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Dealing with non-adherence to therapy 

Dealing with non-adherence to therapy
Chapter:
Dealing with non-adherence to therapy
Author(s):

Jeremy Hull

, Julian Forton

, and Anne Thomson

DOI:
10.1093/med/9780199687060.003.0060
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Introduction

  • Non-adherence to paediatric medical treatment regimens may occur in up to 50% of cases. This problem becomes particularly prominent in adolescence where the adolescent agenda of self-definition, social exploration, and independence naturally conflicts with the demands of treatment for chronic disease.

  • Chronic disease and complex treatment regimens impact both patient and family, and ensuring good adherence to treatment therefore necessitates the cooperation of both patient and parents. This requires the acceptance of both the disease itself and the validity of the proposed treatment.

  • A well-organized household, with a well-structured daily routine, will tend to promote adherence to medical treatment.

  • Chaotic households are more likely to struggle with adherence, with difficulty incorporating new tasks into the daily routine, especially time-consuming treatments such as physiotherapy. They are more likely to fail on lifestyle advice, such as dietary guidance, rules about smoking in the house, or situations and activities to avoid, and are more likely to default on tasks that require planning ahead such as refilling prescriptions or attending hospital appointments.

  • A cohesive family, where the climate is supportive and responsive, rather than critical and disengaging, will be more successful at accommodating the additional pressures and change in family dynamics that chronic disease may impose.

Approach to non-adherence to therapy

  • It is important first to clarify whether the parents and patient have a clear understanding of what treatments are to be implemented. Treatment compliance is unlikely to be successful if the reasons for treatment have not been made clear.

  • A written treatment plan is an essential part of any treatment regimen, providing all carers within the family, as well as the patient, with a clear guideline. It helps avoid confusion that may occur during a short consultation with the health carer. It should be user-friendly for the family.

  • For children with chronic disease, copies of clinic letters forwarded to the family can provide a clear progress report and help re-clarify any changes made to treatment.

  • Non-adherence to treatment in adolescence is very common. It is recognized that a successful transition from being a child to a responsible adult looking after their own health is a slow process. Teenagers >14 years of age (depending on the child’s maturity) should be seen alone in clinic consultations, as well as with their parents, so they have an opportunity to express themselves in confidence.

  • The setting and the quality of the physician–patient relationship may be important in improving treatment adherence, and teenagers with poor compliance should be seen by the same physician over time, so that a trusting relationship can develop.

  • Information regarding the disease should be given at a level appropriate to the maturational stage of the patient.

  • Difficulties in adhering to the treatment strategy should be discussed openly and sympathetically, rather than in a disappointed or paternalistic manner. Teenagers are more likely to be truthful about compliance in a non-judgemental environment.

  • Evidence indicates that adherence to one aspect of the treatment does not necessarily mean adherence to all aspects of the regimen. All components of the treatment should therefore be discussed. What compliance is demonstrated should be praised.

  • Asking for proposals from the patient may help engage them in treatment plans. Within reason, the treatment should be simplified as much as possible and be open to negotiation. Therapy should be adapted to the teenager’s lifestyle.

Transition

Transition from paediatric to adult care should be planned and occur in stages over time, as it is a period where adherence to treatment can be difficult, particularly if the young person feels they are losing support structures they relied on. Transitional services should be seen as ‘youth friendly’, and the transition plan should address psychosocial and vocational concerns, as well as medical issues.

Further information

Michaud PA, Suris JC, Viner R (2004). The adolescent with a chronic condition. Part II: healthcare provision. Arch Dis Child 89, 943–9.Find this resource:

Shaw KL, Watanabe A, Rankin E, McDonagh JE (2014). Walking the talk. Implementation of transitional care guidance in a UK paediatric and a neighbouring adult facility. Child Care Health Dev 40, 663–70.Find this resource: