 .4
Caucasian 94.3 92.1
Other .6 1.4
Years of Experience
1–10 years 52.1 46.8
11–20 years 27.8 32.8
20 years 20.1 20.4
Type of Degree
Nondoctoral 72.4 72.3c
Doctoral 27.6 27.7c
aSample size (N320).
bNovember 1999 NASP membership information.
cExcludes B.A., B.S., and other degree type to match those included in this
study.
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instrument was conducted with 10 graduate students in school psychology who recently com-
pleted school practicum placements. Some modifications (e.g., item wording, item deletion) were
made to the survey with the feedback provided by respondents, and it was determined that the
survey took approximately 10 minutes to complete.
Data-Collection Procedures
The central office of NASP provided mailing labels for a random sample of 1,000 members.
A cover letter explaining the purpose of the study, the time estimated to complete the study, and
contact information along with the two-page survey instrument were mailed to these members in
February 2001. As an incentive for responding, participants were notified that their name would be
entered into a random drawing for one of five copies of the book Taking Charge of ADHD (Bark-
ley, 2000). Respondents were asked to complete the survey within 2 weeks. Returned question-
naires were indicative of the participants’ consent. A follow-up reminder postcard or additional
mailings were not utilized due to costs and the results of previous studies utilizing homogenous
professional samples that failed to demonstrate substantial differences between first- and second-
mailing respondents (Carlson, Kratochwill, & Johnston, 1994; Pelco et al., 2000). Others have
indicated that if respondents match the population from which they were selected along dimen-
sions including years of experience, age, gender, and ethnicity, respondents would not signifi-
cantly differ from nonrespondents (e.g., Green, 1991).
Results
Descriptive statistics and frequencies for school psychologists’ responses to specific survey
items can found in Table 2. A summary of the major findings is presented next.
Roles and Responsibilities Associated With Child Psychopharmacology
The first issue addressed within this study was the frequency with which school psychologists
face psychopharmacological issues within their daily practice. Nearly one of every four cases
(M23.27, SD 20.68) seen by school psychologists is reportedly receiving psychotropic treat-
ment. Asecond area investigated in this study was the involvement of school psychologists in cases
who were diagnosed with attention deficit hyperactivity disorder (ADHD). When averaged across
respondents, one of every five children (M21.38, SD 18.08) was reported by school psychol-
ogists to have a diagnosis of ADHD. Of theADHD cases seen by school psychologists, it was repor ted
that two of every five children (M40.46, SD 33.39) were being treated with medication. A
final area in which data was gathered regarding school psychologists’ roles and responsibilities
related to child psychopharmacology included information about discussions of psychotropic med-
ications within case-management activities. Almost every surveyed school psychologist had been
involved in cases in which there had been discussion around medication treatment issues. It is
noted that evaluations “often” involve “any discussion” of psychotropic medication more fre-
quently within evaluation cases (41%) as compared to consultation/intervention cases (29%).
Types and Perceptions of Current Training Related to Child Psychopharmacology
A second area of investigation within this study was on the types of child psychopharmacol-
ogy training opportunities that exist for school psychologists. The majority of survey respondents
(81%) had not taken a child and adolescent psychopharmacology course. The primary means by
which school psychologists acquired knowledge in this area was reported to occur through work-
shops (88%) and independent reading (96%). With respect to training in associated areas of child
psychopharmacology, it was found that half of the respondents indicated having taken a biological
bases of psychological disorders course, yet this decreased substantially when the course focus was
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Table 2
Survey Results for Respondents’ Caseloads, Training, and Practice
Survey Question Participant Response
Caseload Information
1. What percent of children/adolescents that you work with are currently on psychotropic
(e.g., psychostimulants, antidepressants) medication (approximately)?
M23.27, SD 20.68
(Range 1–95)
2. What percent of the children/adolescents you work with have ADHD (approximately)? M21.38, SD 18.08
(Range 1–90)
2b. What percent of these children/adolescents are on medication for ADHD? M40.46, SD 33.39
(Range 0 –100)
3. How often does an evaluation include any discussion of psychotropic medication (e.g.,
the child is currently on medication or has been in the past, etc.):
Never Sometimes Often
1 (1%) 2 (4%) 3 (28%) 4 (25%) 5 (41%)
4. How often does an intervention or consultation case include any discussion of psychotropic
medication (e.g., intervention includes medication treatment, etc.):
Never Sometimes Often
1 (1%) 2 (9%) 3 (35%) 4 (26%) 5 (29%)
Training
1. What training have you had in the area of child and adolescent psychopharmacology?
a. Entire course(s) Yes (19%) No (81%)
b. Portions of a course(s) Yes (55%) No (45%)
c. Workshop(s) Yes (88%) No (12%)
d. Independent reading Yes (96%) No (4%)
2. Have you ever taken a biological basis of psychological disorders class? Yes (50%) No (50%)
3. Have you ever taken a university-based course on psychopharmacology? Yes (20%) No (80%)
4. Was a course on psychopharmacology available to you at your school? Yes (24%) No (76%)
5. Have you ever attended a professional workshop for Continuing Education Units (CEUs)
on psychopharmacology?
Yes (61%) No (39%)
6. Should school psychologists receive training in the area of child psychopharmacology? Yes (97%) No (3%)
7. Should school psychologists seek prescription privileges? Yes (10%) No (90%)
8. How well trained do you feel in psychopharmacology?
Not well trained Somewhat well trained Very well trained
1 (22%) 2 (33%) 3 (35%) 4 (10%) 5 (1%)
9. How much additional training in psychopharmacology do you wish you had?
None Some A lot
1(1%) 2 (4%) 3 (37%) 4 (34%) 5 (24%)
10. How important is it for you to have knowledge about psychotropic medications in order
to perform your main roles in assessment, treatment, and consultation?
Not important Somewhat important Very important
1(1%) 2 (7%) 3 (33%) 4 (36%) 5 (24%)
Practice
1. For children who are being placed on medication for ADHD, how often do you work
with the students’ physicians to collaborate on medication treatment (e.g., monitor side
effects, monitor improvement)?
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
(16%) (32%) (14%) (8%) (7%) (6%) (4%) (4%) (4%) (4%) (1%)
2. Do you work with physicians and/or parents to evaluate medication trials? Yes (62%) No (38%)
3. If you were a parent of a child with ADHD, would you seek medication treatment for
them?
Yes (87%) No (13%)
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on psychopharmacology (20%). The majority of respondents (76%) reported that such a course was
not offered at their university. Instead, it appears that most formal training, as indicated by
Continuing Education Units (CEU) credits, is being done through professional workshops (61%).
Perceptions related to school psychologists’ training in child psychopharmacology were
obtained via a number of different questions. Almost all of the respondents (97%) indicated that
there was a need for training in child psychopharmacology, yet it was clear that they (90%) were
not at all interested in having the profession move toward seeking prescription privileges. Data
also revealed a perceived need for additional training in child psychopharmacology, as nearly 1 in
4 respondents indicated that it was “very important” to have knowledge of psychotropic medica-
tions to perform their roles and jobs. Very few (1%) indicated that knowledge in this area is “not
important” for their work.
Collaborative Practices in School Psychopharmacology
The final section of the two-page survey focused on three questions pertaining to collabora-
tive consultation surrounding medication issues. One question related to issues of acceptance (i.e.,
comfort level) of medication as a treatment option by school psychologists. In other words, how
did participants personally perceive medication as a treatment for ADHD? Only about 1 of every
10 (13%) school psychologists who “hypothetically speaking” had a child with ADHD would not
seek out medication treatment for them. Additionally, data were gathered on treatment-consultation
and medication-evaluation practices. Almost two thirds (62%) of school psychologists reported
that they had worked with physicians and/or parents to evaluate medication trials for children, yet
collaborative monitoring occurred infrequently in those cases where children were being placed
on medication to treat ADHD symptoms.
Discussion
To our knowledge, this is the first study to examine the training and practices of school
psychologists in the area of child psychopharmacology. Results of this survey of practicing school
psychologists, who are members of NASP, indicated that medication treatment of emotional and
behavioral problems is highly prevalent within their caseloads. Almost one in four of cases seen by
school psychologists were reported as being treated with medications. Combined with previous
research indicating that more than one half of special education students have been treated with a
psychotropic medication in the past 3 years (Mattison, 1999), this appears to be a fairly common
treatment approach used with school-aged children seen within the delivery of school psycholog-
ical services. For those students diagnosed with ADHD, medication treatment appears to be even
more common, as results have indicated that 40% of children are reported to be receiving this
treatment modality. This data may support the controversial notion that there remains a large
percentage of children who are currently being undertreated, given that data in the literature have
strongly implicated the importance of both medication and behavior-management approaches for
this condition (Jensen et al., 1999; MTA Cooperative Group, 1999). Alternatively, if 60% of
ADHD children in schools are being managed appropriately through nonmedication approaches
(e.g., behavior management), further questions pertaining to diagnostic reliability of this disorder
may be raised. In sum, interpretations regarding the frequency with which school-aged children
are being treated “appropriately” for symptoms associated with ADHD cannot be ascertained by
this study and are important for future study.
Many school psychologists are providing services to students for which discussions of med-
ication treatment are warranted as part of evaluations, consultation, and intervention activities. In
addition, very few (1%) cases were reported by school psychologists to “never” involve medi-
cation discussions. Discussion of treatment history along with a need to discuss future interventions
628 Carlson, Kilpatrick Demaray, and Hunter-Oehmke
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that are multidimensional (i.e., biopsychosocial) may be an important part of the special education
service-delivery responsibilities of currently practicing school psychologists. Legislating these
discussions and considerations may significantly alter current practices within the field, and future
study of these implications are needed.
School psychologists’ caseloads and responsibilities pertaining to medication treatments appear
to be commensurate with reports from other treatment providers including doctoral-level school
psychologists and licensed psychologists. For example, many clients/cases are currently receiving
medication, and the impact of treatment histories on effective service delivery is an important part
of current case-management responsibilities (Kubiszyn & Carlson, 1995; VandenBos & Williams,
2000). Basic education in psychopharmacology or Level 1 training as recommended by APA
(1995) would appear to be essential for effective service delivery by school psychologists, irrespec-
tive of master’s- or doctoral-level training goals. Training models to improve school psycholo-
gists’ knowledge in child psychopharmacology should be developed, implemented, and evaluated.
In addition, a focus on the specific types of activities that school psychologists might engage in
related to child psychopharmacology (e.g., progress monitoring, using treatment-sensitive rating
scales, collaborating with physicians/psychiatrists, parent and teacher consultation, professional
inservice or other knowledge dissemination efforts) is an important area for discussion and future
consideration within the field (DuPaul & Carlson, 2005).
Results from this survey indicate that school psychologists are aware of the gap between their
limited formal training and their frequent responsibilities related to medication treatments. The
majority of school psychologists reported training in this area via independent reading (96%) and
through workshop participation (88%). As indicated within the school psychology literature, there
appear to be limited opportunities for formalized training in child psychopharmacology at the
predoctoral level (Carlson, 2001). More than 75% of respondents indicated that courses on this
topic were not available as part of graduate course offerings. In addition, there may be limited
links between the more frequently taken related courses, such as biological-basis courses (taken
by 50% of respondents) offered by universities, and the types of pragmatic skills and responsibil-
ities associated with school psychopharmacology (DuPaul & Carlson, 2005). One example of
these skills is training in school-based medication-monitoring practices. Arecent survey (Gureasko-
Moore, DuPaul, & Power, 2005) on this specific topic found that the majority of school psychol-
ogists (58%) had not received formal training in this area. This decreased even further (20%)
when considering graduate-school training in medication monitoring and is consistent with the
percentage of responding school psychologists (20%) in this study who had taken a graduate
course in psychopharmacology. Results from these two survey studies indicate that a gap appears
to exist between school psychology program training opportunities in child psychopharmacology
and practices associated with this knowledge base. Additional training appears warranted, and the
value that school psychologists place on this knowledge supports this conclusion.
A number of school psychologists (24%) believe that knowledge of psychotropic medications
is “very important” for their roles and functions. An equal percentage reported the need for “a lot”
more training in this area due to insufficient knowledge and training. It is unknown whether
postdegree training is the most appropriate avenue for acquiring the knowledge needed within
current roles, yet this is the predominant method currently being reported by school psychologists.
The importance of child psychopharmacology training for school psychologists was clearly indi-
cated by 97% of the participants in this study. When this question was altered to represent a greater
level of competence for the purpose of prescription privileges, respondents almost uniformly
(90%) were opposed to this idea for school psychologists. This contrasts with previous reports
from doctoral school psychologists and other professional psychologists who are more supportive
of seeking prescription privileges (Kubiszyn & Carlson, 1995; Sammons, Gorny, Zinner, &Allen,
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2000). Practicing members of NASP, which is heavily represented by nondoctoral clinicians, do
not appear to be interested in seeking prescription privileges, and this response appears to be
consistent with ethical issues of competence and training espoused by NASP ethical and practice
guidelines.
Most respondents indicated a favorable opinion of medication treatment for children diag-
nosed with ADHD, as indicated by their willingness to seek medication treatment for a child of
their own who was diagnosed with this condition; however, linking one’s attitudes toward a med-
ication approach for their own personal situation and bringing these beliefs into practice are not
one in the same. Maintaining an objective, balanced approach to working with families who may
have a different belief and value system is an important consideration for service delivery.
The findings from this study indicate that the professional responsibilities of practicing school
psychologists include significant involvement in medication-monitoring practices; 62% of respon-
dents indicated working with physicians and/or parents to monitor response to medication treat-
ment. This report is slightly higher than the 55% of ADHD monitoring practices reported from a
survey of school psychologists. Both findings should be interpreted in the context of the average
time (2 hr per week) that school psychologists engage in these activities (Gureasko-Moore et al.,
2005). Involvement differentials between these studies may indicate that school psychologists
also are active in evaluating symptom reduction of medications for other psychological conditions.
The consistent and/or active engagement in medication treatment activities (e.g., medication
monitoring), however, appears limited within school psychologists’ responsibilities. The majority
of school psychologists reported being involved in less than 20% of the potential cases who begin
a trial of medication for treating symptoms of ADHD. In addition, school psychologists reported
being engaged collaboratively with physicians in less than one third of ADHD cases being treated
with medications. Given the importance of closely monitoring the medication treatment response
of children and other issues of helping parents to make decisions regarding the data-based costs
and benefits of this treatment modality, this may be an important area of responsibility within
future practices. Such a role also would support the need that physicians have expressed for more
school-based information when considering treatment selection and responsiveness (Haile-
Mariam, Bradley-Johnson, & Johnson, 2002; Kainz, 2002).
School-aged children are being treated with psychotropic medications at an increasing rate,
and a considerable percentage of cases seen by school psychologists indirectly implicates the need
for training in child psychopharmacology. Psychologists, specifically those working in the schools,
theoretically are in a good position to assist parents in critically considering the costs and benefits
of potential interventions (Phelps et al., 2002). Pragmatically speaking, issues of medication treat-
ment are currently being addressed by school psychologists within their roles and responsibilities
as treatment evaluators and consultants (DuPaul & Carlson, 2005; Gureasko-Moore et al., 2005).
As a whole, curriculum in this area has been limited within training programs, and practitioners
instead seek knowledge through independent readings and continuing-education opportunities.
Limitations
There are a number of limitations to the current study. First, response-rate bias may have
impacted the results of this study. Specifically, those who responded may have greater familiarity,
interest, or experience in child psychopharmacological practices than those individuals who did
not respond to the study. Thus, medication treatment rates of caseloads, actual practices, training
opportunities, and interest level in these training efforts may be overestimated by the study results.
An additional consideration related to the generalizability of study results to other NASP members
is whether the homogeneity of the members of this professional organization and the close link
between survey participants and the overall membership characteristics may help to overcome the
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low response rate, as has been reported by some survey researchers (e.g., Green, 1991). In other
words, not only are there questions about the generalizability of study results to NASP members
but there also are uncertainties regarding how well these data would represent those practicing
school psychologists who are not NASP members. Given the progressive nature of this organization’s
practice guidelines and emphasis on interventions, it is likely that study results may not align with
efforts of the profession as a whole.
The use of survey responses as a means of data collection also limits the interpretation of
study results. Self-report data may not be reflective of actual training, knowledge, or perceptions
of school psychologists. We are unable to determine the accuracy of responding, and there is no
way for these responses to be verified. Future research should target student records and files as a
means of data collection. Such an approach would be consistent with medication prevalence rates
that have been determined from insurance and practice data. Future research examining which
professionals within the school setting may be in the best position in terms of knowledge and
training to complete school-based medication evaluations is warranted, given the importance of
close monitoring to the beneficial outcomes of this treatment approach.
Implications for Training, Practice, and Research
The results of this study indicate a need for a working-knowledge base of psychotropic
medications, given the frequency with which school psychologists work with children receiving
these treatments during the school day. In addition, as a profession, we need greater accountability
for the utility of our knowledge as outside pressures attempt to limit our role in collaborative
treatment decision-making activities. Medication treatment for childhood disorders will continue
to receive increased attention in the 21st century due to factors involving societal pressures on
time, money, and resources. School psychologists, given their scientist–practitioner training in the
areas of assessment, consultation, and intervention, are in a unique position to impact the research
and physician use of medications with school-aged youth (Kubiszyn, 1994). Training in school
psychopharmacology should not overshadow training in school-based prevention and intervention
efforts. It is a field of study that complements current initiatives being undertaken by training
programs related to developing course work to provide exposure to child-based psychosocial
treatments that demonstrate empirical support. Children’s mental health conditions are complex
and due to a multitude of ecological, biological, and psychological variables. Intervention curric-
ulum within training programs should parallel the theoretical and empirical support that exists for
treating psychological disorders. Alternatively, interdisciplinary collaboration may effectively alle-
viate difficulties in attempting to do too much within our professional training programs (DuPaul
& Carlson, 2005).
There are a number of important directions for future research in school psychopharmacol-
ogy. Limited attention has been given to the types of training opportunities present within gradu-
ate programs in school psychology. A comparison of doctoral and specialist/master’s training via
a survey of program directors and/or a survey of program curricula would provide additional
information about how the field is addressing the increased emergence of medication issues within
school psychological practice. Alternatively, a survey of recent graduates might provide informa-
tion on the current efforts of training programs to add child psychopharmacology knowledge into
curricular requirements. Medication evaluation issues including the need, importance, and benefit
of intensively monitoring response to pharmacological interventions within the school context are
unresolved and important for future study. One specific area of research that has received limited
attention within the child psychopharmacology and school psychology literature is the impact that
medication treatments may have on indirectly altering classroom and other ecological variables
such as instructional time, social support, and/or teacher–student relationships. This biopsychosocial
Child Psychopharmacology 631
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erspective is an important one as the profession continues to look for ways to contribute to effec-
tive outcomes for school-aged populations.
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... Dramatic increases in the prescription rates of psychotropic drugs in child populations and in the support for EBIs have prompted many R researchers to question the amount of training practitioners receive on evidence-based pharmacological interventions (Shahidullah and Carlson 2014;Shernoff et al. 2003). Several studies that investigated school personnel training in EBIs concluded that additional training for teachers and school psychologists should be available (Lien et al. 2007;Carlson et al. 2006). ...
... Although the APA has established criteria for providing psychopharmacology training to doctoral students, the National Association of School Psychologists (NASP) has yet to develop or recommend training for school psychologists who possess the educational specialist (Ed.S) credential (Yssledyke et al. 2006). Carlson et al. (2006) investigated school psychologists' psychopharmacology training by surveying 320 practicing school psychologists from urban, suburban, and rural areas. The sample featured in this study was comprised predominately of school psychologists who possessed the education specialist credential (72.4%) and doctoral level school psychologists (27.6%). ...
... The results of this study showed that 81% of the 320 school psychologists surveyed have never taken a course in child or adolescent psychopharmacology. Also, 88% stated they acquired their knowledge of psychotropic drugs through professional workshops and 97% stated more training in child psychopharmacology should be available (Carlson et al. 2006). ...
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... This accountability includes collaborative assessment protocols, whereby diagnostic accuracy is enhanced and treatments are individualized, implemented with fidelity, and empirically monitored to ensure high-quality care. Most school psychologists work directly with students taking psychotropic medication (Carlson, Demaray, & Hunter-Oehmke, 2006;Kubiszyn & Carlson, 1995) and already have established rapport with these students and their families through previous correspondence within counseling, consultation, referral, and/or other entitlement meetings. With this rapport, they are well positioned to advocate for a student's treatment needs, facilitate cross-setting communication, and support school-based treatment monitoring and evaluation by collaborating with physicians to integrate academic, behavioral, and pharmacological interventions into a comprehensive treatment plan that ensures sustained long-term progress with the lowest therapeutic dose (Evers, 2011). ...
... Given the critical indirect and direct psychopharmacological service roles that school psychologists can undertake, which are legally and ethically contingent on the training they have received (APA, 2010; National Association of School Psychologists [NASP], 2010b;Shahidullah, 2014), it is important to empirically investigate their training competencies to undertake these roles. Obtaining additional information about these important issues from practicing school psychologists across the country contributes to the current empirical knowledge base pertaining to school psychopharmacology (e.g., Carlson et al., 2006;Gureasko-Moore et al., 2005). ...
... The purpose of this study was to examine the results from a national survey of randomly selected practicing NCSPs (n = 548). This investigation continued the prior survey work pertaining to school psychopharmacology (Carlson et al., 2006;Gureasko-Moore et al., 2005) and provides a unique contribution to the literature by empirically investigating the proposed medication evaluation practice roles described within the school psychology literature by DuPaul and Carlson (2005). In addition, the prevalence of training received across an array of recommended training types (APA-conceptualized Levels 1-3) was examined more comprehensively than prior work in this area. ...
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A randomly selected group of Nationally Certified School Psychologists (NCSPs; n = 817) were mailed the 42-item School Psychopharmacology Roles and Training Evaluation (SPRTE) which inquired about their caseloads, practice roles as proposed by DuPaul and Carlson (2005), and prior training in psychopharmacology. A modified Tailored Design Methodology (TDM; Dillman, Smyth, & Christian, 2009), involving four mail-based contacts, was used to yield a 74% survey return rate (n = 607). Of the returned surveys, a 72% (n = 548) usable response rate was obtained and used in the present study. Consistent with prior literature, nearly all (99.6%) school psychologists reported serving at least one student taking psychotropic medication. Primary direct service roles included monitoring behavioral response to psychotropic treatment (28%), monitoring treatment side-effects (23%), and developing psychotropic treatment goals from direct assessment measures (14%). Primary indirect service roles included providing behavior management consultation to teachers of students taking medication (96%), implementing adjunctive psychosocial supports (87%), and providing assessment data to physicians for diagnostic purposes (84%). Despite differences in established psychopharmacological training standards, actual practice roles and training received did not differ between NCSPs from APA-accredited programs and those from National Association of School Psychologists (NASP)-approved programs. Implications for school psychopharmacology practice, training and research are addressed.
... Some of the factors that parents consider when deciding whether to choose psychotropic medication include perceived side effects of medication, age of the child, stigma, and cost (Pham et al. 2010). Schoolaged children are being treated with psychotropic medication at an increasing rate; one out of every four cases seen by a school psychologist was receiving medication (Carlson et al. 2006) particularly for behavior or social-emotional problems. ...
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The biopsychosocial-cultural framework is a systemic and multifaceted approach to assessment and intervention that takes into account biological, psychological, and socio-cultural factors that influence human functioning and service delivery. Although originally developed to assess physical health and medical illness, this contemporary model can be used as a framework for school psychologists to address the mental health needs of culturally and linguistically diverse youth with Attention-Deficit/Hyperactivity Disorder (ADHD). School psychologists can apply this model when conceptualizing academic, behavioral, and social-emotional functioning of children and adolescents, while also considering cultural barriers relating to treatment acceptability when working with families. Because it encourages school psychologists to address presenting problems in a culturally sensitive and contextual manner, this model may reduce bias and result in more equitable mental health outcomes. The purpose of this article is to discuss the biopsychosocial-cultural model, its advantages and disadvantages, and its application in a case study of a Hispanic child with ADHD.
... School psychologists can serve as a liaison between the school and primary care to ensure the provision of high quality treatment across settings. Nearly all school psychologists already report having at least one student on their caseload who is prescribed with and taking psychotropic medication (Carlson, Demaray, & Hunter-Oehmke, 2006). Of those, the most common medication class is psychostimulants for the treatment of ADHD. ...
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... After obtaining approval by the local IRB, 1,000 names were randomly extracted from the NCSP database (n ϭ 13,156) using an Internetbased random number generator. This quantity was selected due to prior survey studies using similar mail-based Tailored Design Methodology (TDM; Dillman, Smyth, & Christian, 2009) procedures obtaining response rates between 40 and 70% (e.g., Carlson et al., 2006;Gureasko-Moore et al., 2005;Fowler & Harrison, 2001). The TDM is an empirically supported survey methodology designed to maximize the representativeness of the sample and increase response rates. ...
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The purpose of this study was to empirically investigate Nationally Certified School Psychologists' (NCSP) training in and use of evidence-based interventions (EBIs) for child behavior concerns as well as their reported implementation barriers. A modified Tailored Design Method (TDM; Dillman, Smyth, & Christian, 2009) using up to four mail-based participant contacts was used to obtain survey data (72% usable response rate; n = 392) from a randomly selected national sample of 548 currently practicing NCSPs. Lack of time was rated as the most serious barrier to behavioral EBI implementation, followed by a lack of necessary resources, and financial constraints. Nearly three-quarters (71%) of respondents reported a perceived inadequacy of graduate program training in behavioral EBIs, with a statistically significant difference found between respondents who attended American Psychological Association (APA)-accredited/National Association of School Psychologists (NASP)-approved programs and those who did not. These findings highlight the significant barriers school psychologists encounter when attempting to implement behavioral EBIs within applied practice, as well as the importance of graduate program training in implementation science. Implications for training, practice, and research are discussed. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
... The third level of psychopharmacological involvement (i.e., prescriptive authority) that Kubiszyn refers to has historically been a topic of much debate within in the larger field of psychology (Bascue and Zlotowski 1981). While the attitudes of school psychologists, specifically, towards obtaining the right to prescribe medication indicate that few desire this status (e.g., Carlson et al. 2006;Kubiszyn and Carlson 1995), Kubiszyn (1994) posited that school psychologists with prescriptive authority might utilize their roles to affect change in the following ways: (a) improve on existing pediatric medication dispensing and evaluation protocols, (b) ensure greater continuity of care by integrating psychotherapy and pharmacotherapy into an integrated service approach, and (c) recognize that the ability to prescribe is also the ability not to prescribe. However, the ability of school psychologists to be able to prescribe varies on the jurisdiction of the state in which treatment is provided since Louisiana and New Mexico are currently the only states with psychologist prescriptive authority legislation (Muse et al. 2011). ...
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Given the prevalence of school-age children and adolescents who are prescribed with and are taking psychotropic medications, a critical issue that school psychologists may likely encounter in contemporary practice is providing both quality and continuity of care to these students in the context of relevant legal and ethical parameters.With a thorough understanding of federal, state, and local legislation, relevant case law, and ethical standards, school psychologists are well positioned to competently navigate these situations in school-based practice. This article highlights critical practice roles for school psychologists to undertake in working with students who are prescribed with and are taking psychotropic medications within the school setting.
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Chapter
Given the important involvement of psychologists and school professionals in psychopharmacological treatment, the purpose of this chapter is to address legal, ethical, and professional issues related to the use of psychoactive medications in the school-aged population. Specific attention is given to the implications of these issues for the roles and responsibilities of school personnel when working with families and physicians around medication treatment decisions. The chapter concludes with a list of readings and websites that may be helpful for readers seeking more information on this topic.
Chapter
School Psychopharmacology: Translating Research into Practice uniquely contributes to the child psychopharmacology literature via its focus on service sector coordination, an emphasis on school-related medication treatment outcomes, a review of medication evaluations specific to the school context, and through its use of case study examples from the educational setting. This edited book brings together the latest in school psychopharmacology-related research and practice from experts across the fields of school psychology, clinical psychology, and child psychiatry. This introductory chapter reviews the importance of school psychopharmacology within the mental health treatment of children and adolescents and a preview of each chapter is presented.
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Recent studies on the prevalence of autism indicate that approximately 1 in 200 children meet diagnostic criteria, significantly greater than rates reported just a decade ago (Blanchard, Gurka, & Blackman, 2006). Concurrently, biomedical treatments including psychotropic medication have been used with increased frequency to treat children diagnosed with autism spectrum disorders (Aman, Lam, & Van Bourgondien, 2005). Medication treatments are often sought as an adjunct to social, behavioral, and educational interventions in an attempt to improve children’s academic, social, behavioral, and emotional functioning. Anticipated and unanticipated effects of medications commonly used to treat behaviors associated with autism are reviewed. Knowledge about the types and evidence-based support for different medication treatments used within this population of children is essential to integrating medical, educational, and psychosocial treatments within the school context. Finally, a simple and efficient means by which school psychologists may contribute to the evaluation of treatment services to those with autism is provided.
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Attention-Deficit/Hyperactivity Disorder (ADHD) is commonly treated with stimulant medications, and several models for school-based medication monitoring have been proposed. Nevertheless, there is a paucity of research examining the prevalence of medication monitoring. A survey examining the medication monitoring practices of school psychologists was sent to 700 potential participants, with a usable return rate of 64.7%. Nearly 55% of the respondents were involved in monitoring the effects of medications for students with ADHD, and a higher percentage indicated that medication monitoring is an important role for school psychologists. Teacher and parent rating forms and interviews, direct observation, and review of work samples were perceived as the most effective, acceptable, and feasible monitoring methods. These findings suggest that many school psychologists are engaged in medication monitoring and are willing to perform this role. Barriers and facilitators to medication monitoring in the schools are discussed. In addition, the implications for school-based medication monitoring are explored.
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This study investigates the use of medications by child and adolescent psychiatrists for treating selective mutism. In 1993, a one-page survey was mailed to 962 child and adolescent psychiatrists selected at random from approximately 2500 active members of the American Academy of Child and Adolescent Psychiatry. Of the 962 questionnaires sent, 411 were returned (return rate 43%) and 308 were completed (sample participation rate 32%). A prevalence estimate of selective mutism within a clinical sample was calculated to be 1 case of selective mutism per 936 new patients (0.11%). Less than two-thirds (199/308) of the responding psychiatrists reported having treated a child with selective mutism in their practice. Of those who had treated a child with selective mutism, 36% (n = 71) reported having prescribed medication for this disorder. Antidepressants were the most frequently endorsed medication for being potentially beneficial in treating a hypothetical case example and, in addition, for being actually used by child psychiatrists in clinical practice for children diagnosed with selective mutism. Antianxiety agents were reported, at much lower rates, to be potentially useful in a hypothetical case and actually used in clinical practice for treating children with this disorder. These findings suggest that child psychiatrists may view selective mutism as being related to, having symptoms similar to, or often presenting comorbidly with depressive or anxiety disorders. However, a therapeutic program that includes pharmacotherapy was endorsed as the most effective treatment modality for selective mutism by only 14% of the reporting psychiatrists. Psychiatrists' impressions and observations cannot, even collectively, be used to make clinical inferences about the usefulness of treatments. This study did not examine treatment efficacy, since the outcomes of these open clinical trials were not judged by independent observers but were reported as observed and recollected by the clinicians involved. Moreover, these data on the treatment practices of sampled members of the American Academy of Child and Adolescent Psychiatry may not reflect the practices of other psychiatrists or pediatricians. The results indicate that child and adolescent psychiatrists are prescribing a variety of medications for selective mutism without the benefit of adequate efficacy studies. There is a significant need for further research and dissemination of information in this area.
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Background: Previous studies have demonstrated the short-term efficacy of pharmacotherapy and behavior therapy for attention-deficit/hyperactivity disorder (ADHD), but no longer-term tie, >4 months) investigations have compared these 2 treatments or their combination. Methods: A group of 579 children with ADHD Combined Type, aged 7 to 9.9 years, were assigned to 13 months of medication management (titration followed by monthly visits); intensive behavioral treatment (parent, school, and child components, with therapist involvement gradually reduced over time); the two combined; or standard community care (treatments by community providers). Outcomes were assessed in multiple domains before and during treatment and at treatment end point (with the combined treatment and medication management groups continuing medication at all assessment points). Data were analyzed through intent to-treat random-effects regression procedures. Results: All 4 groups showed sizable reductions in symptoms over time, with significant differences among them in degrees of change. For most ADHD symptoms, children in the combined treatment and medication management groups showed significantly greater improvement than those given intensive behavioral treatment and community care. Combined and medication management treatments did not differ significantly on any direct comparisons, but in several instances (oppositional/aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement) combined treatment proved superior to intensive behavioral treatment and/or community care while medication management did not. Study medication strategies were superior to community care treatments, despite the fact that two thirds of community-treated subjects received medication during the study period. Conclusions: For ADHD symptoms, our carefully crafted medication management was superior to behavioral treatment and to routine community care that included medication. Our combined treatment did not yield significantly greater benefits than medication management for core ADHD symptoms, but may have provided modest advantages for non-ADHD symptom and positive functioning outcomes.
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Research and practice in special education have only begun to incorporate interventions from other disciplines. Child and adolescent psychopharmacology recently has begun to assert itself as a primary intervention in treatment of children with disruptive behavioral disorders, such as attention deficit hyperactivity disorder. Recent findings in this area will be reviewed along with a brief review of medications used for children with mood or schizophrenic disorders. The article concludes with a discussion of collaborative practice with physicians and families in multimodal treatment of children with emotional and behavioral disorders. The authors argue that effective special education practice demands such collaboration.
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How might basic training in psychopharmacology be integrated into psychology internships? The present article describes a brief psychopharmacology curriculum, developed by a prescribing psychologist and a director of training for an internship program accredited by the American Psychological Association, designed to specifically address training needs of predoctoral interns. The authors maintain that focused training in differential medical diagnosis and psychopharmacology is essential to the professional development of the psychology intern. Implementation by a psychologist with advanced knowledge of psychopharmacology may enhance the intern's integration of this material with psychological principles and facilitate active involvement in primary care and remote settings in future practice.
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How involved in the process of prescribing psychotropic drugs is the average practicing professional psychologist today? The answer is "far more than most people realize." Five hundred ninety-six practicing psychologists responded to a survey reporting the types of professional activities in which they regularly engage. Virtually all responding psychologists reported they were involved in making recommendations for medication evaluations, consulting with physicians about which medications to use with specific patients, and discussing medication-related issues with patients. A generally agreed-on model of psychopharmacology training for professional psychologists should emerge over the next 5 to 10 years.
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The purpose of this study was to describe the perspectives and practices of school psychologists toward family-school partnership activities. A national sample of 417 school psychology practitioners rated (a) their perspectives about family-school partnership activities in general, (b) how important it is for them to engage in partnership activities, and (c) whether or not they had engaged in 12 specific partnership activities during the past 12 months. Respondents overwhelmingly supported the general concept of parent involvement in education and perceived their own involvement in family-school partnership activities as important. The activity, "Consulting with families about specific ways they can support their child's learning and behavior at school" received the highest importance rating and was engaged in by more than 95% of the respondents during the last 12-month period. Practitioners who worked primarily within the lower grade levels and those who were more likely to agree with the statement, "Every family has some strengths that can be tapped to increase student success in school" participated in more family-school partnership activities during the past 12 months. Implications of this study for practice and research are discussed.
Article
This book sets the stage for competency domains by reviewing the context in which school psychological services are delivered and how school psychologists are educated. The book focuses initially on the altered social, political, and economic context for education and the practice of psychology in schools. The book then analyzes the ways in which schools have changed since 1984. It describes changes that are taking place in the training of school psychologists and how these changes affect their practice in schools. The report attempts to be sensitive to the fact that school psychologists have varying degrees of autonomy. It recognizes that many of the roles that school psychologists play are dictated by workplace settings and that there is considerable variance in the ways people work. It lists and describes 10 interrelated domains of training and practice and provides a scenario demonstrating how these domains are connected and played out in daily practice. Finally, the report addresses implications for training, practice, and the profession overall. (MKA)