Adhering to your non‐adherent patients: the challenge of non‐compliance

As health care professionals, we are obligated to give our patients comprehensive care in the hopes of improving their medical condition. We obtain a detailed history, conduct a physical exam, sometimes review a few laboratory and imaging tests, and conclude with a diagnosis and recommend appropriate medical therapy. Does our role end here or is this just the beginning of a mutual voyage with peaks and valleys? One of the most challenging obstacles during this journey is non-adherence. When was the last time you were frustrated with patients who did not take their medications as prescribed, despite your continuous efforts? Should we blame the patient’s lack of responsibility and give up, or are there other systematic and ⁄ or creative measures we can use to improve non-adherence among our patients? In our view, adherence must be looked at as a critical component in overall health care management, rather than an isolated behaviour. By focusing on this behaviour to the exclusion of others, an opportunity is missed to teach families how best to help their child acquire responsibility for her ⁄ his health care needs overall. Indeed, for a majority of families, health care management skills are not well transferred from parents to the adolescent. Adherence to treatment regimens is a crucial aspect of health care management, requiring the child’s cooperation and the caregiver’s persistent commitment. Non-adherence to medications can include errors in frequency, dose, or timing required; it may be deliberate or unintentional. Numerous studies have shown that non-adherence is very common among adolescents who have a chronic disease with a resultant cost of approximately $100 billion a year (1). One study of over 1000 adolescents with type 1 diabetes mellitus, asthma, epilepsy, or juvenile rheumatoid arthritis found that less than one-fifth of the sample reported complete adherence with their treatment regimen (2). Awareness of the many identified, modifiable psychosocial risk factors for non-adherence might help clinicians intervene earlier or more aggressively. Non-adherence per se is not a psychiatric disorder. Depression (3) and symptoms of post-traumatic stress (PTS) (4,5), however, are wellestablished risk factors for non-adherence. Two self-report measures of depression and PTS, the Children’s Depression Inventory [CDI; (6)] and the UCLA Posttraumatic Stress Reaction Index (PTSRI;), have been extensively validated in medically ill patients (7,8). These brief measures (approximately 10 min to complete) can be easily completed by patients at routine outpatient visits as a part of screening efforts or in the event depression or PTS is suspected. At our institution, we have found that a history of child abuse is associated with non-adherence (9). Other risk factors include impulsivity and inattention (10,11) and poor family functioning (12). Evidence-based assessment methods for investigating family processes in paediatric populations should be considered (13). In transplant recipients, for example, the Family Assessment Device (FAD), which distinguishes between ‘healthy’ and ‘unhealthy’ families, has demonstrated good psychometric properties (12) and may be helpful in identifying areas for further intervention. In the event a clinician suspects or confirms any of these described risk factors, a referral to a mental health professional deserves consideration. Articles in the series A Different View are edited by Alan Leviton (alan.leviton@childrens.harvard.edu) We encourage you to offer your own different view either in response to A Different View you do not fully agree with, or on an unrelated topic. Acta Pædiatrica ISSN 0803–5253