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Stimulant Treatment in Maryland Public Schools

Daniel J. Safer, MD*, and Michael Malever, PhD‡

ABSTRACT. Objective. A statewide school survey was performed to provide naturalistic data on the prev-alence of medication administered to Maryland public school students for the treatment of attention deficit hy-peractivity disorder (ADHD) to clarify the concern of some state legislators about stimulant treatment for youths.

Methods. In April 1998, school nurses supervised a survey of all Maryland public school students medicated during school hours for ADHD. The data collected on these students included: type of medication adminis-tered, gender, school level, race/ethnicity, special educa-tion and Seceduca-tion 504 status, and the specialist of the prescriber.

Results. Of the 816 465 students surveyed, 20 050 (2.46%) received methylphenidate and 3721 (0.46%) re-ceived other medications for ADHD. Other major find-ings were: 1) methylphenidate constituted 84% of all the medication administered for ADHD; 2) the male:female ratio of the medication’s recipients was 3.5:1 and 4.3:1 in elementary and secondary school, respectively; 3) black and Hispanic students received methylphenidate at ap-proximately half the rate of their white counterparts; 4) 45% of all students receiving methylphenidate had spe-cial education status and an additional 8% had Section 504 status; and 5) nurse practitioners were the prescribers of 3% of the methylphenidate prescribed to Maryland students.

Conclusions. This large, population-based, point prevalence study of medication administered to students for ADHD adds new and updated findings on prevalence variations, rates for minority and special education/ Section 504 students, and specialty prescriber rates. Pediatrics 2000;106:533–539;attention deficit hyperactiv-ity disorder, methylphenidate, stimulant medication, pharmacoepidemiology.

ABBREVIATIONS. ADHD, attention deficit hyperactivity disor-der; Section 504, Section 504 of the Rehabilitation Act of 1973; ADD, attention deficit disorder; IEP, Individualized Education Program.

I

n 1997, the Maryland General Assembly passed

House Bill 971, which created a task force to “study the uses of methylphenidate and other drugs on school children.” One charge of the task force was to “determine the prevalence of use of methylphenidate among school-aged children in the

state.” The responsibility for carrying out this school survey was given to the Maryland State Department of Education, which assigned school nurses within each of the state’s 24 school districts to supervise the completion of a comprehensive survey on all public school students recorded as receiving medication for attention deficit hyperactivity disorder (ADHD) dur-ing school hours.

The model for this prevalence study was the bien-nial survey used in Baltimore County, Maryland from 1971 through 1997 to record medication treat-ment patterns for students with ADHD.1,2That sur-vey was modified in this instance to include only public school students administered medication for ADHD during school hours. Furthermore, some ad-ditional information was requested. When finalized, the requested student data included, in addition to the name of the school-administered medication, the following: gender, race/ethnicity, school level, and special education and Section 504 status. The spe-cialty of the medication prescriber was also recorded. The sociodemographic factors included in this medication survey were viewed as at least as impor-tant the total prevalence. Recent studies of US youths have revealed that drug treatment prevalence for ADHD varies substantially in relation to: 1) the child’s characteristics: age, gender, comorbid disor-ders, socioeconomic status, race/ethnicity, special education or regular education status 2) treatment factors: physician specialty, medical payment source 3) temporal factors: duration of the reporting period, year of the study 4) societal factors: adverse or pos-itive media influences, geographic area, pharmaceu-tical promotion, and 5) changing diagnostic bound-aries: the expansion of the category of hyperkinesis/ attention deficit disorder (ADD)/ADHD which began in 1980.1Consequently, total medication prev-alence and differences by subpopulation are detailed and discussed herein and are related to the findings of previous surveys.

METHODS

The Maryland State Department of Education, under legislative mandate, contacted all school districts in the state (n⫽24) and instructed school nurses in each district to obtain complete infor-mation on students who, during school hours, were receiving methylphenidate or other medications for the treatment of ADHD. The recording of medications other than methylphenidate for the treatment of ADHD was listed separately on the survey form so that it is possible—though not likely—that a student could be recorded twice if receiving both methylphenidate and other med-ications for ADHD. The survey was performed in April 1998 and focused on youths receiving medication at the time of the survey. In addition to gathering data on the medication administered for ADHD, the following relevant data were recorded: 1) gender; 2) From the *Departments of Psychiatry and Pediatrics, Johns Hopkins

Med-ical Institutions, and the ‡Maryland State Department of Education, Balti-more, Maryland.

Received for publication Jul 29, 1999; accepted Jan 7, 2000.

Reprint requests to (D.J.S.) 7702 Dunmanway, Baltimore, MD 21222. E-mail: dsafer@jhmi.edu

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school level (grouped as elementary [grades K–5], middle [6 – 8], and high [9 –12]); 3) race/ethnicity (white, black, Hispanic, Asian, Native-American); 4) special education status (determined by hav-ing an Individualized Education Program [IEP]); 5) Section 504 status; and 6) prescriber specialty (pediatrician, family practitio-ner, psychiatrist, nurse practitiopractitio-ner, other).

In the 24 jurisdictions of the state, school health suites are managed by registered nurses, licensed practical nurses, and/or health aides— depending on the school district. All school districts have at least 1 registered school nurse and registered school nurses in each district were responsible for gathering the survey data.

In the statewide survey of students administered medication treatment for ADHD, .3% were uncoded (missing) for special education status, .6% were uncoded for race/ethnicity, and the prescribing provider specialty was not known in 6.4%. In Mary-land State Department of Education enrollment data, 1.6% of students were not assigned to specific grade levels. School enroll-ment in Maryland public schools was obtained from the Maryland State Department of Education figures for September and Decem-ber 1997.

The data were analyzed using primarily descriptive statistics and a nonparametric test. The data were collected in summary form, which did not permit the use of multivariate techniques. Individual school district rate differences in student medication treatment for ADHD were evaluated in relation to school district student race/ethnicity patterns and in relation to 1998 median household income by county/jurisdiction.3 Where appropriate,

these data comparisons were analyzed using the Spearman rank order statistic.

The estimate of youths who were given medication for ADHD only at home was based on data from 2 sources, both of which found it to be approximately 20% of the total on medication. The first estimate came from a 1997 consumer survey of parents in an ADD support group,4and the second came from a 1993 school

nurse survey in Baltimore County which separately tabulated in-school and home-administered medication for ADHD.5

RESULTS

Percent of Public School Students Receiving Medication for ADHD During School Hours

Table 1 presents the data on the prevalence of medications administered for ADHD to Maryland public school students. The prevalence of methyl-phenidate and of other medications administered to treat ADHD during school hours was 2.46% and .46%, respectively. In all, 2.92% of all public school students were administered a medication for ADHD in school. The male:female ratio for students admin-istered medication was 3.5:1 in elementary and 4.3:1 in secondary schools.

Estimated Total Prevalence of Medication Treatment for ADHD in Maryland Public Schools

The statewide public school survey recorded only medication administered for ADHD during school hours, which was 2.92%. Because 2.92% was deter-mined to approximate 80% of the total, 3.65% was

calculated to be the overall estimate of the point prevalence of medication treatment for ADHD in Maryland public schools in April 1998. This disag-gregates by school level to rates of 4.5% in elemen-tary, 4.3% in middle, and 1.3% in high school. The male:female gender ratio is 3.76:1, indicating a med-ication rate for ADHD of 5.75% for boys and 1.53% for girls.

Types of Medications Administered During School Hours

The medications administered for ADHD in school were of the following proportions: 84.2% methyl-phenidate, 11.6% amphetamines, 1.7% clonidine, .4% pemoline, and .4% tricyclic antidepressants. Of the medications ‘other than methylphenidate’ adminis-tered for ADHD in school, 73% belonged to the am-phetamine class.

Influence of Race/Ethnicity

Table 2 focuses on the variation in school admin-istered methylphenidate by race/ethnicity. Compar-ing the treatment and enrollment proportions, it is apparent that non-white students had a proportional rate of methylphenidate treatment nearly half that of their proportional school enrollment (23.76% vs 44.09%). When methylphenidate prevalence data are presented in relation to school level, one race/eth-nicity disparity widens with advancing grade levels. The white/black methylphenidate prevalence ratio increases as follows: 2.0:1 in the elementary school, 2.6:1 in the middle school, and 5.2:1 in high school. The pattern was not attributable to a declining en-rollment by blacks and was not present for Hispanics or other minorities (Tables 2 and 3).

Special Education Status

In Maryland public schools, 13% of the students enrolled were receiving special education services during the 1997–1998 school year.6Table 4 presents the rate of school-administered methylphenidate treatment for students with ADHD receiving special education services compared with those in regular education. Overall, 1.55% of regular education stu-dents received this ADHD treatment compared with 8.70% of students who had an IEP, a marker for special education. This represents a 5.6-fold higher medication rate for students receiving special educa-tion services compared with students in regular ed-ucation. In high school, students with an IEP were 10-fold more likely than their regular education

TABLE 1. Prevalence of Enrolled Students Receiving Medication for ADHD by School Level

Elementary Middle High Total

% N/T % N/T % N/T % N/T

Methylphenidate 3.11 12 744

410 664

2.91 5338

183 803

.87 1938

221 998

2.46 20 050 816 465

Other psychotropic medications .55 2246 410 664

.57 1044

183 803

.19 431

221 998

.46 3721

816 465

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counterparts to be receiving methylphenidate in school (Table 4).

Table 5 presents the percent of special education students and students with a Section 504 plan who were administered methylphenidate for ADHD in school. Overall, 45% of the students receiving meth-ylphenidate were in special education and an addi-tional 8.3% had a 504 plan. Thus, 53% of all students receiving methylphenidate during school hours had an official school-documented impairment.

Geographic Variations

The school district rates of methylphenidate treat-ment for ADHD varied fivefold geographically, from a low of 1.18% to a high of 6.02%. Race/ethnicity demographics were not uniform throughout the state and appeared to dramatically influence the prevalence variability. The jurisdictions with the lowest rate of methylphenidate treatment, Prince George’s County and Baltimore City, had the highest minority student enrollment rates in the state, 84.7% and 87.2%, respectively. At the opposite extreme, the jurisdictions with the highest ADHD medication prevalence rates, Allegany and Garrett Counties, had among the lowest rates of minority student enroll-ment, 4.0% and .7%, respectively.6A second possible geographic influence is the presence locally of a large clinic specifically treating children with ADHD. Only 3 such clinics reportedly exist in the Maryland area,

and the 3 counties that are served by these clinics are among the highest 4 in methylphenidate prevalence.

Medical Specialty Prescribers of Methylphenidate for ADHD

The prescribers of methylphenidate for ADHD were reported in 94% of cases. Their rank order of prescribing by specialty (where known) is as follows: pediatricians, 63%; family practitioners, 17%; psychi-atrists, 11%; behavioral clinic, 5%; nurse practitio-ners, 3%; and others, 2%. Pediatricians prescribed 67% of the medication for elementary school youths with ADHD, whereas family practitioners and psy-chiatrists together prescribed equally as much as did pediatricians for high school youths with ADHD (47% vs 46%). The proportion of medications other than methylphenidate prescribed by psychiatrists was nearly threefold greater than the proportion of methylphenidate that they prescribed (29% vs 11%).

DISCUSSION

Comparative Rates of Medication Treatment for ADHD Among School-Aged Youths

In addition to the 1997 Baltimore County public school survey of medication for ADHD,1there are 2 other recent school medication surveys. LeFever et al7,8reported on a methylphenidate treatment survey covering 2 school districts in eastern Virginia during the 1995–1996 school year. The point prevalence of methylphenidate treatment in the second through the fifth grades was 10.8% for white and 5.4% for black students. In a central Wisconsin school district in 1996, Musser et al9surveyed all public and paro-chial school students who received stimulant medi-cation treatment for ADHD during school hours. She and her colleagues reported that 3.7% of the entire student body were administered stimulant medica-tion then.

Generalizations from these school district surveys to the state as a whole or to other school districts are quite difficult because of differences in school sub-populations and wide variations in the prevalence of medication treatment for ADHD from one school district to another.

Survey Inclusiveness

In assessments of the prevalence of stimulant med-ication treatment for youths, the most inclusive study was done by Rappley et al.10 She and her colleagues obtained complete methylphenidate pre-scription information from the entire state of Michi-gan using controlled substances triplicate

prescrip-TABLE 2. Proportion of Students Receiving Methylphenidate and Enrolled in Relation to Race/ Ethnicity

Proportion Receiving Methylphenidate in School Race/Ethnicity Proportions in School Enrollment

Elementary Middle High Total

White 73.11 79.83 86.89 76.23 55.91

Black 24.20 16.98 10.47 20.95 36.08

Hispanic 1.68 2.06 1.70 1.79 3.72

Asian .82 .96 .77 .85 3.97

Native-American .18 .17 .15 .17 .32

TABLE 3. Comparative Prevalence of Methylphenidate Treat-ment for ADHD by Race/Ethnicity at Each School Level

School Level White Black Hispanic

Elementary

Rate* 9339

226 739

3091 153 447

215 17 452

% 4.12 2.01 1.23

White/minority ratio — 2.0:1 3.3:1

Middle

Rate 4261

98 904

907 54 159

110 5439

% 4.31 1.67 2.02

White/minority ratio — 2.6:1 2.1:1

High

Rate 1684

125 262

203 76 889

33 7710

% 1.34 .26 .43

White/minority ratio — 5.2:1 3.1:1

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tion data. The research team found that 1.96% of all 5- to 14-year-old youths and 1.6% of all 5- to 17-year-old youths in that state (as determined by census figures) had been prescribed methylphenidate in February or March 1992.

A slightly less comprehensive survey of youths receiving stimulant treatment would include all pub-lic school students in 1 or more school districts. Vir-tually all youths aged 5 to 18 years would then be covered in such a survey except high school drop-outs and students enrolled in private or parochial schools. (In Maryland, 4.66% of public high school students dropped out of school during the 1996 –1997 school year and 17% of all enrolled students matric-ulated in nonpublic schools in the fall of 1997.6) Another limitation of a school-based medication sur-vey is that it could less accurately record exclusively home-administered medication for ADHD. School surveys of ADHD drug treatment nonetheless have an advantage over prescription based surveys in that they can assess a greater range of factors relevant to the initiation and administration of the medication.

Treatment-based surveys have their own set of limitations. Nationally stratified surveys based on data from office-based physicians underrepresent clinic medical coverage and are limited frequently by low reliability.11 Data-based records of treatment from health maintenance organization enrollees in-clude few with low incomes, and Medicaid datasets focus primarily on low-income recipients.12

State-by-State Comparisons

There are no state-by-state population-based methylphenidate treatment comparisons. The only state-by-state comparison is based on a crude mea-sure, kilograms of methylphenidate shipped to retail registrants in the United States by zip code. This

measure is reported in a US Drug Enforcement Ad-ministration13 database whose acronym is ARCOS. In 1994, Maryland had the fourth lowest methyl-phenidate shipment rate among the 50 states, .83 g per 100 population.14In 1997, Maryland ranked 17th among the 50 states with 3.78 g of methylphenidate shipped per 100 population (DEA, 1998). The mark-edly increased shipment rate to Maryland from 1994 to 1997 is at variance with the 1995 to 1997 popula-tion-based increase in the number of students receiv-ing methylphenidate in Baltimore County public schools, an increase of⬍10% over 2 of those 3 years (3.75%– 4.10%) (Safer, unpublished data, 1998). Con-sequently, an accurate state-by-state comparative analysis awaits additional population-based re-search.

Variations in Treatment Prevalence: Replications of Previous Research

A number of the findings of the Maryland 1998 statewide public school survey match those reported previously. A 4:1 male:female ratio of students re-ceiving stimulant medication has been regularly not-ed.10,15,16 The peak age range of stimulant medica-tion during the 1990s has been reported to be ages 8 to 11 years.10,16 The medication prevalence rate for middle schools now nearly equals that of elementary schools.15 The fivefold stimulant medication varia-tion across school districts in Maryland is similar to findings previously reported by Zito et al,16 and these mirror the 10-fold methylphenidate variation across Michigan counties reported by Rappley et al.10 The medical specialty prescriber patterns are also similar to those reported previously. In surveys and in studies assessing prevalence, the proportion of medical specialists prescribing medication for youths with ADHD is as follows: pediatricians (40%– 69%),

TABLE 4. Comparative Prevalence of Regular and Special Education Students Receiving Meth-ylphenidate in School for ADHD

Elementary Middle High Total

% N/T % N/T % N/T % N/T

Regular education 2.03 7318

359 709

1.85 2892

156 201

.44 869

197 414

1.55 11 079 713 324

Special education 10.70 5456 50 995

8.86 2446

27 602

4.35 1069

24 584

8.70 8971

103 141

N/T indicates number on methylphenidate/total enrollment at each grade level.

TABLE 5. Proportion of Special Education and Section 504 Students Receiving Methylphenidate in School in Relation to the Total Number of Students Receiving Methylphenidate

Elementary Middle High Total

% N/T % N/T % N/T % N/T

Special education 43.33 5456 12 592

46.17 2446

5298

50.69 1069

2109

44.86 8971

19 999#

Section 504 7.24 912

12 592

9.55 506

5298

11.52 243

2109

8.31 1661

19 999*

N/T indicates number receiving methylphenidate in special education or Section 504/total number of students at these grade levels receiving methylphenidate.

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family practitioners (15%–37%), psychiatrists (6%– 25%), and neurologists (5%–15%).10,17–21

The twofold lower prevalence of medication treat-ment for ADHD of black compared with white youths has been previously reported by Cullinan et al,22Bussing et al,23Le Fever et al,8and Zito et al.16

New Findings on Treatment Variations

Nurse Practitioners

Not previously reported is the finding that nurse practitioners in Maryland now prescribe 3% of the stimulant medication administered to students with ADHD. Most states in the United States now grant prescribing privileges to nurse practitioners and in Maryland, this includes the right to prescribe con-trolled substances.24

Race/Ethnicity

The statewide Maryland public school survey now provides enough data on all non-white student groups (black, Hispanic, Asian and Native-Ameri-can) to reveal that all have a comparatively lower treatment prevalence for ADHD medication than white students based on their proportional enroll-ment (Table 2). It is particularly noteworthy that the black versus white medication rate disparity in-creased substantially at higher school levels, that this school level disparity was not present for Hispanic or other minority students, and that the proportion of white students administered methylphenidate for ADHD increased from elementary to high school (Tables 2 and 3).

Studies based on teacher ratings suggest that com-pared with white youths, black youths have the same or a greater likelihood of exhibiting the features of ADHD,25–28and there is good evidence that cultural differences explain at least some of the compara-tively low level of stimulant treatment by youths from black families.29 –32 Possibly these cultural fac-tors have their greatest impact on black students at the high school level where their relative rate is lowest (Table 3).

Comparing Maryland school districts, there was a significant inverse relationship between the in-school rate of methylphenidate administration and the pub-lic school percentage of black students (Spearman rank order Correlation ⫽ ⫺.454; P ⬍ .05). At the extremes of the ranking, Prince George’s County and Baltimore City had the lowest in-school rates of methylphenidate treatment (1.18% and 1.20%, re-spectively), but the highest percentages of black pub-lic school enrollment (75% and 86% of the total, respectively). Nonetheless, it is of interest that these 2 jurisdictions were considerably different in their 1998 state-ranked median annual household income (Prince George’s County ⫽ sixth highest, $44 655; Baltimore City⫽ fourth lowest, $26 878).3This sug-gests that race/ethnicity is more associated with the disparity in medication prevalence than is median household income.

The relatively very low medication treatment prevalence for ADHD among Asian students is also striking (Table 2). Some reports suggest that Asian

youths are less likely than whites to exhibit the char-acteristics of ADHD,33although cross-national stud-ies using standardized teacher-rating scales gener-ally show more interpopulation similarities than differences.34,35

Special Education

The finding that 45% of all students in Maryland public schools who received methylphenidate for ADHD during school hours were officially in a spe-cial education category reflects a sizable increase in this group’s share of medication compared with the 25% reported in 1987 by Safer and Krager.2One must consider though that those counted in the 1987 Bal-timore County survey were for the most part in special education classes or schools and that the 1998 Maryland study included all those with an IEP, most of whom were mainstreamed.

The close relationship between special education status and ADHD has now been even more clearly demonstrated. Of course, this relationship has been known for some time. In numerous clinic studies, an average of 45% of all students diagnosed with ADHD receive (or received) special education servic-es.20,36,37 Likewise, Forness38after reviewing the lit-erature reported that an average of 29% of all special education students have ADHD, and that 74% of all ADHD youths receiving special education services have a documented learning disability.

The finding that 8.7% of public school special ed-ucation students receive methylphenidate for ADHD during school hours is difficult to compare with pre-vious reports. Cullinan et al22reported that 6.6% of 6-to 18-year-old public school special education stu-dents in northern Illinois were being treated with stimulant medication in 1985. These students aver-aged 12 years of age and 83% were mainstreamed. Bussing et al23studying public school special educa-tion students in the second through the fourth grades in southeastern Florida reported that 20% were re-ceiving medication therapy for ADHD in 1995.

Section 504 of the Rehabilitation Act of 1973

Although 55% of students medicated in school for ADHD had not been qualified for special education services, a sizable number of these students were still eligible for Section 504 services because they exhib-ited an impairment that substantially limexhib-ited their major life activities.28 In the Maryland medication survey, it was found that 8.3% of all students receiv-ing methylphenidate durreceiv-ing school hours had been qualified by school officials for Section 504 services. Thus, students with a school-identified impairment/ handicap comprised a total of 53% of all those re-ceiving methylphenidate. The 504 category has not previously been assessed in relation to medication treatment.

Limitations of the Study

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were administered methylphenidate and .35% were administered other stimulants (nearly all amphet-amines). It is unlikely that students were adminis-tered 2 different stimulants during school hours. Thus, only the remaining .11% could have reason-ably received 2 different types of medications for ADHD during school hours.

An undercount is more likely. In the late 1990s, the proportion of youths treated with stimulants who were prescribed amphetamine compounds substan-tially increased.39Amphetamines have a longer du-ration of action than methylphenidate and thus are more likely to be administered only at home.40The estimate of 20% for the out-of-school administra-tion of medicaadministra-tion may therefore be somewhat higher. It is also possible that a few students were receiving medications for ADHD, such as atypical neuroleptics, which had not been listed for nurses as applicable for the treatment of ADHD.

CONCLUSION

The Maryland public school survey of medication for ADHD administered to students during school hours provides detail on the statewide prevalence and the variability of this treatment. The rate of medication treatment for ADHD was found to vary fourfold by gender (male vs female), twofold by ethnicity/race (white vs minority), threefold by school level (elementary vs high school), sixfold by educational category (special education vs regular education), and fivefold by school district (highest vs lowest rate). Thus, a given finding for one age group or one geographic locale may be misleading if ap-plied generally.

The inclusion of both sociodemographic and edu-cational variables as part of a medication survey clearly adds depth to the prevalence findings and to some extent clarifies the circumstances related to the prescribing of medication for ADHD. Of the vari-ables researched, the educational category was found to be important in that a majority of public school students administered medication for ADHD were receiving special education or Section 504 services. Consequently, future medication prevalence studies for the treatment of ADHD will need to include this dimension when such data are available.

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37. Biederman J, Faraone S, Milberer S. A prospective 4-year follow-up study of attention deficit hyperactivity and related disorders.Arch Gen Psychiatry.1996;53:437– 446

38. Forness SR. The impact of ADHD on school systems. Read at the NIH Consensus Development Conference on Diagnosis and Treatment of

Attention Deficit Hyperactivity Disorder; Bethesda, MD; November 1998. Abstract, pages 61– 67

39. Shire Pharmaceutical.Shire’s US treatments for ADHD.Accessed July 23, 1999. Available at: http://www.shire.com/press/prframe.him 40. Manos MJ, Short EJ, Findling RL. The differential effectiveness of

meth-ylphenidate and Adderal in school-age youths with attention-deficit/ hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 1999;38: 813– 819

STROKE UNITS IN THEIR NATURAL HABITAT: CAN RESULTS OF RANDOMIZED TRIALS BE REPRODUCED IN ROUTINE

CLINICAL PRACTICE?

Background and Purpose. Meta-analyses of randomized controlled trials of acute stroke care have shown care in stroke units (SUs) to be superior to that in conventional general medical, neurological, or geriatric wards, with reductions in early case fatality, functional outcome, and the need for long-term institutional-ization. This study examined whether these results can be reproduced in clinical practice.

Methods. A multicenter observational study of procedures and outcomes in acute stroke patients admitted to designated SUs or general medical or neurolog-ical wards (GWs), the study included patients of all ages with acute stroke exclud-ing those with subarachnoid hemorrhage, who were entered into the Riks-Stroke (Swedish national quality assessment) database during 1996 (14,308 patients in 80 hospitals).

Conclusions. The improvement in outcomes after stroke care in SUs compared with care in GWs can be reproduced in the routine clinical setting, but the magnitude of the benefit appears smaller than that reported from meta-analyses.

Stegmayr B, et al.Stroke.1999;30:709 –714

Editorial Note. This question of whether trial results can be reproduced in real practice is a very interesting and important question in neonatology. It’s not been studied.

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DOI: 10.1542/peds.106.3.533

2000;106;533

Pediatrics

Daniel J. Safer and Michael Malever

Stimulant Treatment in Maryland Public Schools

Services

Updated Information &

http://pediatrics.aappublications.org/content/106/3/533

including high resolution figures, can be found at:

References

http://pediatrics.aappublications.org/content/106/3/533#BIBL

This article cites 30 articles, 3 of which you can access for free at:

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activity_disorder_adhd_sub

http://www.aappublications.org/cgi/collection/attention-deficit:hyper

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Developmental/Behavioral Pediatrics

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(9)

DOI: 10.1542/peds.106.3.533

2000;106;533

Pediatrics

Daniel J. Safer and Michael Malever

Stimulant Treatment in Maryland Public Schools

http://pediatrics.aappublications.org/content/106/3/533

located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Figure

TABLE 1.Prevalence of Enrolled Students Receiving Medication for ADHD by School Level
TABLE 2.Ethnicity
TABLE 5.Proportion of Special Education and Section 504 Students Receiving Methylphenidatein School in Relation to the Total Number of Students Receiving Methylphenidate

References

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