Robert is a 13-year-old eighth grader who lives with his mother and 17-year-old brother. Robert had been identified with ADHD combined type, generalized anxiety disorder, and oppositional defiant disorder 4 years ago. Because of a reading disability, he has received special education assistance for 3 years and now reads at grade level. Over the past 3 years he has been taking 54 mg of osmotic-release oral methylphenidate(Drug information on methylphenidate), and his mother has noted good improvement.
During a semiannual follow-up appointment, Robert’s mother reports that he is having difficulty completing his in-class work and is forgetting to turn in homework assignments. She has also noticed increased arguments with his older brother, and Robert resents her reminders about homework and other chores. She wonders whether Robert’s dosage should be increased because the current level may no longer be effective.
During the interview, Robert seems bored and somewhat sullen. As in past meetings, he is not very communicative. When asked his opinion about increasing the dose or changing to a new medication, he says he does not see the point in taking medication at all.
Robert’s mother reminds him of his dropping grades. On further questioning, Robert reports that he is “no fun” when he takes the medication—he does not talk much or make jokes—and from time to time he “forgets” to take them. His mother asks if she should return to making sure that Robert takes his medication, something she has not done in at least a year. The clinician, realizing that Robert now has more responsibility for using medication, asks him directly about his beliefs regarding medication. Robert does not think he is having any more trouble finishing assignments than his classmates. He finds his classes boring and has been spending more time talking with friends at school this year compared with last year. He has forgotten his pills many days except when there is going to be a test. This has only been a problem when the teacher gives a surprise quiz. In addition, his father doesn’t think he needs medication and believes that Robert just needs to be motivated to work harder.
After collecting this information, the doctor negotiates with Robert to try an “experiment.” He suggests trying 36 mg of osmotic-release oral methylphenidate during school days, compared with no medication. The smaller dose may strike an acceptable balance between “being no fun” and helping him focus on his work. Robert agrees to fill out a symptom checklist for each dose level and to ask a teacher to do the same. His mother agrees to help him organize the details of the trial. A follow-up appointment is scheduled in one month.
In this vignette, the responsibility for using medication on a daily basis was transferred from the parent to the youth. It is important to remember that this transfer of responsibility takes place at different times for different families. In anticipation of this occurrence, clinicians should remember to inquire about the young person’s point of view about medication use. Youths with ADHD often see themselves as less impaired than their parents see them.16,17 When teens do not think that their symptoms require treatment, they are less likely to accept (or adhere to) medication.18 In addition, it is important to note that adverse effects for young people may not always be physical; embarrassment, peer issues, stigma about taking medications, or experiencing themselves as less sociable can also result in medication refusal.6,19,20
Adjusting medication dosages and formulations can improve the balance between adverse effects and effectiveness, thereby improving adherence. However, for some families, the clinician must recognize that the more challenging step may be accepting the recommendation to use stimulants. Indeed, parents of children and adolescents who take stimulants describe receiving the initial diagnosis of ADHD and the subsequent decision to use medication as difficult hurdles that need to be negotiated.9
Trans-Theoretical Model of Change
Both HBM and TRAPB illustrate adherence behavior at a given point. In contrast, the Trans-Theoretical Model of Change (TTM) highlights how health behavior changes over time.21 This model identifies differences in the parents’ or patient’s level of readiness for change and describes how an individual can move through stages from precontemplation to action (Figure 3).
The clinician needs to evaluate the family’s current level of motivation, both when initiating medication and throughout treatment. Prematurely offering a stimulant prescription, such as when the parent is still coming to terms with the child’s diagnosis, may be experienced negatively. Families often require time to adjust to the psychiatric diagnosis while they experiment with alternative treatment approaches. This progression from precontemplation at initial diagnosis to contemplation at follow-up is illustrated by the continuation of the first vignette.