CHILD & ADOLESCENT PSYCHIATRY
Theoretical Models of Health Behavior
Understanding Treatment Adherence in Children With Attention-Deficit/Hyperactivity Disorder
By Alice Charach, MD
October 1, 2008
Dr Charach is assistant professor in the department of psychiatry at the University of Toronto Hospital for Sick Children in Ontario, Canada. She reports no conflicts of interest concerning the subject matter of this article.
Susie returns for follow-up in April of third grade. She has received weekly tutoring to help with organizational skills and school assignments. Parents and teachers communicate regularly about class assignments and homework. Several times a week, she has leftover tasks that need to be completed at home; she often spends much time on this homework and ends up in tears. Her parents further research ADHD and attend public workshops organized by a local parent support group for families who have children with ADHD. In response to the new information, and advice from other parents who have children with ADHD, they decide it is now time to try medication for her.
This vignette illustrates that access to accurate information about ADHD and evidence-based treatment approaches is very important when parents are contemplating stimulant use for their children. Support groups are helpful not only for access to information but also for parents to speak with others who have gone through the same process and have had similar experiences.
Where families wish the child to participate in the decisions about medication, the child’s readiness to change may also be important. The clinician should discuss treatment options and patient preferences with a flexible attitude, accepting the need for passage of time by offering the opportunity for future meetings to discuss and re-discuss treatment options.
Initiating medication with a trial of psychostimulants is an excellent way to assist families who continue to have doubts about psychostimulant treatment for their child.22-24 Stimulants, especially immediate-release stimulants, often show an immediate effectiveness that offers parents (although not always children) an example of the benefits of increased attention, concentration, and reduced impulsiveness. Parents need feedback that the treatment is effective, either by experiencing the improvements themselves or from teacher feedback. The child also benefits from feedback regarding his or her progress. The experience of benefits in the context of few adverse effects will encourage parents and children to continue with medication following the initial trial.
After initiating stimulant use, regular monitoring should become an important part of the treatment plan, which is essential for encouraging long-term adherence. Such monitoring will detect potential adverse effects or loss of effectiveness, and it will also identify medication doubts as they arise, as in Robert’s case.
As Robert completes the trial of a lower dose of osmotic-release oral methylphenidate(Drug information on methylphenidate) compared with no medication, he reports that he used the medication during 2 of the weeks that he was scheduled not to take medication because he had midterm exams. Furthermore, he found that completing a project was more difficult during the week of no medication than completing similar projects while taking medication. He reports that 2 of his teachers complimented him on his improved work attitude. Robert also discussed medication use with his father, who said Robert could make up his own mind. On the basis of this trial, Robert decided to keep using 36 mg of osmotic-release oral methylphenidate for most school days, and asked if he could use extra on days that he had to work on homework projects.
In both vignettes, the treatment decision was made in the context of both the patient’s and parents’ concerns. Susie’s family used information from her schoolteachers and from the parent support group to decide about the assessment and treatment. Robert’s decisions were influenced by his peers, his father, and his teachers.
The Illness-Career Model
A fourth model of health behavior, the Illness-Career Model, emphasizes both changes over time and the dynamic relationships between patient, extended family, and larger community, including school (Figure 4).25 Often, other family members, neighbors, or friends question a parent’s or young person’s decision to use stimulants.9 Media stories raise concerns about overmedicating children, and valued community leaders may express negative opinions; these experiences can complicate the decision process.9,26 In addition, comments from peers can interfere with a child’s willingness to cooperate.
For medication to remain an integral part of the young person’s overall treatment plan, the prescribing physician and associated health care team must remain accessible over time and become embedded as part of the family’s community network, with contact frequent enough to balance out other influences.
Discontinuation trials can identify whether the child is continuing to benefit from medication treatment.24 They can also be useful in medication adherence since children, especially as they get older, may be skeptical that medication continues to be helpful. If the youth stops taking the medications and experiences academic difficulties, then he is more likely to return to using medications. This process can also help establish the treatment relationship between physician and teen, rather than physician and parent. Using symptom and adverse-effect checklists before and after medication cessation provides information useful for re-establishing the medication’s risks and benefits. Alternatively, the dose of the current psychostimulant can be adjusted or a switch made to another agent to address specific concerns. This process can be seen in the follow-up with Robert.
Clinicians need to keep in mind that parent beliefs and attitudes strongly influence treatment choices for their child. However, attitudes and beliefs can change with time. An important aspect of initial assessment and ongoing monitoring should be an exploration of the family’s and young person’s perspectives, since patient preferences are an integral part of the best clinical practices. We also know that peoples’ experiences—including those that they have with health care practitioners—will have an impact on these beliefs. Clinicians need to provide a flexible and open-minded approach, communicating with patients and their parents that their doubts and concerns about medications and the illness will be heard and responded to with respect and with a fundamental regard for their health and welfare.
|Drugs Mentioned in this Article|
|Amphetamine (Adderall, others)|
|Methylphenidate (Ritalin LA, others)|
|Methylphenidate transdermal (Daytrana)|
|Mixed amphetamine salts (Adderall XR)|
|Osmotic-release oral methylphenidate (OROS-MPH)|
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Gau SS, Chen SJ, Chou WJ, et al. National survey of adherence, efficacy, and side effects of methylphenidate in children with attention-deficit/hyperactivity disorder in Taiwan. J Clin Psychiatry. 2008;69: 131-140.
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